Research Items (35)
Introduction. Cannabinoid Hyperemesis Syndrome (CHS) is a rare condition that includes cyclic severe vomiting in subjects who have been consuming large doses of cannabis for several years. One of the major diagnostic criteria is the alleviation of symptoms by hot showers. The syndrome was first described in 2004 and is so far neither completely understood nor well known. The latter leads to continued morbidity in concerned subjects and unnecessary expenses for futile investigations. Standard treatments of vomiting as 5-HT3 or D2-receptor antagonists have been shown to be ineffective in alleviating the symptoms. The only long-term satisfying treatment option is the complete abstinence from cannabis consumption. Case Summary. In this case report we describe a 26-year-old male Caucasian long-term cannabis consumer who repeatedly presented in our emergency room with cyclic severe nausea and vomiting ceased by hot showers and resistant to all other treatments. The final diagnosis was not established until his third visit to the ER. Conclusion. CHS is an important differential diagnosis in patients who present with cyclic vomiting and abdominal pain with a history of long-term cannabis use. Recognition of this syndrome is important in order to avoid unnecessary clinical testing and to help the patients break the cycle of drug use.
The inflammatory properties of propofol are still debated. Apolipoprotein A-I is involved in the inflammation. We sought to determine how propofol or its solvent Intralipid® modulate Apolipoprotein A-I and the inflammatory response after surgical stress. Patients undergoing laparoscopic inguinal hernia repair were allocated to anesthesia with propofol (n=25), isoflurane alone (n=27) or in combination with Intralipid® (n=27). Apolipoprotein A-I and inflammation were assessed before, during and after surgery. Following a decrease in all groups, Apolipoprotein A-I levels tended to recover significantly earlier when propofol or Intralipid® were given (p<0.05). Cortisol increased in the control group whereas it remained at baseline levels when lipids were given. In this study the administration of lipids, i.e. propofol or its solvent Intralipid®, in the perioperative setting was associated with a more pronounced yet rapidly recovering acute phase reaction.
- Mar 2013
Background: Recent developments in minimal invasive surgery have led to laparoendoscopic single site surgery (LESS). This new approach has great potential but remains technically challenging. In order to relieve these difficulties many authors have adapted robotic technology to single site surgery. Numerous approaches have been developed and there is no real consensus. Methods: A transdisiplinary systematic review of the literature and analysis of the techniques were performed using PubMed up to 31 December 2011. Results: A total of 41 publications were found and included. Seven used the da Vinci Single Site Instrumentation (Intuitive Surgical, Sunnyvale, CA, USA) whereas others used various access devices including: GelPort/GelPOINT (Applied Medical, Rancho Santa Margarita, CA, USA) and a glove technique. Conclusions: The technical feasibility of robotic LESS is established for numerous and various procedures. However, each kind of procedure requires a customized selection from among the da Vinci new platform, glove technique or GelPort/GelPOINT as well as instrument crossing with respect to minimal distances.
Elective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results. Of 113 patients randomized to undergo laparoscopic (LAP) versus open (OP) sigmoid resection for diverticulitis, 105 (93%, LAP = 54, OP = 51) patients were examined and answered the Gastrointestinal Quality of Life Index (GIQLI) questionnaire, with a median follow-up of 30 (range, 9-63) months after surgery. Incisional hernias were detected in five (9.8%) patients in the OP group versus seven (12.9%) in the LAP group, P = 0.84). Overall satisfaction with the operation on a scale of 0 (very poor) to 10 (excellent) was 9 (range, 2-10) in the OP group versus 9 (range, 2-10) in the LAP group (P = 0.78). Median GIQLI score was 115 (range, 57-144) in the OP group versus 110 (range, 61-134) in the LAP group (P = 0.17). Overall satisfaction with the cosmetic aspect of the scar on a scale of 0 (very poor) to 10 (excellent) was 8 (range, 1-10) in the OP group versus 9 (range, 0-10) in the LAP group (P = 0.01). Finally, median hospital cost (including reoperations for hernias) was 11,606 (5,230-147,982) CHF in the LAP group versus 12,138 (6,098-39,786) CHF in the OP group (P = 0.47). Both open and laparoscopic approaches for sigmoid resection achieve good long-term results in terms of gastrointestinal function, quality of life, and patients' satisfaction. Significant long-term benefits of laparoscopic surgery are restricted to cosmetic (ClinicalTrials.gov protocol #NCT00453830).
- Feb 2011
Single-incision laparoscopy (SIL) is a rapidly growing procedure in the field of surgery. The most frequent site of abdominal access is the umbilicus. Its appearance can be altered during SIL procedures. The literature suggests that the umbilicus plays an important role in the overall physical appearance of patients. This study therefore investigated the perception of the general population regarding the cosmetics of the umbilicus. An online survey with 10 questions about the aesthetic importance of the umbilicus was circulated worldwide in both the English and French languages. All the answers then were gathered and analyzed. The majority of the participants considered both their umbilicus and that of their partner as "unimportant." The total loss of their umbilicus and any undesired changes in its size, shape, and skin color were considered disturbing by most participants, but not its depth. In this survey, 39% of the women and 29% of the men agreed on a negative impact of an undesired change in their umbilicus, whereas 19% of the women and 36% of the men agreed on a negative impact of such a change in the umbilicus of their partner. The majority of the participants did not consider the umbilicus as playing a major role in sexual attractiveness. The majority of the participants gave a limited cosmetic role to the umbilicus and would therefore be good candidates for an umbilical surgical access. Among the minority of participants who considered the umbilicus to be cosmetically important, the men tended to be more concerned about the aesthetic aspect of their partner's umbilicus, and a one-third of them agreed on its role in sexual appeal. Although not the majority, a significant proportion of participants were sensitive about the aspect of their umbilicus. Special care should be given to identify this population and choose the appropriate minimally invasive access.
- Sep 2010
Single-incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology. The da Vinci Standard and S System (Intuitive, Sunnyvale, USA) were used in human cadavers and pigs to perform single-incision transabdominal and transvaginal surgery. Robotic arms were crossed and control-switched to achieve intuitive control. It was possible to perform robotic single-incision laparoscopy in the typical, intuitive fashion. Transvaginal set-up, including docking of the system and introduction of instruments into the abdominal cavity, was possible but no useful manipulation could be performed. While robotic NOTES with the da Vinci surgical system was not successful, robotic single-incision surgery is feasible using the above set-up. This new approach seems to offer the advantages of single-incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified.
- Jul 2010
The aim of this study was to compare open and laparoscopic sigmoid resection for diverticulitis with the patient and the nursing staff blinded to the surgical approach. A total of 113 patients scheduled for an elective sigmoidectomy were randomized to receive either a conventional open (54 patients) or a laparoscopic (59 patients) approach. Postoperatively, an opaque wound dressing was applied and left in place for 4 days, and patients from both groups were managed similarly. The primary endpoints for analysis were (1) postoperative pain; (2) duration of postoperative ileus; and (3) duration of hospital stay (ClinicalTrials.gov, number NCT 00453830). The median duration of procedure was 165 minutes (range, 90-285) in the laparoscopy group and 110 minutes (range, 70-210) in the open group (P < 0.0001). The median delay between surgery and first bowel movement was 76 (range, 31-163) hours in the laparoscopy group versus 105 (range, 53-175) hours in the open group (P < 0.0001). The median score for maximal pain (assessed by a visual analog scale) was 4 (range, 1-10) in the laparoscopy group and 5 (range, 1-10) in the open group (P = 0.05). Finally, the median duration of hospital stay was 5 days (range, 4-69) in the laparoscopy group versus 7 days (range, 5-17) in the open group (P < 0.0001). Laparoscopic sigmoid resection is associated with a 30% reduction in duration of postoperative ileus and hospital stay; by comparison, benefits in terms of postoperative pain appear less impressive, when the patient is blinded to the surgical technique.
- Mar 2010
Set-up and docking of the da Vinci surgical system are assumed to extend overall operating times. We hypothesized that these tasks could be achieved in adequate times. Therefore, a prospective analysis of set-up and docking times of the da Vinci Surgical System was conducted. We prospectively analysed set-up and docking times with the da Vinci surgical system in our division. Ninety-six patients were operated on over 30 months in our institution. Median set-up time was 22 (range 9-50) min and median docking time was 10 (range 2-70) min. Surgeons with previous docking experience were significantly faster than inexperienced surgeons: 8 (range 2-50) vs. 17.5 (range 10-70) min. Both set-up and docking showed a fast learning curve. The data support the conclusion that both set-up and docking of the robot can be achieved in adequate times and have a low impact on overall operating time.
- Dec 2009
Laparoscopic splenectomy (LS) is becoming the "gold standard" technique for splenectomy. The aim of this study was to evaluate the hospital experience, body image, and cosmesis after LS or open splenectomy (OS). Patients who underwent LS or OS were invited to fill out questionnaires evaluating their hospital experience, body image, and cosmetic results. A total of 72 patients (34 LS and 38 OS) agreed to participate in the study. No significant difference was observed between the groups in terms of age, sex, body mass index, or indication for splenectomy. Mean spleen weight and postoperative complications were slightly higher (P>0.05) and the postoperative hospital stay was significantly longer (P<0.05) in the OS group compared with the LS group. Scores from the modified Body Image, Hospital Experience, and Photo Series Questionnaires were higher (favorable) in the LS group compared with the OS group (P<0.01, P<0.001, and P<0.001, respectively). LS is the procedure of choice for most indications of splenectomy, which has comparable or better perioperative outcomes and complication rate as well as the advantages of better body image, cosmesis, and hospital experience compared with OS. Our results presenting improved outcomes with LS will contribute to the widespread application of laparoscopy for splenectomy.
Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci robot. Thirty-four individuals were tested for robotic dexterity, IQ elements, computer-gaming skills and general dexterity. Eighteen surgically inexperienced and 16 laparoscopically trained surgeons were included. Each individual performed three different tasks with the da Vinci surgical system and their times were recorded. An IQ test (elements: logical thinking, 3D imagination and technical understanding) was completed by each participant. Computer skills were tested with a simple computer game (hand-eye coordination) and general dexterity was evaluated by the ability to use chopsticks. We found no correlation between logical thinking, 3D imagination and robotic skills. Both computer gaming and general dexterity showed a slight but non-significant improvement in performance with the da Vinci robot (p > 0.05). A significant correlation between robotic skills, technical understanding and laparoscopic experience was observed (p < 0.05). The data support the conclusion that there are no significant correlations between robotic performance and logical thinking, 3D understanding, computer gaming skills and general dexterity. A correlation between robotic skills and technical understanding may exist. Laparoscopic experience seems to be the strongest predictor of performance with the da Vinci surgical system. Generally, it appears difficult to determine non-surgical predictors for robotic surgery.
Amyand's hernia is an atypical groin hernia which contains the vermiform appendix. The aim of this study was to review a single institution's experience in the clinical presentation, management and prognostic factors of this rare hernia. The authors reviewed records of all patients undergoing hernia surgery from 1996 to 2006 at their institution, a tertiary care, University-affiliated hospital. Twelve patients (six men) with a median age of 88 years (range 60-97) were included. Six presented with right inguinal hernias and six presented with right femoral hernias. All required emergency surgery: eight for strangulated hernias, two for hernias with lower quadrant peritonism and two for incarcerated hernia. Despite small differences in outcome and length of hospitalisation between Amyand types, appendix inflammation, pre-operative blood examinations and hernia localisation, only right lower quadrant peritonism as a presenting sign (p=0.004) and age greater than 90 years old (p=0.04) were significantly associated with a poor outcome. Amyand's hernia is a rare hernia which is seldom diagnosed before operation. It must be considered in the evaluation of a strangulated or incarcerated hernia. Further studies are required to define the optimal surgical strategy, prognostic factors and risks of hernia recurrence.
- Oct 2008
The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery. All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database. The median age of patients was 73 (range 17-98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm(3) (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score > or =3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003). The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.
- Sep 2008
Natural orifice transluminal endoscopic surgery (NOTES) is a multidisciplinary surgical technique. If conventional endoscopic instrumentation can be easily mastered, surgeons with laparoscopic experience could head NOTES interventions. Thirty individuals were tested for endoscopic dexterity. Group 1 included seven gastroenterologists, group 2 included 12 laparoscopically experienced surgeons lacking endoscopic experience, and group 3 included 11 interns who had no hands-on endoscopic or surgical experience. Each individual repeated an easy (T1), medium (T2), and difficult (T3) task ten times with endoscopic equipment on a NOTES skills-box. Group 3 had significantly poorer performances for all three tasks compared to the other groups. No significant differences were seen between groups 1 and 2 for T1 and T2. The initial T3 performance of group 1 was better than that of group 2, but their performance after repetition was not statistically different. Groups 2 and 3 improved significantly with repetition, and group 2 eventually performed as well as group 1. The data indicate that laparoscopic surgeons quickly learned to handle the endoscopic equipment. This suggests that a lack of endoscopic experience does not handicap laparoscopic surgeons when performing endoscopic tasks. Based on their knowledge of anatomy and the complication management acquired during surgical education, surgeons are well equipped to take the lead in interdisciplinary NOTES collaborations.
- Jul 2008
The lack of haptic feedback (HF) in robotic surgery is one of the major concerns of novice surgeons to that field. The superior visual appearances acquired during robotic surgery may give clues that make HF less important. We surveyed 52 individuals on their perception of HF during robotic surgery. The first group of 34 surgically inexperienced people used the da Vinci robot for their first time (drylab). The second group included 8 laparoscopic surgeons with experience up to a fifth robotic operation. The third group included 10 surgical experts with substantial experience (150-650 robotic cases). Visual analog assessment was made of perception of HF, how much HF was missed, how much the absence of HF impaired the operators' level of comfort. Robotic experts were asked if complications have occurred as a result of a lack of HF. Of the first group, 50% reported the perception of HF, as did 55% of the second group and 100% of the third group (difference between group 1 and group 3: p < 0.05). The first group missed HF for 6.5; the second group for 4.3, and the third group for 4 (difference between groups 1 and 3: p < 0.05). The surgical experts claimed to have missed HF for 7.2 s when they first started robotic surgery (Difference to now: p < 0.05). The lack of HF caused discomfort for the first group of 4; for the second group of 4,4, and for the third group of 2,6. One complication was reported by the robotic experts as resulting from the lack of HF. The data support the conclusion that even beginners quickly experience the perception of HF when performing robotic surgery. With more experience, perception of HF and the level of comfort with robotic surgery increases significantly. This perception of HF makes "real" HF less important and demonstrates that its importance is overestimated by novices in robotic surgery.
Pleural or peritoneal effusions (ascites) are frequent in terminal stage malignancies. Medical management may be hazardous. A 60-year-old man with metastatic malignant melanoma presented refractory ascites as well as bilateral pleural effusions. After failure of the medical treatment, bilateral pleural aspiration and paracentesis became necessary two to three times a week. A multi perforated 15F silicone catheter connected with a subcutaneous port was implanted in peritoneal and both pleural cavities surgically under general anesthesia. Leakage around the catheter is prevented by subcutaneous tunneling. Surgical technique is described and illustrated in a video. Implanted systems were immediately operational. Follow up period was 41 days. Each port was accessed 10 times and a total of 65'200 ml of fluid was drained. By the end of the forth week, pleural effusions diminished, systems were controlled for permeability and chest x-rays confirmed absence of effusion. Implanted port systems for refractory ascites and pleural effusions avoid morbidity and the patient's anxiety related to repeated puncture-aspiration. Large catheter diameter allows an easy and fast drainage of large volumes. Compared to chronic indwelling catheters, subcutaneous location of port system allows an entire integration, giving the patient a total liberty in daily life between two sessions of drainage. Drainage can be performed in an outpatient basis as an ambulatory procedure. This patient-friendly technique may be a treatment option in case of failure of other techniques.
Pyoderma gangrenosum is an aseptic skin disease. The ulcerative form of pyoderma gangrenosum is characterized by a rapidly progressing painful irregular and undermined bordered necrotic ulcer. The aetiology of pyoderma gangrenosum remains unclear. In about 70% of cases, it is associated with a systemic disorder, most often inflammatory bowel disease, haematological disease or arthritis. In 25-50% of cases, a triggering factor such as recent surgery or trauma is identified. Treatment consists of local and systemic approaches. Systemic steroids are generally used first. If the lesions are refractory, steroids are combined with other immunosuppressive therapy or to antimicrobial agents. A 90 years old patient with myelodysplastic syndrome, seeking regular transfusions required totally implanted central venous access device (Port-a-Cath(R)) insertion. Fever and inflammatory skin reaction at the site of insertion developed on the seventh post-operative day, requiring the device's explanation. A rapid progression of the skin lesions evolved into a circular skin necrosis. Intravenous steroid treatment stopped the necrosis' progression. Early diagnosis remains the most important step to the successful treatment of pyoderma gangrenosum.
Surgical repair of parastomal hernias is usually performed through a laparotomy (stoma translocation) or a peristomal incision (mesh repair). Laparoscopic approach may minimize the risks of mesh infection and, thus, represents an attractive alternative. Permacol (Tissue Science Laboratories plc, Aldershot, Hampshire, U.K.) is a new biomaterial implant, which combines the strength and biocompatibility. Case 1: A 67-year-old patient presented with paracolostomal hernia causing discomfort and intermittent obstructive episodes, 12 months after a proctectomy for severe radiation proctitis. Case 2: A 74-year-old patient presented with a symptomatic paracolostomal hernia 18 years after abdominoperineal amputation. Both procedures took less than 120 minutes. Patients were started on a liquid and solid diet on postoperative Day 1 and discharged to home on the sixth and seventh postoperative days. There was no evidence of hernia recurrence or mesh-related complication at the time of last follow-up: nine months and three months postoperatively. Compared with the traditional open technique, the technique described has two potential benefits: 1) the laparoscopic approach provides a means to avoid operating in a contaminated field and may reduce the risks of mesh infection; and 2) the use of a biologic graft may minimize the incidence of synthetic mesh-related complications, such as erosion into viscera and fistula. The use of biologic implants in this indication seems promising and deserves further evaluation.
- Jul 2007
Since 1990, laparoscopy and minimally invasive techniques in general, have been widely adopted in the field of digestive surgery. However, due to its technical limitations, the use of conventional laparoscopy remains limited to procedures of low (cholecystectomy, appendectomy) or intermediate (Nissen fundoplication, sigmoidectomy) complexity. This paper reviews the technical aspects of the da Vinci robot, as well as its potential applications to digestive surgery. While robotic-assisted cholecystectomy and fundoplication are feasible, this approach is not superior to conventional laparoscopy; by contrast, preliminary data suggest that robotic-assisted surgery might be superior to laparoscopy in more complex procedures, such as gastric bypass and total mesorectum excision for rectal cancer.
- Jul 2006
Optimal treatment of groin hernia is a primary public health concern. The inguinal hernia is associated with dysfunctions of the collagen matrix of genetic or acquired origin. Recurrence rate after hernia surgery without mesh reinforcement is estimated at 10-15%. The use of mesh decreases the risk of recurrence by between 50 and 70%. The open techniques (Lichtenstein and derived) are easy to learn, feasible with local anaesthesia and in outpatient setting but they produce chronic pain and sexual disorders. Laparoscopic surgery produces less acute and chronic pain, allows a faster return to the daily activities and allows better cosmetic results. Well codified and taught, the laparoscopy has an important role to play in hernia surgery today as well as in the future.
- Jun 2006
Since an increasing number of appendectomies are performed via laparoscopy, it is crucial to determine the impact of this approach on appendix carcinoid (AC) outcome. The goal of this study was to compare results of laparoscopic (LAP) versus open (OP) appendectomy for AC according to intend to treat approach. A retrospective review (1991-2003) identified 39 patients (median age, 36 years; range, 12-83) treated by laparoscopy (LAP) or laparotomy (OP) for AC in a single institution. Follow-up was complete for all patients (median, 67 months; range, 4-132). Most cases had associated acute appendicitis (64%). Median carcinoid size was 1.1 cm (range, 0.3-5) and 0.4 cm (range, 0.2-3) in the LAP and OP groups, respectively. LAP and OP were performed in 21 (54%) and 18 (46%) patients, respectively. Surgical margins were positive in two patients in the LAP group and one patient in the OP group (p = 0.6). Right colectomies were performed for AC >2 cm in five patients after LAP and in four patients after OP (p = 0.9). Actuarial 5-year survival rates were 100 and 94% in the LAP and OP groups, respectively (p = 0.2). Two patients died in the OP group, one due to metastatic carcinoid and the other due to metachronous colorectal cancer. Synchronous or metachronous colorectal carcinomas developed in six patients (15%). Laparoscopic appendectomy is a safe procedure for AC, with carcinologic and long-term results similar to those of conventional appendectomy. Thus, pre- or per-operative suspicion of AC is not a contraindication to LAP. Prognosis of AC appears more dependent on carcinoid malignant potential or associated tumors. Risk for developing colorectal adenocarcinoma is high in AC patients and warrants follow-up of all patients with colonoscopic screening.
- Jun 2003
The diagnosis of acute appendicitis remains difficult in certain circumstances, as in case of the Amyand's hernia. Development of an acute appendicitis in an external hernia is called Amyand's hernia in honour of the English surgeon, Claudius Amyand, author of the first appendicectomy of the history of medicine in 1735. Amyand's hernia is a rare occurrence, but knowledge of it's existence is important. We present here five cases of Amyand's hernia and report the clinical presentation, the management and compare them with the literature. The knowledge of this rare pathology is essential in order to allow a preoperative diagnosis and a rapid and adequate management.
- Jun 2002
The introduction of complex and long-term intravenous therapies requires reliable venous access. Totally implantable central venous access devices improve treatment and quality of life for patients. However, the long-term function of such devices depends on an analysis adapted to each patient. Many complications could be avoided by a methodological choice of the type of system, the site and technique of implantation.
- Jan 2000
- Port-Site and Wound Recurrences in Cancer Surgery
The patient, a 67-year-old man, presented with nonspecific abdominal pain over the last 3 weeks. The personal history was uneventful with the exception of a known diverticulosis. Abdominal examination was normal. Barium enema revealed a large caecal tumor, that was suspected to be malignant (Fig. 2.1). Coloscopy showed the presence of an unique, bulky tumor, and histopathological analysis of the biopsy confirmed the malignant nature. A computerized tomography of the abdomen detected no distant metastases, locally the tumor was described to infiltrate the pericolic fatty tissue.
- Jan 1999
The first reported series of laparoscopic colorectal resection in the early nineties were met with skepticism, probably because of the complexity of the technique. Since then, the laparoscopic procedure has gained acceptance in terms of faisability and safety. Since early 1995, colorectal surgery for benign diseases is included among the laparoscopic operations performed in our unit. We report the results of the first 60 patients, including the complications related to the long learning curve.