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Robotic-assisted laparoscopic radical prostatectomy: Learning curve of first 100 cases

INTERNATIONAL JOURNAL OF UROLOGY, Issue 7 2010
Yen Chuan Ou
Objective: Robotic-assisted laparoscopic radical prostatectomy (RALP) is gaining popularity for treating localized prostate cancer. We aimed to analyze the learning curve of a single surgeon using RALP in Taiwan. Methods: Medical records of 100 consecutive patients who underwent RALP were retrospectively reviewed. Preoperative, perioperative and postoperative parameters between patients in the first 30 cases (Group I), the second 30 cases (Group II) and cases 61,100 (Group III) undergoing RALP were analyzed. Results: Console time was shorter and blood loss was reduced in Groups II and III compared with Group I. Significant differences were found in vesicourethral anastomosis time (46.38 min for Group I vs 31.0 min for Group II vs 27 min for Group III, P < 0.01). Postoperative stay became statistically significantly shorter, from 7.33 days for Group I to 3.93 days for Group II to 3.0 days for Group III. Positive surgical margin of pT2 was reduced (13.3% for Group I, 7.1% for Group II and 0% for Group III) but not of pT3 (86.7% for Group I, 75% for Group II and 62.9% for Group III). Continence rate at 3 months was higher in Groups II (95%) and III (96.6%) than in Group 1 (76.7%, P < 0.05). Conclusions: For every 30 cases of RALP, vesicourethral anastomosis time and postoperative stay were significantly shorter. However, the incidence of surgical margin in pT3 prostate cancer was not significantly reduced. A learning curve of more than 100 cases is required to decrease the positive surgical margin in pT3 tumors. [source]

Primary hydatid cysts of psoas muscle

ANZ JOURNAL OF SURGERY, Issue 6 2002
Marcovalerio Melis
Background:, Hydatid cysts may occur in any area of the body, but they usually localize to the liver and the lungs. Primary localization in muscle is not common, accounting for 2,3% of all sites; even rarer is the development of multiple cysts. Methods: The patient presented with a painless abdominal mass which gradually increased in size to a diameter of approximately 16 cm. Organ imaging scan revealed multiple hydatid cysts within the right psoas muscle. Because of the proximity of the lesions to the iliac vessels, ureter and nerves to the lower limb, percutaneous drainage and alcoholization under local anaesthesia were performed with the aim of reducing the size of the cysts and sterilizing them prior to definitive surgery. This procedure was not effective. Two weeks after percutaneous treatment the patient underwent surgery. Results:, At operation the cysts were localized and successfully removed under ultrasound guidance. Postoperative stay was uneventful. Two years after surgery the patient has no evidence of recurrent hydatid disease. Conclusions:, Ultrasonography is the preferred method for detecting muscular hydatid cyst and for guiding the surgeon during resection. [source]

Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 2 2001
Dr K. Smedh
Background: Surgery for rectal cancer is associated with high morbidity and mortality rates. The reason for this has been much debated. This population-based study reports the findings on postoperative morbidity and mortality after rectal cancer surgery following the introduction of a centralized colorectal unit in a county central hospital, supervised by a colorectal surgeon using the most recent techniques. Methods: All consecutive patients with rectal cancer who underwent surgery at four county hospitals in the Västmanland county in Sweden during 1993,1996 (n = 133) were compared with patients who underwent surgery at the new colorectal unit in the county central hospital from 1996 to 1999 (n = 144). Results: The number of operating surgeons was reduced from 26 to four. The postoperative mortality rate decreased from 8 to 1 per cent (P = 0·002) and the total postoperative complication rate was reduced from 57 to 24 per cent (P < 0·001). Surgical complications dropped from 37 to 11 per cent (P < 0·001). The relaparotomy rate fell from 11 to 4 per cent (P < 0·05). Postoperative stay in hospital was reduced from a median of 13 to 9 days (P < 0·001). Conclusion: The new organization, with centralized rectal cancer surgery using modern techniques, reduced postoperative mortality and overall morbidity rates to less than half. © 2001 British Journal of Surgery Society Ltd [source]

Surgical treatment of esophageal leiomyoma located near or at the esophagogastric junction via a thoracoscopic approach

DISEASES OF THE ESOPHAGUS, Issue 2 2009
Z. G. Li
SUMMARY Esophageal leiomyoma can be enucleated safely and effectively by minimally invasive surgery. The laparoscopic approach has been a conventional option for this kind of tumor located near or at the esophagogastric (EG) junction. The aims of this study were to evaluate the surgical outcome of thoracoscopic resection of leiomyoma at the EG junction, and discuss factors affecting the incidence of postoperative gastroesophageal reflux. Fourteen patients who underwent thoracoscopic resection of esophageal leiomyoma located near or at the EG junction (<4 cm above the esophageal hiatus) from January 2002 to August 2007 were reviewed retrospectively. Tumor characteristics, surgical methods, and postoperative outcomes were evaluated. A left approach of video-assisted thoracoscopy was used in 13 patients; a right approach was used for the other patient, whose multiple tumors were located in the EG junction and mid-esophagus. Postoperative recovery was uneventful in all patients, with no mucosa leakage or other significant complications. Mean tumor size was 3.2 cm (1.2,6.0 cm). Of the 14 patients, two had serpiginous leiomyoma, two had multiple tumors, and the others had solitary tumors. Mean postoperative stay in hospital was 7 days (4,11 days). Postoperative dysphagia was not reported, although gastroesophageal reflux was noted in one patient. Thoracoscopic resection of esophageal leiomyomas near or at the EG junction is feasible, with a low prevalence of postoperative gastroesophageal reflux. [source]

Robotic-assisted laparoscopic radical prostatectomy: Learning curve of first 100 cases

Prethymectomy plasmapheresis in myasthenia gravis

JOURNAL OF CLINICAL APHERESIS, Issue 4 2005
Jiann-Horng Yeh
Abstract Plasma exchange before thymectomy may decrease the time on mechanical ventilation (MV) and shorten the stay in the intensive care unit (ICU) for patients with myasthenia gravis (MG). This study evaluated the effects of prethymectomy plasmapheresis. A total of 29 myasthenic patients, 18 women and 11 men aged 20,73 years, were treated with double filtration plasmapheresis (DFP) for two to five consecutive sessions over a period between 2 and 21 days (mean 8.1 days) before transsternal thymectomy. Acetylcholine receptor antibody (AchRAb) titers, vital capacity (VC), maximal inspiratory pressure (Pimax), and MG score were measured before and after the course of DFP. Three outcome measures including duration of postoperative hospital stay, duration of ICU stay, and duration of MV were analyzed for correlation with clinical variables. The duration of MV ranged from 6 to 93 h, with a median of 21 h. The median ICU stay was one day and the median postoperative hospital stay was 10 days. A higher removal rate of AchRAb was associated with a shorter duration of ICU and postoperative hospital stay (P = 0.001 and 0.019, respectively). Postoperative hospital stay was strongly correlated with post-DFP Pimax (P = 0.010), and marginally correlated with pre-DFP VC (P = 0.047) and to a lesser extent with pre-DFP Pimax (P = 0.063). Univariate analysis using the log rank test revealed that removal rate of AchRAb <30% (P = 0.043) and pre-DFP Pimax <,60 cmH2O (P = 0.024) were significantly associated with prolonged ICU stay. Risk factors for prolonged postoperative stay included post-DFP Pimax <,60 cmH2O (P = 0.017), pre-DFP Pimax <,60 cmH2O (P = 0.031), and post-DFP VC < 1.0 L (P = 0.046). Our results confirmed the efficacy and safety of DFP in prethymectomy preparation for myasthenic patients. J. Clin. Apheresis, 2005 © 2005 Wiley-Liss, Inc. [source]

Liver transplantation in patients with portal vein thrombosis

LIVER TRANSPLANTATION, Issue 2 2001
Gerardo Manzanet MD
The aim of this study is to analyze the incidence, risk factors, management, and follow-up of patients with portal vein thrombosis (PVT) undergoing primary orthotopic liver transplantation (OLT). Four hundred fifteen OLTs were performed in 391 patients. In 62 patients, partial (group 1; n = 48) or complete (group 2; n = 14) PVT was found at the time of surgery. Portal flow was reestablished by venous thrombectomy. In this study, we compare 62 primary OLTs performed in patients with PVT at the time of OLT with a group of 329 primary OLTs performed in patients without PVT (group 3) and analyze the incidence of PVT, use of diagnostic methods, surgical management, and outcome. We found no significant differences among the 3 groups for length of surgery, cold and warm ischemic times, and postoperative stay in the intensive care unit. With the piggyback technique, groups 1 and 2 had greater blood losses and required more blood transfusions than group 3. The early reoperation rate was greater in group 2. The incidence of rethrombosis was 4.8% (group 1, 2%; group 2, 14.3%). Reexploration and thrombectomy (2 patients) and retransplantation (1 patient) had a 100% mortality rate. In particular, the mortality rate of patients with complete PVT with extension into the splanchnic veins is high (33%). Three-month and 4-year patient survival rates were statistically similar in the 3 groups. The presence of PVT at the time of OLT is not a contraindication for OLT. However, if PVT extends into the splanchnic veins, the outcome is guarded. [source]

LAPAROSCOPIC CHOLECYSTECTOMY IN CIRRHOTIC PATIENTS WITH SYMPTOMATIC GALLSTONE DISEASE

ANZ JOURNAL OF SURGERY, Issue 5 2008
Emmanuel Leandros
Background: The aim of this study was to evaluate the outcome in patients with liver cirrhosis who underwent laparoscopic cholecystectomy for symptomatic gallstone disease. Methods: Retrospective analysis of prospectively collected data of 34 patients operated between March 1998 and April 2006. Results: There were 19 male and 15 female patients with a median age of 62 years. Cirrhosis aetiology was viral hepatitis in 25 patients, alcohol in 6, primary biliary cirrhosis in 2 and in 1 patient the cause was not identified. Twenty-three were classified as Child,Pugh,Turcotte stage A and 11 as Child,Pugh,Turcotte stage B. The median Model For End-Stage Liver Disease score was 12. Median operating time was 96 min. In three patients there was conversion to open cholecystectomy. Postoperatively, one patient died and six more patients had complications. Median postoperative stay was 3 days. Patients with acute cholecystitis did not have increased morbidity, but had significantly longer hospital stay. Conclusion: Laparoscopic cholecystectomy can be carried out with acceptable morbidity in selected patients with well-compensated Child A and B stages liver cirrhosis. Patients with evidence of significant portal hypertension and severe coagulopathy should avoid surgery. [source]

GS28P LAPAROSCOPIC CHOLECYSTECTOMY FOR OBESE PATIENTS

ANZ JOURNAL OF SURGERY, Issue 2007
S. W. Li
Background Laparoscopic surgery is often perceived to be more difficult for obese patients. Middlemore Hospital has unique patient population with high prevalence of obesity. This is a pilot study to compare the outcome of obese and non-obese patients who had laparoscopic cholecystectomy in our institution. Our hypothesis is that obese patients do not suffer more adverse postoperative outcome. Methods We reviewed all patients undergoing acute and elective cholecystectomy from January 2004 to December 2006, 100 obese patients were identified. The control group consists of 100 non-obese patients matched for age, sex and type of admission. Outcome assessed includes length of recovery period, complication and conversion rate. Results Over the three year period there were 1400 cholecystectomies, of which 96% were commenced laparoscopically. Overall conversion rate was 3.8%. The obese group has increased rate of wound complication (10% vs 2%, p = 0.037) and conversion rate (8% vs 3.5%, p = 0.28). The two study groups have similar median length of postoperative stay of 4 days. Conclusion This confirms our hypothesis that it is safe for obese patients to have laparoscopic cholecystectomy. However there is increased risk of conversion and wound complication. [source]

PREDICTING IATROGENIC GALL BLADDER PERFORATION DURING LAPAROSCOPIC CHOLECYSTECTOMY: A MULTIVARIATE LOGISTIC REGRESSION ANALYSIS OF RISK FACTORS

ANZ JOURNAL OF SURGERY, Issue 3 2006
Kamran Mohiuddin
Background: Seventeen independent risk factors were examined using multivariate logistic regression analysis to develop a profile of patients most likely at risk from iatrogenic gall bladder perforation (IGBP) during laparoscopic cholecystectomy. Methods: Since 1989, a prospectively maintained database on 856 (women, 659; men, 197) consecutive laparoscopic cholecystectomies by a single surgeon (R. J. F.) was analysed. The mean age was 48 years (range, 17,94 years). The mean operating time was 88 min (range, 25,375 min) and the mean postoperative stay was 1 day (range, 1,24 days). There were 311 (women, 214; men, 97) IGBP. Seventeen independent variables, which included sex, race, history of biliary colic, dyspepsia, history of acute cholecystitis, acute pancreatitis and jaundice, previous abdominal surgery, previous upper abdominal surgery, medical illness, use of intraoperative laser or electrodiathermy, performance of intraoperative cholangiogram, positive intraoperative cholangiogram, intraoperative common bile duct exploration, presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively and success of the operation, were analysed using multivariate logistic regression for predicting IGBP. Results: Multivariate logistic regression analysis against all 17 predictors was significant (,2 = 94.5, d.f. = 17, P = 0.0001), and the variables male sex, history of acute cholecystitis, use of laser and presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively were individually significant (P < 0.05) by the Wald ,2 -test. Conclusion: Laparoscopic cholecystectomy, using laser, in a male patient with a history of acute cholecystitis or during an acute attack of cholecystitis is associated with a significantly higher incidence of IGBP. [source]

Ten-year experience of totally laparoscopic liver resection in a single institution

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2009
A. Sasaki
Background: Recent developments in liver surgery include the introduction of laparoscopic liver resection. The aim of the present study was to review a single institution's 10-year experience of totally laparoscopic liver resection (TLLR). Methods: Between May 1997 and April 2008, 82 patients underwent TLLR for hepatocellular carcinoma (HCC) (37 patients), liver metastases (39) and benign liver lesions (six). Operations included 69 laparoscopic wedge resections, 11 laparoscopic left lateral sectionectomies and two thoracoscopic wedge resections. Nine patients underwent simultaneous laparoscopic resection of colorectal primary cancer and synchronous liver metastases. Results: Median operating time was 177 (range 70,430) min and blood loss 64 (range 1,917) ml. Median tumour size and surgical margin were 25 (range 15,85) and 6 (range 0,40) mm respectively. One procedure was converted to a laparoscopically assisted hepatectomy. Three patients developed complications. Median postoperative stay was 9 (range 3,37) days. The overall 5-year survival rate after surgery for HCC and colorectal metastases was 53 and 64 per cent respectively. Conclusion: TLLR can be performed safely for a variety of primary and secondary liver tumours, and seems to offer at least short-term benefits in selected patients. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]

Patient personality predicts postoperative stay after colorectal cancer resection

COLORECTAL DISEASE, Issue 2 2008
A. Sharma
Abstract Objective, Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS. Method, A consecutive series of 110 eligible patients undergoing elective resection for colorectal cancer were invited to participate in the study. A battery of psychometric questionnaires including the Hospital Anxiety and Depression Scale, the Functional Assessment of Cancer Therapy (colorectal), the Courtauld Emotional Control Scale, the Positive and Negative Affectivity Scale and the Eysenck Personality Questionnaire (EPQ) were administered 5,12 days before surgery. Nonparametric correlations were computed for psychometric scores, demographic variables and the LOS. Factors found to be significantly correlated on this analysis were entered into a multiple regression model to determine the independent predictors of LOS. Results, One hundred and four patients with colorectal cancer participated. Seventy were male (67%) and the mean age was 68 years (range 39,86). The median LOS was 10 days (range 4,108). LOS was negatively correlated with pre- and postoperative albumin levels, PANAS +ve affect, Functional Assessment of Cancer Therapy questionnaire with the colorectal module functional well-being score and EPQ extroversion score. LOS was strongly positively correlated with postoperative morbidity. LOS was positively correlated with CECS anger score, age and being male. Postoperative morbidity (, = 0.379, P = 0.007) and extroversion (, = ,0.318, P = 0.05) were independent predictors of LOS. Conclusion, Personality as measured by EPQ predicts postoperative LOS in patients with colorectal cancer. Extroverts have a higher pain threshold and this may be part of the explanation. [source]

Laparoscopic resection of diverticular fistulae: a 10-year experience

COLORECTAL DISEASE, Issue 7 2007
A. H. Engledow
Abstract Objective, Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach. Method, Between April 1994 and May 2005, 31 consecutive patients [17 male, median age of 63 years (range 40,85)], underwent attempted laparoscopic resection for diverticular fistulae. Patient data were prospectively recorded. Results, There were 22 colovesical and nine colovaginal fistulae. The median operative time was 150 min (range 60,310) and the median postoperative stay was 7 days (range 3,21). Conversion to an open procedure was required in nine of 31 patients (29%). This rate fell to 10% in cases performed after April 2000. There were two nonsurgically related postoperative deaths. Both occurred in the converted group. At 3 months follow-up, two patients complained of frequency of stools, which settled by 6 months. To date there has been no recurrence of symptomatic diverticulosis or fistulation. Conclusion, Totally laparoscopic resection for diverticular fistulae is safe and feasible. Fistulae should not be considered as a contraindication to laparoscopic resection for an experienced laparoscopic surgeon. [source]

Laparoscopic vs open subtotal colectomy for benign and malignant disease

COLORECTAL DISEASE, Issue 5 2006
H. S. Tilney
Abstract Aim, The present meta-analysis aims to compare short-term and long-term outcomes in patients undergoing laparoscopic or open subtotal colectomy for benign and malignant disease. Methods, A literature search of Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1992 and 2005, comparing laparoscopic (LSC) and open (OSC) subtotal colectomy. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since the beginning of 2000, higher quality papers, those reporting on more than 40 patients, and those studies reporting on adult cases or acute colitis. Results, A total of eight studies satisfied the criteria for inclusion. These included outcomes on 336 patients, 143 (42.6%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 5% (range 0,11.8%). Operative time was significantly longer in the laparoscopic group by 86.2 min (P < 0.001) and throughout subgroup analysis, although it was only in patients with acute colitis that this finding was without significant heterogeneity. Operative blood loss was less in the laparoscopic group by 57.5 millilitres in high quality and studies published since 2000, and 65.3 millilitres in those reporting on more than 40 patients. There was no significant difference in early or long-term complications between the groups. A statistically significant reduction in length of postoperative stay was observed in the laparoscopic groups by 2.9 days (P < 0.001). Conclusion, Laparoscopic subtotal colectomy was associated with longer operating times but a reduced length of stay compared to open surgery. Although short-term outcomes were equivalent in both groups, the suggested benefits in terms of reduced long-term obstructive complications were not supported by this meta-analysis. [source]