Seminars in laparoscopic surgery最新文献

In any large practice, some patients will be identified with polyps that are unable to be safely removed with a colonoscope. For those few polyps that cannot be endoscopically managed, laparoscopic techniques provide a safe and attractive option. They have the potential to decrease patient discomfort and length of stay and still provide adequate oncologic treatment of these potentially malignant lesions.

Surgery induces alterations in local and systemic immune responses. These changes appear to be associated with an increase in postoperative morbidity. Minimally invasive techniques are considered to improve the preservation of immune function compared with open surgery and may therefore be beneficial for patient recovery. As laparoscopic techniques are increasingly used in abdominal surgery, more research has focussed on the immunologic consequences of these techniques. Nevertheless, the changes that occur in response to trauma are still not completely understood. The immunologic benefits of laparoscopic surgery are the most obvious for minor surgical procedures such as cholecystectomy and antireflux surgery. For more complex procedures such as colorectal surgery for cancer, the benefits are not immediately obvious. Although laparoscopic surgery for colorectal malignancies may be associated with higher survival rates and lower recurrence rates because of improved immune function, it has also been related to high incidences of port-site metastases. Reviews in the literature have now shown that incidences of port-site metastases are comparable to incidences of wound metastases after open surgery. However, it will be necessary to wait for the long-term results of randomized, clinical trials to provide further clarification of how immune function is altered after laparoscopic and open surgery for colorectal cancer.

Transanal endoscopic microsurgery has become an established method of transanally excising rectal tumors. It uses a closed, airtight system that provides constant rectal distension, improved visibility, and longer reach than conventional instrumentation. Virtually any rectal adenoma and properly selected cancers can be removed with this technique. Transanal endoscopic microsurgery excision of cancers requires that strict selection criteria be satisfied and is best suited for T1 cancers. Transanal endoscopic microsurgery should not replace low anterior resection or abdominoperineal resection for those cancers that have either deep penetration into the rectal wall or lymph node metastases. This procedure is safe, is associated with minimal complications, and most patients can be treated on an outpatient basis. Complications include bleeding, urinary retention, temporary soilage, and inadvertent entry into the peritoneal cavity. Once transanal endoscopic microsurgery has been mastered, it may become the technique of choice for locally excising rectal neoplasms.

Laparoscopic anterior resection is a technically demanding procedure with a steep learning curve. In expert hands, this procedure has a place in the operative armamentarium for the treatment of benign disease. Its application in the treatment of rectal carcinoma is more difficult to address. The evidence available suggests that laparoscopic anterior resection is a feasible and appropriate option for the treatment of rectal carcinoma. The skill and technology to perform the procedure are developing apace, and level 1 evidence to support its use is tantalizingly close. In this paper, we outline the development of the procedure, the operative approach, and the available evidence for its use in the treatment of rectal carcinoma.

The acceptance of laparoscopy for the management of oncologic disease has been slow because of initial fears regarding the effect of this new approach on the interaction between the patient and the tumor. Since the initial attempts at laparoscopic resection, experience and technology have improved in parallel, facilitating improvements in this area. Laparoscopic oncologic surgery has a role in the management of oncologic patients at all stages of disease. Good evidence exists that laparoscopy has become an invaluable staging tool in many upper gastrointestinal cancers as well as lymphomas. The specter of port-site recurrence has loomed over the use of a laparoscopic approach for curative resections. However, it is clear from many reported trials that the initial prevalence of port-site metastases was more a technical issue rather than a problem with laparoscopy. Current large, multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and its comparison with open surgery. It does appear that laparoscopic cancer surgery is feasible, safe, and oncologically sound. We fully believe that laparoscopic cancer surgery will play an increasingly major role in the management of gastrointestinal malignancies.

The advantages of laparoscopy in the treatment of benign disease have been well demonstrated. Compared to open surgery, laparoscopy is associated with a shorter hospital stay, less ileus, decreased postoperative pain, earlier return to work, and better cosmesis. The role of laparoscopy for the cure of malignant disease, however, remains controversial. In order to elucidate the safety and efficacy of laparoscopy for malignancy, worldwide large controlled randomized trials were developed. While awaiting the results of large randomized trials, a review of the many published studies to date was undertaken demonstrating a high level of evidence of the superiority of laparoscopy over laparotomy in regard to short-term benefits, when performed by appropriately skilled surgeons in properly selected patients. The data also suggest similar or superior local recurrence and long-term survival rates. However, further follow-up and review of large, multicenter, randomized trials will be needed before widespread acceptance of the technique can be recommended.

The enthusiasm for laparoscopic procedures in the field of visceral and colorectal surgery, in particular, has increased. Potential advantages include a reduction in pain as a result of less trauma, improved postoperative immune function, the earlier reestablishment of postoperative intestinal transit, shorter hospitalization, improved cosmesis, and reduced formation of intra-abdominal adhesions. In contrast to treatment for benign conditions, laparoscopic surgery with curative intent for malignancy is still controversial. In particular, compliance with the required criteria of oncologic radicality (extent of lymph node dissection, prevention of intraoperative tumor cell dissemination, assurance of acceptable margins of clearance) and thus, the achievement of long-term results identical with those results obtained after laparotomy, are considerations that have repeatedly been questioned. However, a number of published reports have confirmed that all the criteria for oncologic radicality in colorectal surgery can be met. An additional advantage of laparoscopic abdominoperineal excision is that it avoids a number of general problems associated with laparoscopic colorectal surgery. However, despite this encouraging information, a general recommendation for the use of laparoscopic abdominoperineal excision can be made only when definitive long-term results are available. Against this background, we discuss the questions of oncologic radicality and long-term outcome on the basis of currently available published data and our own results.

In the last decade, laparoscopic surgery has revolutionized the practice of surgery to a great extent. Experienced laparoscopic surgeons have acquired proficiency for advanced procedures; however, complex laparoscopic procedures are still unpopular due to the high technical demand. Hand-assisted laparoscopic surgery or handoscopy has been developed as an adjunct to conventional laparoscopy, but its role for the management of malignancy is controversial. This technique allows the surgeon to insert a hand into the body cavities via a glovesize skin incision, while maintaining the pneumoperitoneum. The hand insertion allows tactile sensation, assists in atraumatic retraction and blunt dissection, and helps safeguard vascular control. The hand-assisted device also provides wound protection and allows intact specimen retrieval. Its applications in various oncologic procedures have demonstrated feasibility and even better recovery in some selected procedures compared with laparotomy. It may also help to reduce conversions. Handoscopic procedures allow a shorter learning curve and operative time, thereby attracting more surgeons to attempt advanced laparoscopic operations. Thus, in a selected group of complicated procedures, handoscopy provides an alternative to laparoscopy and the traditional open approach in the management of malignancy.