Seminars in laparoscopic surgery最新文献

Intestinal and abdominal adhesions may be responsible for a variety of clinical conditions, including chronic recurrent small-bowel obstruction, acute small-bowel obstruction, closed-loop bowel obstruction and, debatably, abdominal or pelvic pain. Experience in laparoscopic surgery has increased at a rapid pace, thus adhesions are no longer considered a contraindication to treatment of these conditions. In recent years, numerous publications have reported the feasibility, safety, and favorable outcome of laparoscopic intervention in various adhesion-related conditions. As adhesions are the most common cause of recurrent or acute bowel obstruction, this review will focus on the laparoscopic management of these conditions and outline the technical considerations, indications, contraindications, and results.

Telementoring began in the 1950s and is an advanced application of telemedicine that involves the removed guidance of a procedure where the student has no or limited experience. In the past 10 to 15 years, telemedicine has been revisited as a result of the healthcare delivery crisis, budgetary concerns, and the impact of managed care. In recent years, telementoring has had a number of successes which have led to further recent telementoring investigations and developments. Telementoring programs were established because it was impractical for specialized minimally invasive surgeons to proctor fellow surgeons during the adoption phase of new techniques. This catalyzed the establishment of formal telementoring procedural guidelines and networks. Efforts have been made in the remote direction of laparoscopic spermatic vein ligations, renal biopsy, nephrectomy, varicocelectomy, fetoscopy, and ophthalmology. Pilot studies in 2000 have statistically validated that telementoring can be as effective as on-site mentoring. In order to successfully conduct telementoring missions, however, it is important to follow a precise algorithm. If a standardized protocol is followed, it will ensure that telementoring is practiced safely and efficiently.

Laparoscopic colon and rectal surgery has gained popularity over the last 10 years. The experience obtained from the more simple surgeries, such as cholecystectomy and appendectomy, and the development of better instruments have made colorectal standard laparoscopic surgery an easier procedure. However, the downside associated with this technique includes longer operative times, higher costs, loss of tactile sensation, and a two-dimensional view. In the last 5 years, a new type of instrument has appeared on the market: the hand-assist device. It gives back the tactile feeling and allows the surgeon to retrieve a three-dimensional evaluation of the abdomen. This instrument has changed the laparoscopic surgery field and permitted the expansion of laparoscopic colectomy to the most challenging and complex cases. Hand-assisted laparoscopic surgery seems to retain the same benefits as standard laparoscopic surgery and improve the operative time and the learning curve. This article reviews the benefits and the indications for the use of the hand-assist device, and the characteristics and types of hand-assist devices available and their instruction for use. It also focuses on the technical aspects of hand-assisted laparoscopic surgery.

The use of laparoscopic techniques when surgical therapy is required for the treatment of mucosal ulcerative colitis has been slow to develop; the surgery is extensive, and the instruments are limited. The often urgent nature of the surgery, along with the fragile inflamed colon, have contributed to the limited development of this surgical approach. Yet there is a paradox, as these patients have often anticipated surgery and thus are extremely frightened about it, or must undergo a major operation under urgent circumstances. In this setting, it would seem that a minimally invasive surgical approach would make sense if safe and reasonable, because healing, scarring, and patient fears can be minimized. We are encouraged by the experience we have gained over the past several years in performing these complex laparoscopic cases. The development of some of the newer surgical technologies has shortened operative times. Several recent studies have demonstrated short-term advantages with the laparoscopic approach compared with standard open operations for mucosal ulcerative colitis. Thus, this new approach is a viable and valuable option that may be offered to some patients with mucosal ulcerative colitis.

Rectal prolapse is a lifestyle-altering disability which has been treated with over 100 surgical options. The specific goals of surgical management of full thickness rectal prolapse are to minimize the operative risk in this typically elderly population, eradicate the external prolapse of the rectum, improve continence, improve bowel function, and reduce the risk of recurrence. The theoretical advantages of a laparoscopic approach are to couple reductions in surgical morbidity and good post-operative outcome. Studies which compare the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function. Virtually every type of open transabdominal surgical approach to rectal prolapse has been laparoscopically accomplished. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy. The growing body of literature supports the concept that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with full thickness rectal prolapse.

The laparoscopic approach to Crohn disease offers the multiple potential benefits of faster recovery, better cosmesis, and a lower incidence of adhesion-related complications and incisional hernias. Most of these advantages are unproven, but a review of the current literature reveals that advantages have been suggested in almost all series that have compared laparoscopy to laparotomy. Some features of Crohn disease, such as fistula, abscess, and phlegmon, may pose a surgical challenge; however, laparoscopic resection is often feasible, with morbidity rates comparable to or lower than those associated with laparotomy. Experience both in advanced laparoscopic techniques and surgery for Crohn disease, coupled with sound surgical judgment and a reasonably low threshold to convert to laparotomy before intraoperative complications occur, are essential for the successful and safe employment of these procedures.

Currently available robotic surgical systems appear to be particularly suited for use in benign diseases of the gastrointestinal system. Minimally invasive operations for foregut conditions, such as gastroesophageal reflux disease and achalasia, require excellent visibility and precise tissue dissection. Benign lower gastrointestinal diseases, including inflammatory bowel disease and diverticulitis, also can be approached using robotic assistance. Disadvantages include expense and the loss of tactile feedback. Early clinical results are promising.

Laparoscopic surgery has demonstrated advantages over conventional open procedures. Specifically, avoiding an abdominal incision and allowing the complete inspection of the abdominal cavity, as well as the ability to obtain a biopsy sample, are some of the reasons that made this method of stoma creation advantageous. The creation of stomas by laparoscopy is one of the simpler laparoscopic procedures and is associated with a shorter learning curve compared with other colorectal procedures. This section discusses the indications, methods, and complications associated with the laparoscopic creation of stomas.