open versus laparoscopic surgery what is a myth and what is not!

Open Versus Laparoscopic Surgery

What Is A Myth And What Is Not !

George Ferzli, MD, FACS

Open Versus Laparoscopic Surgery

• Esophageal

• Gastric

• Liver

• Biliary

• Pancreatic

• Adrenal

• Splenic

• Bowel• Prostate• Hernia

Laparoscopic Esophageal Surgery

EsophagectomyEsophagomyotomyParaesophageal Hernia RepairNissen Fundoplication

Minimally Invasive Esophagectomy

• Is it safe and does it have any advantages over the open techniques?

Nguyen NT et al, Arch Surg. 2000;135:920-925

Study Design• Retrospective comparison of 3 methods of

esophagectomy: combined thoracoscopic and laparoscopic (TM/LE), transthoracic (TT), and blunt transhiatal (THE)

• Setting: University Medical Center• Patients: – TM/LE: 18 consecutive patients (10/9/98 to

1/19/00); data collected prospectively – TT and THE: 16 and 20 patients respectively

(6/1/93 to 8/5/98); data collected from a retrospective chart review

Esophagectomy

TM/LE

(n=18)

TT

(n=16)

THE

(n=20)

Operative time, min 364+73* 437+65 391+144

Blood loss, mL 297+233* 1046+792 1142+785

Intraop. transfusion, U 0.3+0.7* 1.8+2.2 2.9+3.1

ICU stay, days 6.1+11.3* 9.9+16.3 11.1+15.7

Hospital stay, days 11.3+14.2* 23.0+22.3 22.3+16.1

No. of nodes removed 10.8+8.4 6.3+6.0 6.9+5.4

* P<.05, compared with TT and THE groups,Mann-Whitney Test


EsophagectomyComplication TM/LE (n=18) TT (n=16) THE (n=20)

GI bleeding 0 1 (6) 0

Anastomotic leak 2 (11) 2 (12) 2 (10)

Gastric conduit ischemia 0 1 (6) 0

Pulmonary embolism 1 (6) 0 1 (5)

Respiratory failure 2 (11) 3 (19) 3 (15)

Delayed gastric emptying 1 (6) 0 0

Chylous ascites 0 0 1 (5)

Hoarseness 0 0 4 (20)

Intra-abdominal abscess 0 1 (6) 0

Tracheal-gastric fistula 1 (6) 0 0


Minimally Invasive EsophagectomySummary

• It is safe as the complication rate is comparable to open surgery

• It is effective as the lymph node yield is comparable to open surgery

• It has advantages over the open techniques as there is significantly less blood loss, and transfusion rate, and shorter operative time,ICU stay, and hospital length of stay

Minimally Invasive Esophagomyotomy

•How does the morbidity and outcome compare to the open technique?

Dempsey et al, Surg Endosc (1999) 13: 747-750

Minimally Invasive EsophagomyotomyStudy Design

• Retrospective analysis• Open myotomy: 10 patients from a pool of

20 (10 lost to follow-up) operated upon between Aug.1988 and Jan.1996

• Laparoscopic esophagomyotomy and Dor anterior fundoplication: 12 patients

• Mean follow-up: 60 months in open group and 16 months in laparoscopic group

Dempsey et al, Surg Endosc (1999) 13: 747-750

Esophagomyotomy

Laparoscopic (n=12) Open (n=10)

Operating time, min 137+25 122+32

Blood loss, mL 50+26* 220+156

Mucosal perforation 2/12 2/10

Parenteral narcotic, days 2.1+1.0* 5.3+1.4

Parenteral narcotic, mg 18+2* 39+7

Hospital stay, days 2.7* 8.8

Improved dysphagia 92% 90%

Overall satisfaction 84% 80%

Post-op GERD 25% 40%

Days off work post-op 19+16* 85+60

*P<.05 Dempsey et al, Surg Endosc (1999) 13: 747-750

Minimally Invasive EsophagomyotomySummary

• Symptomatic improvement and high patient satisfaction comparable to the open procedure

• Significantly less morbidity: less intra-op blood loss, post-op pain and parenteral narcotic use, shorter hospital stay and fewer days off from work

Laparoscopic Paraesophageal Hernia Repair

•Is it associated with higher recurrence compared to open repair ?

•Should mesh be used ?

•How does symptomatic outcome compare to open repair ?

Hashemi et al, J Am Coll Surg 2000;190:553-561Frantzides CT et al, Surg Endosc (1999) 13: 906-908

Paraesophageal Hernia RepairStudy Design

• Retrospective review of 54 patients who underwent repair of large type III hiatal hernia between 1985 and 1998

• Laparotomy – 13, Thoracotomy – 14, Laparoscopy – 27

• Follow-up: Symptomatic outcomes at median 24 months, integrity of repair using video esophagogram at median 27 months

Hashemi et al, J Am Coll Surg 2000;190:553-561

Paraesophageal Hernia RepairTechnique and Recurrence

Open Surgery•Reduction of hernia

•Complete excision of sac

•Primary closure of crura

•Antireflux procedure

Laparoscopic Surgery•Reduction of sac

•No excision of sac

•Primary closure of crura

•No mesh or gastropexy0

10

20

30

40

50

% R

ecur

renc

e

Laparoscopic Repair (n=21) Open Repair(n=20)


P<.001

Paraesophageal Hernia RepairSymptomatic Outcomes

0

20

40

60

80

100

Excellent/Good Fair/Poor Satisfied

% p

atie

nts

Laparoscopic (n=26) Open (n=25)


Paraesophageal Hernia RepairTechnique and Recurrence

0

5

10

15

20

% R

ecur

renc

e

PTFE mesh (n=17) No mesh (n=18)

Mesh vs. No Mesh

•Prospective randomized trial

•Hiatal defect >8cm diameter

•Excision of sac, primary closure of crura, Nissen fundoplication in all cases

•Randomized intra-op to mesh vs. no mesh

•Follow-up for 6 months

Frantzides CT et al, Surg Endosc (1999) 13: 906-908

16%

0%

Paraesophageal Hernia RepairSummary

• Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair

• Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20)

• Use of mesh reduces paraesophageal hernia recurrence significantly

Laparoscopic Nissen Fundoplication

• Is there a higher incidence of complications ?

• How are the functional results ?

Laine S et al, Surg Endosc (1997) 11: 441-444Bais JE et al, Lancet 2000; 355: 170-74

Laparoscopic Nissen FundoplicationStudy Design

• Prospective randomized trial• 110 consecutive patients with prolonged

symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic and 55 to open repair

• Follow-up: Post-op recovery, complications and outcome at 3- and 12-months were compared

Laine S et al, Surg Endosc (1997) 11: 441-444

Nissen FundoplicationComplications

Complication Lap. Open

Esophageal perforation 2 0

Intraoperative bleeding 1 0

Splenic bleeding and splenectomy 0 2

Pneumonia 0 1

Subphrenic abscess 0 1

Wound infection 0 3


0

5

10

15

20

25

Open Lap

% ti

me

mea

n p

H<

4

Pre-op 3 mo post-op 1 yr post-op

Nissen FundoplicationProportion of Time (%) Mean pH<4


Nissen FundoplicationMean LES Pressure


0

5

10

15

20

25

30

Open Lap

Mea

n LE

S p

ress

ure

Pre-op 3 mo post-op 1 yr post-op

Nissen FundoplicationSymptoms 3 Months After the Operation

Open

No symptoms Bloating wound painHeartburn Upper abd. Pain Dysphagia

Laparoscopic

No symptoms Bloating wound painHeartburn Upper abd. Pain Dysphagia


53%16%

22%

2%

4%

2%56%

18%

22%

4%

(n=55) (n=55)

Nissen FundoplicationSymptoms 12 Months After the Operation

Open

No symptoms Bloating HeartburnUpper abd. Pain Dysphagia

Laparoscopic

No symptoms Bloating HeartburnUpper abd. Pain Dysphagia


70% 83%

17%13%3%

7%

7%

(n=55) (n=55)

Laparoscopic Nissen FundoplicationStudy Design

• Interim analysis of a prospective randomized trial comparing open and laparoscopic Nissen fundoplication

• 46 patients in open group and 57 in laparoscopic group operated before interim analysis

• Follow-up: 3 months• Primary endpoints: Dysphagia, recurrent GERD, and

intrathoracic hernia• Technical observation: No bougie used in either group

Bais JE et al, Lancet 2000; 355: 170-74

Laparoscopic Nissen FundoplicationResults

Laparoscopy

(n=57)

Laparotomy

(n=46)

Persistent dysphagia* (>3 months)

7 0

Recurrent GERD at 3 months

2 1

Intrathoracic herniation 2 0

Total** 11 1

*p=0.016, **p=0.011 (Fisher’s exact test)

Bais JE et al, Lancet 2000; 355: 170-74

Laparoscopic Nissen FundoplicationSummary

• Safe and feasible procedure• Complications are few and functional results

(post-op pH, LES pressure, symptoms) are good if not better than open surgery

• High rate of post-op dysphagia in study by Bais et al may be a result of not using bougie which more important for laparoscopic surgery as there is no tactile sensation

Laparoscopic Gastric Surgery

Billroth I Gastrectomy Surgery for Perforated Peptic Ulcer Bariatric Surgery

Laparoscopy-Assisted Billroth I Gastrectomy

•Is it safe ?

•Is it useful for patients with early gastric cancer ?

•Does it have advantages over open surgery ?

Adachi Y et al, Arch Surg. 2000;135:806-810

Billroth I GastrectomyStudy Design

• Retrospective review of operative data, blood analyses and post-op clinical course

• Setting: University hospital in Japan

• Patients: 102 patients who underwent Billroth I gastrectomy for early-stage gastric cancer from 1/93 to 7/99. 49 laparoscopy-assisted and 53 open procedures Adachi Y et al, Arch Surg. 2000;135:806-810

Billroth I GastrectomyLaparoscopic (n=49) Open (n=53)

Blood loss, mL 158 302

Leukocyte count, day1 9.42 11.14

Leukocyte count, day 3 6.99 8.22

Granulocyte count, day1 7.28 8.9

C-reactive protein, day 7, mg% 2.91 5.19

Interleukin-6, day 3, U/mL 4.2 26

Serum albumin, day 7 35.6 33.9

Analgesics, times given 3.3 6.2

Time to liquid diet, days 5.0 5.7

Post-op hospital stay, days 17.6 22.5

Weight loss on day 14 5.5% 7.7%

Time to first flatus, days 3.9 4.5P<.05, all features Adachi Y et al, Arch Surg. 2000;135:806-810

Billroth I Gastrectomy

Laparoscopic

(n=49)

Open

(n=53)

Operation time, min 246 228

Proximal margin, cm 6.2 6.0

No. of lymph nodes 18.4 22.1

Complication rate 8% 21%

P=NS, all features Adachi Y et al, Arch Surg. 2000;135:806-810

Laparoscopy-Assisted Billroth I Gastrectomy

Summary

• It is a safe procedure• It has several advantages over open surgery including

less surgical trauma, less impaired nutrition, less pain, rapid return of GI function, shorter hospital stay and no decrease in operative curability (proximal margin, # of lymph nodes harvested)

• Prospective-randomized trial with long-term follow-up required

Perforated Peptic Ulcer

Perforated Peptic UlcerTechniques

• Simple closure Memon MA et al, Br. Med. J. 86:106-107, 1993

• Omental patchSo JB et al, Surg Endosc, 10:1060-63, 1996

• Fibrin glue Mouret P et al, Br J Surg, 77:1006,1990

• Placement of oxidized cellulose gauzeTate JJT et al, Br J Surg, 80:35, 1993

• Falciform ligament patchMunro WS et al, Ann R Coll Surg, 78:390-1, 1996

• Ligamentum teres patchCastalab G et al, Surg Endosc, 6:677-9, 1995

Perforated Duodenal UlcerLaparoscopic vs. Open Repair

• Decreased perioperative analgesic requirements in laparoscopic group

• No benefit in length of hospital stay, time to resume normal diet or return to normal activity

• Increased operative time and cost

Miserey M et al, Surg Endosc. 10:831-6, 1996So JB et al, Surg Endosc. 10:1060-63, 1996Lau WY et al, Ann Surg. 224: 131-38, 1996Lau WY et al, Br J Surg. 82:814-6, 1995

Laparoscopic Bariatric Surgery

•Is it safe ?

•Does it reduce post-op morbidity ?

•How does the outcome and cost compare to open surgery ?

Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001de Wit LT et al, Annals of Surgery, 230(6);800-807, Dec. 1999

Roux-en-Y Gastric BypassStudy Design

• Prospective randomized trial• Setting: University of California, Davis• Patients: From 5/99 to 3/01, 155 patients

with a BMI of 40-60 kg/m2 were randomly assigned to undergo laparoscopic (n=79) or open (n=76) GBP

• Outcome, quality of life and cost was compared

Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001

Roux-en-Y Gastric BypassPerioperative Outcomes

Results Laparoscopic GBP (n=79)

Open GBP (n=76)

P Value

Operative time, min 225+40 195+41 <.001

Blood loss, mL 137+79 395+284 <.001

ICU stay, No. of Pts. 6 (7.6%) 16 (21.1%) .03

Median hospital LOS, days 3 (IQR 1) 4 (IQR 2) <.001

Reoperation, No. of Pts. 6 (7.6%) 5 (6.6%) NS

Return to daily activity, days 8.4+8.6 17.7+19.1 <.001

Return to work, days 32.2+19.8 46.1+20.6 .02


Roux-en-Y Gastric BypassMean % of Excess Body Weight loss

0

20

40

60

80

100

0 5 10 15

Time (months)

Exc

ess

Bo

dy

Wei

gh

t L

oss

(%

)

Open GBP Laparoscopic GBP

*

*

n=60

n=45

n=29

n=56

n=44

n=25


*p<.05

Roux-en-Y Gastric BypassMajor Complications

Complication Laparoscopic GBP (n=79) Open GBP (n=76)

Gastrointestinal

Anastomotic leak 1 1

Gastric pouch outlet obstruction 0 1

Hypopharyngeal perforation 1 0

Jejunojejunostomy obstruction 3 0

Pulmonary

Pulmonary embolism 0 1

Respiratory failure 0 1

Gastrointestinal bleeding 1 0

Wound infection 0 2

Retained laparotomy sponge 0 1

Total 6 (7.6%) 7 (9.2%)*

*P=0.78 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001

Adjustable Silicon Gastric BandingStudy Design

• Prospective randomized trial

• Fifty patients with morbid obesity of >5 years’ duration and a BMI > 40 kg/m2 were randomized to undergo laparoscopic or open ASGB

• Complications, hospital stay, readmissions, and weight loss were compared

de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999

Adjustable Silicon Gastric Banding

Parameter Laparoscopic ASGB (n=25)

Open ASGB (n=24)

P Value

Surgical time, min 150+48 76+20 <0.05

Days in hospital, mean (range)

5.9 (4-10) 7.2 (5-13) <0.05

Difficulty of procedure (1-10)(range)

4.7+2.1

(3-10)

3.8+1.1

(3-7)

<0.05

Total readmissions 6 15 <0.05

Overall hospital stay, days 7.8+6 11.8+10.5 <0.05


Adjustable Silicon Gastric Banding

Laparoscopic ASGB (n=25)

Open ASGB (n=24)

P Value

Weight before surgery (kg)

152.2+31.4 146.4+19.9 NS

Weight 52 weeks after surgery (kg)

117.2+25.2 112.0+19.1 NS

Weight loss (kg) 35 34.4

BMI before surgery (kg/m2)

51.3+10.4 49.7+5.6 NS

BMI 52 weeks after surgery (kg/m2)

39.7+8.7 39.1+8.2 NS

All values are expressed as mean+SDP value difference before and 52 weeks after is < 0.05


Laparoscopic Bariatric SurgerySummary

• Compared to open surgery, laparoscopic Roux-en-Y gastric bypass is associated with: 1) Significantly decreased blood loss, ICU stay, and hospital stay,

2) Earlier return to daily activity and work, 3) Longer operative time, 4) Fewer complications, and 5) Equivalent weight loss at 1 year.

Laparoscopic Bariatric SurgerySummary

• Compared to open surgery, laparoscopic adjustable silicon gastric banding is associated with:

1) Significantly decreased length of hospital stay and readmission rate,

2) Increased OR time, and

3) Equivalent weight loss at 52 weeks.

Laparoscopic Liver Resection

Liver Resection

Laparoscopic (n=17)

Conventional (n=17)

p value

(Mann-Whitney U Test)

Age (years) 48.0+9.8 46.8+13.9 NS

Parenchymal hepatic resection rate (%)

11.6+6.1 10.8+4.6 NS

Operation time (min) 183.5+55.1 128.2+37.0 <0.05

Blood loss (mL) 457.6+343.7 555.9+385.8 NS

Post-op hospital stay (days)

7.8+8.2 11.6+12.8 <0.05

Rau HG et al, Hepato-Gastroenterology 1998; 45:2333-2338

Liver ResectionSummary

• Data on laparoscopic liver resection scarce

• At present laparoscopy appears to have a role in laparoscopic ultrasound and radiofrequency ablation and cryoablation of liver tumors

Laparoscopic Common Bile Duct Exploration

PREOPPREOP INTRAOINTRAOPP

POSTOPOSTOPP

ERCPERCP Lap Lap transcystictranscysticLap CBDLap CBDOpen CBDOpen CBDExpectantExpectant

ERCPERCP

Management Options

Laparoscopic CBD Exploration

Study No. of patients

No. of cholangio.

No. of pts with CBD

stones

Trans-

cystic

Choledo-

chotomy

Comment

Shuchleib et al

50 - 50 13 37 8% conversion. 92% success. 1 death. LOS 4.3d

Berci et al 226 99.5% 94% 83%, 5% conversion

17%, 19% conversion

2 duct injuries. 1 death. 7% morbidity 2.6% retained stones.

Paganini et al

1975 1975 161 107 50 Major complications 3.8%. 1 death. 5% retained stones. 3.2% recurrent stones on f/u

Berthou et al

220 - 220 112, 68.8% success

137, 97.1% success

4 deaths. Morbidity 9.1%. 7 with residual stones.

Phillips et al

1231 99% 145 123, 91% success

10 1 death. Shorter LOS (3.4d), lesser morbidity (5%), fewer retained stones (5%) for transcystic.

Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001

Laparoscopic CBD ExplorationStudy No. of

patientsNo. of

cholangio.No. of pts with

CBD stonesTrans-

cystic

Choledo-

chotomy

Comment

Drouard et al

161 - 161 82,67% success

101, 96% success

No mortality. Morbidity 7.4%. LOS 7.6 days.

Cuschieri et al

133 132 109 56,80% success

55, 85% success

15.8% complication rate. 1 death. 13% conversion. LOS 6 days.

Giurgiu et al

217 - 217 217 0 No late retained stones or stricture.

Arvidsson et al

39 - 39 22 11 Overall success 82%. No mortality. Morbidity 10%

Gigot et al 92 - 92 63% success

93% success

12% conversion. 2 deaths. 15% complication rate.

Millat et al

247 - 247 116 92 Overall success 88%. 20 conversions. 22 major & 9 minor complications. 1 death.

Khoo et al 60 - 60 46 14 Overall success rate 75%

Stoker et al

700 - 80 33 27 Overall success rate 94%. Complication rate 10%

Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001

Laparoscopic Pancreatic Surgery

Diagnostic laparoscopy for staging of pancreatic cancer Laparoscopic ultrasound for staging of pancreatic cancer Pancreatic resection Palliative surgery for pancreatic cancer

“In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence”.

1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A.

Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911

• Prospective study of 88 consecutive patients

• Pancreatic and periampullary adenocarcinoma

• Preoperative evaluation– CT scan with contrast 88 pts– MRI 20 pts– Laparoscopy 47 pts– Angiography 85 pts

Preoperative Staging and Assessment of Resectability of Pancreatic Cancer

Warshaw,A et al: Arch Surg 1990; 125:230-233

Results

• Overall resectability 33/88 (38%)

• Laparoscopy found metastatic disease when present in 22/23 patients (96%)

• Laparoscopy found no metastatic disease in 24/24 patients (100%)


Conclusion

• Laparoscopy is particularly sensitive for detecting small metastases (96%)

• This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances


The Value of Laparoscopy in the Staging of Patients with Potentially Resectable

Peripancreatic Malignancies

• 115 patients- radiologically resectable

• Extensive laparoscopy performed

– assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

Unresectability• Metastases

– hepatic, serosal, peritoneal• Extrapancreatic extension

– mesocolic involvement• Nodal involvement

– celiac or portal• Vascular invasion

– celiac axis or hepatic artery– portal vein, SMV, SMA


• Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient

• Positive predictive index of 100%

• Negative predictive index of 91%

• Accuracy of 94%

Results


Laparoscopic Ultrasound in the Staging of Pancreatic Cancer

• Prospective evaluation of 90 patients

• All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography

• All patients had laparoscopy and laparoscopic ultrasound

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

CT LAP LAP SONO

ACTUAL

UNRESECTABLE 17

(19%)

41

(46%)

49

(54%)

50

(56%)

EQUIVOCAL 8

(9%)

13

(14%)

___ ___

Results


Laparoscopic Ultrasound

• Sensitivity 100%

• Specificity 98%

• Accuracy 98%


Summary

• Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection

• The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer

Laparoscopic Pancreatic Resection

Laparoscopic Pancreatic ResectionAuthor (y) n Length

of stay (d)

OR time (h)

Total comp. (%)

Minor comp. (%)

Major comp. (%)

Panc. Fistula

(%)

30-day mortality

(%)

Laparoscopic

Patterson (2001) 19 7 4.3 26 10 16 16 0

Salky (2000) 7 4 3.7 28 28 0 0 0

Vezakis (1999) 6 34.5 5.0 33 0 33 33 0

Park (1999) 5 5 5.0 20 0 20 20 -

Gagner (1997) 13 - - 38 8 31 8 -

•Distal pancreatectomy

•Islet cell enucleation

9

4

5

4

4.5

3

-

-

-

-

-

-

-

-

-

-

Cuschieri (1996) 5 6 4.5 40 20 20 20 -

Open

Lillemoe (1999) 235 10 4.3 31 NR 31 5 0.9

Benoist (1999) 40 15 - 63 5 58 23 -

Broughan (1986) 84 - - - - 24 6 3.6

Patterson JE, J Am Coll Surg 2001;193:281-287

Laparoscopic Palliative Surgery for Unresectable Pancreatic

Cancer

Laparoscopic Gastro- and Hepaticojejunostomy

Case-Control Study 14 patients – open palliation10 patients – laparoscopic palliation4 patients – diagnostic laparoscopy

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

Results

OPEN

(n=14)

LAP

(n=14)MORBIDITY 43% 7%

MORTALITY 29%

0%

HOSPITAL STAY

21 days

9 days

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

p < 0.05

p < 0.05

p < 0.06

Summary

• Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer

• Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma

Laparoscopic Versus Open Adrenalectomy

Adrenalectomy

First author

Approach (n)

EBL (cc)

Operative time (min)

LOS (days)

OI (days)

Pain meds (mg)

Cost ($)

Brunt OA(25) 408 142 8.7 6.0 142 16,972

OP(17) 366 136 6.2 2.8 54 12,266

Lap(24) 104* 183* 3.2 * 1.6 * 15.9 * 13,184

Guazzoni Open(20) 450 145 9 2.8 320

Lap(20) 100 * 170 * 3.4 * 1.1 * 175 *

Prinz OA(11) 391 174 6.4 1002

OP(13) 288 139 * 5.5 801

Lap(10) 228 212 2.1 * 93 *

Korman OA(5) 200 141 6.2 3.4 3.6(days) 14,487

OP(5) 220 106 * 5.6 2.2 3.2(days) 11,193

Lap(10) 118 164 4.1 1.8 1.9(days) 8,188

OA, open anterior; OP, open posterior; Lap, laparoscopic; EBL, estimated blood loss; LOS, length of stay; OI, oral intake* Significant outcome compared to other outcome measures in same series (p<0.05)

AdrenalectomyPosterior open

(n=50)Laparoscopic

(n=50)p Value

OR time (min) 127 167 0.0002

Blood transfusion (total group) None 2 units NS

MSO4 equivalents 48 28 0.002

Toradol doses 1.7 0.7 0.75

Antiemetic doses 5.7 3.1 0.50

Hospital stay (days) 5.7 3.1 0.0001

Early complications (%) 18 6 0.25

Late complications (%) 54 0 0.0001

Return to normal (weeks) 7 3.8 0.0001

Patient satisfaction (1-10) 7 9 0.0001

Adjusted hospital charges (median)

$6000 $7000 0.05

Thompson GB, Surgery 1997;122:1132-6

Adrenalectomy

Laparoscopic (n=40)

Open (n=40) P Value

Operating time (min)

•Skin to removal 147 79 <0.0001

•Skin to skin 180 127 <0.0001

Estimated blood loss (g) 40 162 <0.0001

Analgesic (times) 2.9 5.8 <0.0001

Hospital stay (days) 12 18 <0.0001

Hospital costs (dollars) $7000 $8000 NS

First solid food (days) 1.3 1.3 NS

Ambulatory (days) 1.3 1.5 NS

Imai T et al, Am J Surg. 1999;178:50-54

Laparoscopic AdrenalectomySummary

• It is a safe and feasible procedure• Data suggests significantly decreased blood

loss, hospital length of stay, time to oral intake, post-op analgesic use, and late complications and increased patient satisfaction compared to open surgery

• Significantly longer OR time• No difference in overall charges and early

complications

Laparoscopic Versus Open Splenectomy

Splenectomy

0

200

400

600

Donini et al, Jan 1999 Park et al, Nov 1999 Shimomatsuya et al,Feb 1999

Blo

od lo

ss (

mL)

LS OS

0

50

100

150

200

250


Op

erat

ive

time

(min

)

LS OS

0

4

8

12

16


Hos

pita

l sta

y (d

ays)

LS OS

*

*

* *

**

*p < 0.05

SplenectomyResults LS (n=44) OS (n=56) p

Average age (range) 40 (13-64) 39 (18-64) -

Splenic weight (g) 773+1,112 732+1,184 0.86

Blood loss (mL) 295+269 347+511 0.67

Transfusion (patients) 2 (5%) 15 (26%) 0.004

Operative time (min) 130+62 133+42 0.76

Accessory spleens (No. of pts) 4 (4) 7 (5) 0.70

Time to oral liquids (days) 1.7+0.8 3.6+0.8 <0.0001

Post-op stay (days) 5.1+2.7 7.2+2.1 0.0002

Post-op complications 3 (7%) 13 (23%) 0.03

Pain medication (No.of vials) 2.4 +1.7 4+2.8 <0.0001

Deaths 0 0 -

Donini A et al, Surg Endosc (1999) 13: 1220-1225

Laparoscopic SplenectomySummary

• It is a safe and feasible procedure• Data suggests significantly decreased blood

loss and transfusion rate, hospital length of stay, time to oral intake, post-op analgesic use, and complications compared to open surgery

• Significantly longer OR time

Laparoscopic Bowel Surgery

Diagnosis and treatment of small bowel obstruction Colectomy for benign and malignant disease

Small Bowel ObstructionDiagnostic and Therapeutic Laparoscopy

Author Total #

Diagnostic laparoscopy

Laparoscopic treatment

Converted to laparotomy

Iatrogenic bowel injury

Navez B, 1998 150 68 31 (46%) 31 (46%) 6 (9%)

Strickland P, 1999 40 40 24 (60%) 13 (32%) 4 (10%)

Agresta F, 2000 136 63 52 (82%) 11 (17.4%) 1 (1.5%)

Suter M, 2000 83 83 47 (57%) 36 (43%) 4 (8%)

Leon EL, 1998 40 40 14 (35%) 26 (65%) 3 (7.5%)

Al-Mulhim A, 2000 19 19 13 (68%) 6 (32%) 0 (0%)

Bailey IS, 1998 139 65 35 (54%) 30 (46%) 1 (1.5%)

Small Bowel ObstructionSummary

• Only 35-82% success rate in laparoscopic treatment of SBO

• Some studies report high incidence of iatrogenic small bowel injury

• No prospective randomized trial to address whether laparoscopic or open treatment of SBO is better

Laparoscopic Versus Open Colectomy for Cancer

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

0

10

20

30

40

RHC Trans AR Sig LAR APR Total

Ave

. # ly

mp

h no

des

0

5

10

15

20

25

RHC Trans AR Sig LAR APR

Ave

. spe

cim

en le

ngth

, cm

0

4

8

12

16

20


Ave

. dis

tal m

arg

in, c

m

LCR OCR

0

7

14

21

28

35


Ave

. pro

xim

al m

arg

in, c

m

LCR OCR

RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46


Laparoscopic

(n=192)

Open

(n=224)

Hospitalization, days 5.6 9

Blood loss, mL 150 450

Wound complications 0.5% 6%

Recurrence rates 12.2% 22%

Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III)

13% 19.1%

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46


Lap (n=18) Open (n=18) Converted (n=7)

Operating room time (min) 210 138 242

Blood loss (mL) 284 407 683

ICU stay (days) 3 4 6

Clear liquids (days) 2.7 4.4 5

Regular diet (days) 4.1 5.8 7

Length of stay (days) 5.2 7.3 8

Complications (n, %) 1, 5% 5, 28% 8, 100%

Length of specimen (cm) 26 26 32

Number of lymph nodes 11 10 12

Late death from cancer (mean follow-up 4.9 years)

4 6 1

Recurrence 0 1 1

Curet MJ et al, Surg Endosc (2000) 14: 1062-1066


Follow-up Lap. Open

No. of cases (n) 40 43

Overall metastases 8 (20%)

10 (23%)

Single site 3 5

Liver 2 4

Regional 1 1

Multiple sites 5 5

Liver+ Peritoneum 4 4

Liver+Peritoneum+

Trocar-site or scar

1 1

Five-year overall survival

020406080

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Five-year disease-free survival

0

50

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Lap OpenSantoro E et al, Hepato-Gastroenterology 1999; 46:900-904

Colorectal ResectionSummary

• No difference compared to open surgery in terms of average lymph node yield, specimen length, proximal margin, distal margin, 5-year disease free and overall survival

• Shorter ICU and hospital stay, less blood loss and wound complications

• Low incidence of port site recurrence and no difference open scar site recurrence

Laparoscopic Prostatectomy

Laparoscopic Prostatectomy

Total Procedures 1-10

Procedures 50-79

Procedures 80-125

Operative time (mean), min 265 352 210 200

Conversion, % 0 0 0 0

Blood loss (mean), mL 185 250 140 145

Transfusion, % 2 20 0 0

Catheter time (mean), days 12 19 6.5 5.5

Hospital stay (mean), days 8 10 7 6.5

Turk I et al, Eur Urol 2001;40:46-53

Laparoscopic ProstatectomyTotal Procedures

1-50Procedures

51-100Procedures

101-240

Operative time (mean), min 232 278 240 206

Blood loss (mean), mL 370 280

Transfusion, % 15 6 1.4

Catheter time (mean), days 7.8 7 4.2

Hospital stay (mean), days 5.2

Complications• Rectal injury

• Peritonitis

• Ureteral injury

• Urinary leakage

• Obturator nerve injury

• Anastomotic stricture

3

1

1

1

1

1

Guillonneau B et al, Urologic Clinics of North America 28(1);189-202: Feb 2001

Laparoscopic ProstatectomySummary

• Laparoscopic prostatectomy is a safe procedure but has a steep learning curve

• OR time, blood loss and transfusion, catheter time and length of hospital stay decrease as the surgeon becomes more experienced with the procedure

• A prospective randomized trial comparing results of open and laparoscopic prostatectomy is required

Laparoscopic Inguinal Hernia Repair

Laparoscopic Inguinal Hernia RepairOutcomes Analyzed

Cost

Operative time

Complications

Recurrence

Return to work

Inguinal Hernia RepairCost

0

2000

4000

6000

8000

10000C

ost (

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Author

Laparoscopic Open

Inguinal Hernia RepairOperative Time

0

20

40

60

80

100

120

140

Ope

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Laparoscopic Open

Inguinal Hernia RepairComplications

0

0.2

0.4

0.6

0.8

1

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Laparoscopic Open

Inguinal Hernia RepairRecurrence

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0.2

0.3R

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Author

Laparoscopic Open

Inguinal Hernia RepairReturn to Work

0

10

20

30

40

50D

ays

Zie

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Sch

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Author

Laparoscopic Open

Laparoscopic Inguinal Hernia RepairSummary

• Higher cost

• Longer OR time

• Fewer complications

• Low recurrence rate equivalent to open technique

• Faster return to work

Open Versus Laparoscopic SurgerySummary

Operation Yes No Needs additional trials

Esophagectomy X X

Esophagomyotomy X X

Paraesophageal hernia X

Nissen fundoplication X

Billroth II gastrectomy X X

Peptic ulcer disease X

Roux-en-Y GBP X

Adjustable silicon GB X

Hepatectomy X X

Open Versus Laparoscopic SurgerySummary

Operation Yes No Needs additional trials

CBDE X X

Diagnostic laparoscopy / Sono pancreatic ca.

X

Distal pancreatectomy X X

Palliative pancreatic ca. X

Adrenalectomy X

Splenectomy X

Small bowel obstruction X

Colectomy for cancer X X

Prostatectomy X X

Inguinal hernia repair X

open versus laparoscopic surgery what is a myth and what is not!

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