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#July 2019
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Radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction: 3D HD video laparoscopy
The author presents the case of a 64-year-old male patient with a high-grade urothelial carcinoma infiltrating the bladders (pT2-G2), with a CT-scan of the abdomen and thorax negative for secondary localizations. The patient was subjected to a radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction, performed entirely in 3D HD videolaparoscopy. After the intervention, the patient is mobilized early. Parenteral feeding is given until restoration of bowel peristalsis. The nasogastric tube is removed with restoration of bowel peristalsis. Continuous antibiotic treatment is administered for 7 days after surgery. Neobladder lavage is performed daily to evacuate mucus. Stents are inspected daily to ensure patency and sterile saline is used if there is any suspicion of obstruction. Deep vein thrombosis prophylaxis is continued. The drain is removed when the draining liquid is less than 50cc per day and when there is no urine leak. A cystogram is performed on postoperative day 14. The stents are removed sequentially at 24 hours of interval. The catheter is extracted from the neobladder 20 days after surgery. The patient is discharged from hospital 21 days after surgery. Two years after the intervention, he presents a negative oncology follow-up. The patient is in a satisfactory general health condition. He has fully recovered and returned to a normal professional life. He urinates regularly and empties his neobladder every 3 to 4 hours, with minimal stress incontinence, particularly in the evening when he is physically tired; he gains erectile activity with the use of medical devices, benefiting from a more effective intracavernous injection therapy and vacuum device, and pharmacotherapy proves less effective.
D Geddo
Surgical intervention
27 days ago
417 views
3 likes
1 comment
17:33
Radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction: 3D HD video laparoscopy
The author presents the case of a 64-year-old male patient with a high-grade urothelial carcinoma infiltrating the bladders (pT2-G2), with a CT-scan of the abdomen and thorax negative for secondary localizations. The patient was subjected to a radical cystoprostatectomy with intracorporeal orthotopic ileal neobladder reconstruction, performed entirely in 3D HD videolaparoscopy. After the intervention, the patient is mobilized early. Parenteral feeding is given until restoration of bowel peristalsis. The nasogastric tube is removed with restoration of bowel peristalsis. Continuous antibiotic treatment is administered for 7 days after surgery. Neobladder lavage is performed daily to evacuate mucus. Stents are inspected daily to ensure patency and sterile saline is used if there is any suspicion of obstruction. Deep vein thrombosis prophylaxis is continued. The drain is removed when the draining liquid is less than 50cc per day and when there is no urine leak. A cystogram is performed on postoperative day 14. The stents are removed sequentially at 24 hours of interval. The catheter is extracted from the neobladder 20 days after surgery. The patient is discharged from hospital 21 days after surgery. Two years after the intervention, he presents a negative oncology follow-up. The patient is in a satisfactory general health condition. He has fully recovered and returned to a normal professional life. He urinates regularly and empties his neobladder every 3 to 4 hours, with minimal stress incontinence, particularly in the evening when he is physically tired; he gains erectile activity with the use of medical devices, benefiting from a more effective intracavernous injection therapy and vacuum device, and pharmacotherapy proves less effective.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
27 days ago
1370 views
9 likes
2 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
R Chanwat, C Bunchaliew
Surgical intervention
27 days ago
943 views
15 likes
2 comments
10:01
Laparoscopic central hepatectomy for hepatoma using a Glissonian approach
Introduction: Although laparoscopic liver resection has been widely adopted, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes. This video illustrates a useful technique for laparoscopic central hepatectomy, which was successfully performed in a cirrhotic patient with hepatoma. Method: We demonstrated a total laparoscopic central hepatectomy which was performed in a 65-year-old woman who had a centrally located hepatoma, and this tumor was in contact with the middle hepatic vein. The operative procedure was performed by using five ports with the patient placed in a low lithotomy position. Results: The technique was successfully performed without any complications. The operative time was 380 min. Intraoperative blood loss was 60mL. The length of hospital stay was 5 days. The pathological report was well-differentiated HCC and free surgical margins. Conclusions: Laparoscopic central hepatectomy for hepatoma by using a Glissonian approach is feasible and safe.
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
F Signorini, HK Yang
Surgical intervention
27 days ago
464 views
2 likes
1 comment
10:02
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
S Greco, M Giulii Capponi, M Lotti, M Khotcholava
Surgical intervention
27 days ago
403 views
1 like
1 comment
14:14
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
RC Pullatt
Surgical intervention
27 days ago
732 views
4 likes
2 comments
13:00
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Morbid obesity has reached epidemic proportions. Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective bariatric surgery procedure for weight loss. This procedure was first described by Scopinaro in 1979. It consisted of a horizontal gastrectomy, a transection of the bowel halfway from the ligament of Treitz and the ileocecal junction, and a Roux-en-Y reconstruction with a 50cm common channel. This was later modified: the duodenal switch was added and the gastrectomy was performed in a vertical sleeve fashion, thereby preserving the pylorus and increasing the common channel to 100cm. This modification greatly reduced the incidence of marginal ulceration, dumping, and nutritional deficiencies. However, this operation is still uncommon due to the perceived technical difficulty and risk of nutritional morbidity. This video demonstrates a standardized technique for this complex procedure.
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
F Corcione, M D'Ambra, U Bracale, S Dilillo, G Luglio
Surgical intervention
27 days ago
774 views
1 like
0 comments
23:20
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
P Agami, A Andrianov, M Baychorov, R Izrailov
Surgical intervention
27 days ago
608 views
6 likes
0 comments
17:23
Laparoscopic Beger procedure with Roux-en-Y hepaticojejunostomy
This is the case of a 49-year-old male patient presenting with recurrent intractable abdominal pain. The patient had a history of obstructive jaundice and underwent biliary decompression provided by a percutaneous cholecystostomy. CT-scan showed signs of chronic pancreatitis, multiple stones in the pancreatic parenchyma, a compressed portal vein and biliary obstruction. The patient underwent a laparoscopic duodenum-preserving pancreatic head resection (DPPHR) – a technique known as the Beger procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain, combined with portal and biliary compression caused by severe chronic pancreatitis. The surgical procedure preserves the stomach, the duodenum, and the biliary tree unlike standard duodenopancreatectomy (Whipple procedure), which is the other option for these patients. As Beger himself stated: “Preservation of the duodenum and the biliary system has major advantages for patients regarding short- and long-term outcome as compared to the Kausch-Whipple resection and pylorus-preserving resection”.
In this case, after completing the pancreatic head resection and fashioning the distal and proximal pancreaticojejunal anastomosis, a hepaticojejunostomy was performed. It was necessary due to the stenosis of the intrapancreatic segment of the common bile duct.
The purpose of this video is to demonstrate that the laparoscopic Beger procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay.
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.
Y Aawsaj, I Ibrahim, A Mitchell, A Gilliam
Surgical intervention
1 month ago
262 views
5 likes
1 comment
10:08
Laparoscopic common bile duct exploration using a disposable fiber-optic bonchoscope (Ambu® aScope™)
Background: Laparoscopic common bile duct (CBD) exploration can be performed following choledochotomy or via the trancystic approach. Laparoscopic CBD exploration is limited in some benign upper gastrointestinal units due to the cost of sterilization of the reusable choledochoscope.
We have recently published a case series confirming the safety and efficacy of the 5mm reusable bronchoscope for CBD exploration. This case series evaluates a single-use bronchochoscope (Ambu® aScope™) for laparoscopic CBD exploration.
Method: A retrospective study was conducted from January 2015 to December 2016. Data was collected from electronic records of the patients. All cases confirmed the presence of CBD stones using USS and MRCP. The disposable bronchoscope is introduced via an epigastric port. Choledochotomy is performed using a choledochotome, and a transcystic approach is used after cystic duct dilatation, if required. The Ambu® aScope™ 2 (Ambu UK Ltd, Cambridgeshire) is a sterile and single-use flexible bronchoscope, which is normally used by anesthesiologists for difficult tracheal intubation. A disposable bronchoscope is available in two sizes (3.8mm and 5mm). It is a one-piece unit with a single dimensional flexible tip manipulated with a handpiece (150-degree flex in the 5mm model and 130-degree flex in the 3.8mm model). There is a single instrument channel with a 2.2mm diameter, which allows for the passage of standard endoscopic baskets for CBD stone retrieval. The image is projected to a high-resolution 6.5” LCD screen with a resolution of 640x480 pixels. The bronchoscope handpiece includes a suction port, which is used as an irrigation source for CBD dilatation. It requires the use of a standard 3-way connector.
Results: Twenty nine patients had CBD exploration using the disposable bronchochoscope. There were 10 male and 19 female patients (median age: 42). Ten procedures were performed as emergencies and 19 were performed electively. All cases were managed laparoscopically except one, which was planned as an open procedure due to previous extensive open surgery.
Twenty eight patients had their CBD cleared using a disposable bronchoscope and two needed subsequent ERCP. Choledochotomy was performed in 15 patients and a transcystic approach was used in 6 patients. No T-tube was used in the laparoscopic cases. Two cases were performed as day case surgery. Median postoperative hospital stay was 2.5 days.
Conclusion: The disposable bronchoscope is a safe and effective instrument for CBD exploration, with results comparable to our previously published case series. It has guaranteed sterility and is cost-effective compared to the reusable bronchoscope, especially when initial capital outlay, sterile processing and maintenance costs are considered.