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Abstract: Background: Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy. Methods: A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy. Results: The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25–93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention. Conclusion: The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Abstract: Background: Bowel anastomosis is one of the most challenging and difficult tasks to perform during natural orifice translumenal endoscopic surgery (NOTES). The difficulty is mainly due to the technical limitations of the endoscopic instruments available. Currently, endoscopic clips, T-bar sutures, or cumbersome suturing devices are used. A dual-lumen NOTES approach can facilitate bowel resection in a pig model by allowing the use of laparoscopic staplers through the rectum. Methods: Acute studies were performed on four 40-kg pig models. The dual-lumen NOTES approach was used to perform small bowel resection and anastomosis. An endoscope was passed into the stomach and pushed through the stomach wall into the peritoneal cavity (first lumen), and a 12-mm trocar was placed through the anterior rectal wall, allowing access to the peritoneum (second lumen). Handling of the bowel, resection, and anastomosis were performed using endoscopic instruments through the gastric lumen and laparoscopic instruments through the rectal lumen. The resected small bowel then was removed through the rectum. Results: Small bowel resection and anastomosis was successfully completed in all four animals using the dual-lumen NOTES approach. The laparoscopic stapler was used one more time to close the gastrotomy through the rectal port. At autopsy, intact suture lines were noted at the bowel anastomosis and at the stomach, with no evidence of leak from either site. Conclusions: Performing a sutured anastomosis in NOTES is complex and time consuming. The use of stapling devices designed for laparoscopic procedures greatly facilitates gastrointestinal tract operations in NOTES. Using both the upper and lower gastrointestinal tract as entry sites for NOTES eliminates some of the current technical limitations of these procedures.

Carbon dioxide (CO2) pneumoperitoneum has been shown to attenuate the inflammatory response after laparoscopy. This study tested the hypothesis that abdominal insufflation with CO2improves survival in an animal model of sepsis and investigated the associated mechanism.The effect of CO2, helium, and air pneumoperitoneum on mortality was studied by inducing sepsis in 143 rats via intravenous injection of lipopolysaccharide (LPS). To test the protective effect of CO2in the setting of a laparotomy, an additional 65 animals were subjected to CO2pneumoperitoneum, helium pneumoperitoneum, or the control condition after laparotomy and intraperitoneal LPS injection. The mechanism of CO2protection was investigated in another 84 animals. Statistical significance was determined via Kaplan– Meier analysis for survival and analysis of variance (ANOVA) for serum cytokines.Among rats with LPS-induced sepsis, CO2pneumoperitoneum increased survival to 78%, as compared with using helium pneumoperitoneum (52%; p< 0.05), air pneumoperitoneum (55%; p= 0.09), anesthesia control (50%; p< 0.05), and LPS-only control (42%; p< 0.01). Carbon dioxide insufflation also significantly increased survival over the control condition (85% vs 25%; p< 0.05) among laparotomized septic animals, whereas helium insufflation did not (65% survival). Carbon dioxide insufflation increased plasma interleukin-10 (IL-10) levels by 35% compared with helium pneumoperitoneum (p< 0.05), and by 34% compared with anesthesia control (p< 0.05) 90 min after LPS stimulation. Carbon dioxide pneumoperitoneum resulted in a threefold reduction in tumor necrosis factor-α (TNF-α) compared with helium pneumoperitoneum (p< 0.05), and a sixfold reduction with anesthesia control (p< 0.001).Abdominal insufflation with CO2, but not helium or air, significantly reduces mortality among animals with LPS-induced sepsis. Furthermore, CO2pneumoperitoneum rescues animals from abdominal sepsis after a laparotomy. Because IL-10 is known to downregulate TNF-α, the increase in IL-10 and the decrease in TNF-α found among the CO2-insufflated animals in our study provide evidence for a mechanism whereby CO2pneumoperitoneum reduces mortality via IL-10-mediated downregulation of TNF-α.

Laparoscopic surgery preserves the immune system and has anti-inflammatory properties. CO2pneumoperitoneum attenuates lipopolysaccharide (LPS)-induced cytokine production and increases survival. We tested the hypothesis that CO2pneumoperitoneum mediates its immunomodulatory properties via stimulation of the cholinergic pathway.In the first experiment, rats (n= 68) received atropine 1 mg/kg or saline injection 10 min prior to LPS injection and were randomization into four 30-min treatment subgroups: LPS only control, anesthesia control, CO2pneumoperitoneum, and helium pneumoperitoneum. In a second experiment, rats (n= 40) received atropine 2 mg/kg or saline 10 min prior to randomization into the same four subgroups described previously. In a third experiment, rats (n= 96) received atropine 2 mg/kg or saline 10 min prior to randomization into eight 30-min treatment subgroups followed by LPS injection: LPS only control; anesthesia control; and CO2or helium pneumoperitoneum at 4, 8, and 12 mmHg. In a fourth experiment, rats (n= 58) were subjected to bilateral subdiaphragmatic truncal vagotomy or sham operation. Two weeks postoperatively, animals were randomized into four 30-min treatment subgroups followed by LPS injection: LPS only control, anesthesia control, CO2pneumoperitoneum, and helium pneumoperitoneum. Blood samples were collected from all animals 1.5 h after LPS injection, and cytokine levels were determined by enzyme-linked immunosorbent assay.Serum tumor necrosis factor-α (TNF-α) levels were consistently suppressed among the saline–CO2pneumoperitoneum groups compared to saline–LPS only control groups (p< 0.05 for all four experiments). All chemically vagotomized animals had significantly reduced TNF-α levels compared to their saline-treated counterparts (p< 0.05 for all), except among the CO2pneumoperitoneum-treated animals. Increasing insufflation pressure with helium eliminated differences (p< 0.05) in TNF-α production between saline- and atropine-treated groups but had no effect among CO2pneumoperitoneum-treated animals. Finally, vagotomy (whether chemical or surgical) independently decreased LPS-stimulated TNF-α production in all four experiments.CO2pneumoperitoneum modulates the immune system independent of the vagus nerve and the cholinergic pathway.

We have previously reported the feasibility of diagnostic and therapeutic peritoneoscopy including liver biopsy, gastrojejunostomy, and tubal ligation by an oral transgastric approach. We present results of per-oral transgastric splenectomy in a porcine model. The goal of this study was to determine the technical feasibility of per-oral transgastric splenectomy using a flexible endoscope.We performed acute experiments on 50-kg pigs. All animals were fed liquids for 3 days prior to procedure. The procedures were performed under general anesthesia with endotracheal intubation. The flexible endoscope was passed per orally into the stomach and puncture of the gastric wall was performed with a needle knife. The puncture was extended to create a 1.5-cm incision using a pull-type sphincterotome, and a double-channel endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated with air through the endoscope. The spleen was visualized. The splenic vessels were ligated with endoscopic loops and clips, and then mesentery was dissected using electrocautery.Endoscopic splenectomy was performed on six pigs. There were no complications during gastric incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using commercially available devices and endoscopic accessories.Transgastric endoscopic splenectomy in a porcine model appears technically feasible. Additional long-term survival experiments are planned.

Background: Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution’s series of 30 robotic adrenalectomies, and evaluates the procedure’s safety, efficacy, and cost. Methods: Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period. Results: Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy ($12,977) were not significantly different than charges for traditional laparoscopic ($11,599) or open adrenalectomy ($14,600). Conclusions: Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.

Abstract

Abstract: Background: We examined the effects of an identical period of pneumoperitoneum applied at three different time points after lipopolysaccharide (LPS) challenge. Two different insufflation gases were also compared. Methods: Male rats (n=70) were injected intravenously with 1 mg/kg of LPS (time 0). The time relationship between a 1.5-h period of insufflation and initial LPS stimulation was the experimental variable. All rats were killed 6 h after injection. CO2 and helium insufflation were investigated. Ten control rats received LPS only. Serum interleukin-6 (IL-6) levels were determined by enzyme-linked immunosorbent assay (ELISA). Hepatic expression of α2-macroglobulin, β-fibrinogen, and metallothionein were measured by Northern blot analysis. Statistical analysis was performed using one-way analysis of variance (ANOVA). Results: Expression of α2-macroglobulin mRNA was lower in CO2 groups compared to the control group (p<0.05 at time 120 and 270). β-Fibrinogen message was diminished in CO2 0 and 120 groups compared to control. Serum levels of IL-6 and expression of metallothionein mRNA did not show significant differences between groups. Conclusions: These findings suggest that CO2 pneumoperitoneum downregulates the inflammatory response to LPS challenge. Start time of CO2 insufflation does not appear to alter hepatic expression of acute phase genes. The mechanism of α2-macroglobulin downregulation does not appear to be due to IL-6.

Background: We developed a tool, the Surgical Recovery Index (SRI), specifically to measure surgical recovery. We then tested the ability of the SRI to discriminate between patients undergoing laparoscopic (L) operations and patients undergoing open (O) operations. Methods: We surveyed 50 patients drawn from the practice of a single surgeon to establish the types of activities that define recovery from surgery. Their responses were used to construct the SRI, a self-administered questionnaire using a numerical rank-order scale format. A total score and two subscale scores (pain and activity resumption) were calculated for each patient. Mean and median scores were calculated for each patient group. Chi-square tests were used to evaluate group differences for individual questions; t-tests and Kruskal-Wallis tests were used to evaluate group differences for summary scores. Results: In all, 149 patients completed the SRI (60 L, 89 O). Cronbach’s alphas were 0.91 for pain questions and 0.97 for activity resumption questions. The scores for pain level with time (L vs O, 1–10 scale) at week 1 (mean, 4.42 vs 6.06, p = 0.03), week 2 (mean, 3.08 vs 4.38, p = 0.04), week 3 (mean, 2.03 vs 3.16, p = 0.02), and week 4 (mean, 1.18 vs 2.28, p = 0.00) all favored laparoscopy. The scores for pain level with activity (L vs O, 1–3 scale) for getting out of bed (mean, 1.62 vs 1.85, p = 0.04), hygiene activities (mean, 1.38 vs 1.65, p = 0.04), and computer work (mean, 1.15 vs 1.56, p = 0.00) were all significant, although pain with exertion (mean, 1.87 vs 2.10, p = 0.13) was not. Delay until return to activity (L vs O, 1–4 scale) was significant, favoring L for 13 activities (all p < 0.02), but it was not significant for three activities. The scores for subscales for pain (L vs O, mean, 20.7 vs 34.4, respectively) and activity resumption delay (mean, 44.3 vs 62.0), as well as total scores (mean, 33.0 vs 49.0), were also significant (all p = 0.00). The same differences were observed when median scores were considered instead of mean scores, suggesting the robustness of the group difference. Conclusions: Reduction in time to full recovery (i.e., pain resolution and activity resumption) is a fundamental advantage of laparoscopic surgery, yet there are no tools designed to specifically measure recovery. These data provide preliminary evidence of the reliability and validity of the new SRI as a measure of recovery in patients undergoing laparoscopic operations.

Background: The Academic Robotics Group prospectively studied 211 robotically assisted operations to assess the safety and utility of robotically assisted surgery. Methods: All operations took place at one of four member institutions between June 2000 and June 2001 using the recently FDA-approved daVinci robotic system. A variety of procedures were undertaken, including antireflux surgery (69), cholecystectomy (36), Heller myotomy (26), bowel resection (17), donor nephrectomy (15), left internal mammery artery mobilization (14), gastric bypass (seven), splenectomy (seven), adrenalectomy (six), exploratory laparoscopy (three), pyloroplasty (four), gastrojejunostomy (two), distal pancreatectomy (one), duodenal polypectomy (one), esophagectomy (one), gastric mass resection (one), and lysis of adhesions (one). Results: Average operating room time was 188 min (range 45 to 387, SD = 83), surgical time 143 min (range 35 to 462, SD = 63), and robot time 90 min (range 12 to 235, SD = 47). Median length of stay was 1 day (range 0 to 37). There were 8 (4%) technical complications during procedures, five minor (four hook cautery dislodgement, one slipped robotic trocar) and three major (system malfunctions, two of which required conversion to standard laparoscopy). In all cases, technical problems caused only delay, without apparent altered outcome. There were medical/surgical complications in nine patients (4%). Six (3%) were considered major, including one death unrelated to the robotic procedure. Conclusions: The results of robotic-assisted surgery compare favorably with those of conventional laparoscopy with respect to mortality, complications, and length of stay. Robotic-assisted surgery is safe and effective and is a new reality for American surgery. The role of these devices in surgery will expand as the technology evolves.

The surgical creation of an artificial opening in the wall of the ileum, the last section of the small intestine, through which fecal material may be emptied, is known as ileostomy. Usually a section of the inside of the bowel is pulled through the opening (eversion) to form a nipple onto which an appliance for the removal of waste can be attached. Turning a normal segment of the intestines inside out may not be a problem, but forceful attempts to manipulate a diseased section of intestine may damage that tissue. To prevent this, a technique was developed according to the guy rope principle to evert the intestine. This technique can also be used to evert healthy sections of intestine in creating a permanent ileostomy.

Abstract: Background: Single-incision laparoscopic surgery (SILS) has been proposed as a minimally invasive technique with the advantages of smaller external scars and reduced pain. Furthermore, usage of the flexible endoscope for SILS in lieu of the standard laparoscope provides distinct visualization advantages. This video shows a single-incision cholecystectomy performed using a single incision placed through the umbilicus. Methods: A 39-year-old woman with chronic symptomatic cholelithiasis was enrolled under institutional review board protocol to undergo SILS. She had previously undergone a laparoscopic tubal ligation. A single incision was made using the previous umbilical incision, and the abdomen was entered in an open fashion. The flexible endoscope was placed directly through the fascial incision, with two 5-mm ports on either side. Adhesions to the gallbladder were taken down with the harmonic scalpel. Dissection proceeded using an articulating grasper and retraction to identify the cystic duct and artery. The duct and artery were serially clipped and divided. The cystic duct was additionally secured with a loop ligature. The gallbladder was cauterized from the liver bed using the articulating hook cautery and extracted through the wound. Results: The final incision placed at the base of the umbilicus was 7 mm long. The operative time was 58 min, with minimal blood loss recorded. The patient was discharged home on the day of the procedure and did not experience any postoperative complications. Conclusions: Single-incision cholecystectomy can be performed safely through one incision in the umbilicus, optimizing cosmesis. Substitution of the flexible endoscope for the standard laparoscope allows many greater degrees of visualization in SILS. This allows clear identification of the biliary ductal anatomy, allowing cholecystectomy to proceed safely. Placement of the endoscope directly through the incision decreases the profile of ports through the incision and increases maneuverability.