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Purpose: Difficulties at the beginning of the learning curve in minimally invasive surgery (MIS) can well be overcome by simulation outside the operating room. Despite a great number of available devices, standardized, structured, and validated training curricula for video simulators are scarce.Methods: The Lübeck Toolbox (LTB) video trainer provides six training modules and online video tutorials. Proficiency levels for the tasks were defined by performance analysis of MIS experts (n = 15). Mean values of the best performed repetitions were set as benchmarks for a validation study with n = 30 MIS novices and the learning curves calculated. The novices performed a cholecystectomy on a pig organ model before and after the curriculum which were analyzed using the GOALS score.Results: Benchmarks defined by expert performance for the task Nos. 1 to 6 were 72 s (± 8) (Pack Your Luggage), 49 s (± 9) (Weaving), 66 s (± 10) (Chinese Jump Rope), 89 s (± 28) (Triangle Cut), 138 s (± 44) (Hammer Cut), and 98 (± 22) (Suturing). The median numbers of required repetitions by the novices to reach the proficiency level were n = 42 (7-80), n = 26 (9-55), n = 32 (14-77), n = 44 (15-59), n = 19 (6-68), and n = 26 (15-60). These values were all located at the beginning of the plateau phase of the learning curves. GOALS score improved significantly after completion of the curriculum (18.0 (± 2.6) vs. 10.9 (± 1.6), p < 0.0001).Conclusion: The LTB curriculum constitutes a new highly standardized and proficiency level-based training program for basic skills in MIS. Transferability of the task content to a (sub)-realistic environment could be demonstrated. Still, future trials will have to further validate the effectiveness of the LTB curriculum. [ABSTRACT FROM AUTHOR]

Purpose: A perforated peptic ulcer can be managed laparoscopically in selected patients. The purpose of this study was to evaluate whether conversion of emergency laparoscopy is inferior to primary median laparotomy in terms of postoperative morbidity and mortality. Methods: We analyzed patients who underwent laparoscopic or open surgery for a perforated peptic ulcer at the Department of Surgery, University of Schleswig-Holstein, Campus Luebeck between January, 1996 and December, 2010. Perforations were graded according to the Boey classification, a preoperative risk-scoring system. Results: Conversion to laparotomy was necessary in 20 of the 45 patients who underwent laparoscopic surgery (CG); therefore, laparoscopic operations were completed in 25 patients (LG). The third patient cohort comprised 139 patients who underwent primary laparotomy (OG). Overall minor morbidity was significantly lower ( p = 0.048) in the LG patients than in the OG patients, whereas no significant differences were found in major morbidity and mortality, particularly between the OG and CG. Conclusion: Patients' suitability for laparoscopic management should be decided on according to Boey's clinical scoring system. Our findings demonstrated that conversion from laparoscopy to laparotomy was not associated with elevated postoperative morbidity or mortality versus initial laparotomy. Therefore, emergency operations may be commenced laparoscopically in selected patients, especially considering the postoperative advantages of this approach. [ABSTRACT FROM AUTHOR]

Aim The increasing experience within the area of laparoscopic procedures has paved the way for technically-complex procedures, such as distal pancreatectomy. In order to avoid complications associated with concomitant splenectomy, these procedures are increasingly performed with spleen preservation. A drawback is the low number of cases, which does not allow for an evidence-based comparison between laparoscopic and open procedures, and spleen-preserving and concomitant splenectomy procedures. Patients and Methods Between 2006 and 2010, all data for patients who underwent a laparoscopic distal pancreatectomy (LDP) at the Department of Surgery, University of Schleswig- Holstein, Luebeck, Germany, were collected are stored in a prospectively-maintained database. Patients with tumours in the pancreatic tail and body that did not exceed the level of the portal vein were included in this database. Results A total of 22 patients who underwent LDP could be included in the evaluation. Ten of those patients underwent a laparoscopic spleen-preserving distal pancreatectomy ( LSPDP), while the remaining 12 received an LDP with splenectomy ( LDPwS). The median operation time was 155 min (range: 98-253) for the LSPDP group, and 201 min (range: 60-310) for the LDPwS group ( P = 0.06). The median hospital stay was 8.5 days (range: 5-23) in the LSPDP group compared to 11 days (range: 4-41) in the LDPwS group ( P = 0.06). Pancreatic fistula occurred in two patients from each group. It caused an intraabdominal haemorrhage in one patient of the LSPDP group, which required re-laparoscopy. Two patients experienced subphrenic abscesses in the LDPwS group and were treated interventionally. Histological examination revealed six cystadenomas and five pseudocysts (maximum diameter: 7 cm) in the LDPwS group, and six neuroendocrine tumours (maximum diameter: 2 cm) in the LSPDP group. Conclusion LDP can be performed safely. The optic magnification provided by laparoscopy facilitates LSPDP, as dissection of the splenic vessels can be avoided. Although not significant, there was a trend towards reduced hospital stay and operating time for LSPDP. Oncologic outcomes and morbidity seem to not be inferior to open procedures. The size of the tumours and the peripancreatic, as well as paraneoplastic, tissue alterations determine the indication for splenectomy. [ABSTRACT FROM AUTHOR]

Purpose: For treatment of rectal prolapse, abdominal approaches are generally offered to younger patients, whereas perineal, less invasive procedures are considered more beneficial in the elderly. The aim of this study was to analyze whether laparoscopic resection rectopexy (LRR) is suitable for older patients. Patients/Methods: Patients who received LRR for rectal prolapse were selected from a prospective laparoscopic colorectal surgery database. Perioperative and long-term outcome were compared between patients <75 years old (group A) and ≥75 years old (group B). Results: Of 154 patients, 111 were in group A and 43 in group B. There was one conversion that occurred in group B. Overall mortality rate was 1.3% ( n = 2). Both patients were in group B (group B, 4.7%; p = 0.079). Differences in major and minor complications between the groups were not significant. Rates of improvement for incontinence were 62.7% (group A) and 66.7% (group B; p = 0.716); for constipation, the rates were 78.9% (group A) and 73.3% (group B; p = 0.832). All recurrences occurred in group A ( n = 10; overall, 10.3%; group A, 13%). After exclusion of patients who had previously received perineal prolapse surgery, recurrence rate was 3.3% overall (group A, 4.3%). Conclusions: This study supports the benefits of LRR for rectal prolapse in elderly patients. Age per se is not a contraindication for LRR. Elderly patients encounter complications slightly more frequently (although not statistically significant) than younger patients. Therefore, a very careful patient selection in the elderly is of paramount importance. However, the long-term outcome does not seem to differ between younger and elderly patients. [ABSTRACT FROM AUTHOR]

Laparoscopic liver resection has been performed mostly in centers with an extended expertise in both hepatobiliary and laparoscopic surgery and only in highly selected patients. In order to overcome the obstacles of this technique through improved intraoperative visualization we developed a laparoscopic navigation system (LapAssistent) to register pre-operatively reconstructed three-dimensional CT or MRI scans within the intra-operative field. After experimental development of the navigation system, we commenced with the clinical use of navigation-assisted laparoscopic liver surgery in January 2010. In this paper we report the technical aspects of the navigation system and the clinical use in one patient with a large benign adenoma. Preoperative planning data were calculated by Fraunhofer Me Vis Bremen, Germany. After calibration of the system including camera, laparoscopic instruments, and the intraoperative ultrasound scanner we registered the surface of the liver. Applying the navigated ultrasound the preoperatively planned resection plane was then overlain with the patient's liver. The laparoscopic navigation system could be used under sterile conditions and it was possible to register and visualize the preoperatively planned resection plane. These first results now have to be validated and certified in a larger patient collective. A nationwide prospective multicenter study (ProNavic I) has been conducted and launched. [ABSTRACT FROM AUTHOR]

Purpose: For a long time, laparoscopic pancreatic surgery was simply a matter of extended diagnostics without a simultaneous resection. Methods: The increase of experience in complex laparoscopic procedures combined with a substantial improvement in technical equipment has led to the possibility of performing pancreatic resections laparoscopically. Results: In contrast to the experimental laparoscopic pancreaticoduodenectomy, laparoscopic distal pancreatectomy has proved its safety and efficacy. Conclusion: In order to avoid splenectomy-associated complications, such as the OPSI-syndrome or formation of abscesses in the splenic area, the spleen-preserving technique is more favorable. Due to ischemia caused by the resection of the splenic vessels, as well as portal hypertension in the long-term follow-up, those vessels should remain untouched. The following article and video describe our approach for laparoscopic spleen-preserving distal pancreatectomy with sparing of the splenic vessels. [ABSTRACT FROM AUTHOR]

Introduction: A variety of surgical strategies have been suggested and many surgical techniques, both abdominal and perineal, have been introduced for treatment of rectal prolapse. All these techniques and approaches are based on the attempt to restore the normal anatomy and physiologic function. Methods: In 1992, Berman et al. published the first laparoscopically performed rectopexy. Meanwhile, many different minimally invasive procedures have been described. Throughout the past century, more than 100 different surgical techniques have been introduced to treat patients with rectal prolapse. Unfortunately, there is still lack of one generally accepted standard technique for the surgical treatment of rectal prolapse. Results and discussion: Our current data strongly supports laparoscopic resection rectopexy to be a safe, fast, and very effective procedure to improve function in patients with rectal prolapse. More evaluations of long-term outcome are needed that focus on each particular laparoscopic procedure to adequately compare different techniques. The indication to perform a laparoscopic resection rectopexy in patients with a previous perineal procedure and a recurrent prolapse should be stated critically because these patients seem to have a high risk to develop yet another recurrence. [ABSTRACT FROM AUTHOR]

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk for perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. Between January 1993 and December 2004, more than 2,500 endoscopic polypectomies were performed at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Germany. In patients which could not be treated by endoscopic polypectomy due to size, location, and/or risk of complications, a laparoscopic colorectal resection was performed. All data were prospectively assessed in our “colorectal resection” database. The database analysis revealed 58 patients with endoscopically not resectable colorectal polyps who underwent a laparoscopic colorectal resection (intend to treat). In 54 patients, the operative procedure could be finished by the laparoscopic approach (study population). The conversion rate was 6.9% (four of 58). An ileocolic resection was performed in 20 patients (37.0%), and 14 patients (25.9%) underwent an anterior rectal resection. A right colectomy was necessary in 12 patients (22.2%), and six patients (11.1%) underwent a sigmoid resection. In the remaining two patients, a left colectomy and a resection of the transverse colon were performed. Intra- and postoperative complications occurred in five patients (9.3%). Perioperative mortality was not registered. The histopathological work-up revealed benign disease in all cases. Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of benign colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps enriches the therapeutic spectrum. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. This study aimed to develop a perfusable ex vivo tumor-mimic model for laparoscopic radiofrequency ablation training.Methods: After rinsing the prepared liver vessels with anticoagulants, porcine livers were perfused. Tumor-mimics were created by injecting a mixture consisting of 3% agarose, 3% cellulose, 7% glycerol, and 0.05% methylene blue, creating hyperechoic lesions in ultrasound. Heparinized porcine blood was used as perfusion medium. Continuous perfusion of the porcine liver was provided by connection of a pump system to the portal vein and the vena cava inferior. Laparoscopic RFA techniques were taught using a laparoscopic pelvi-trainer.Results: A total of 30 laparoscopic ablations were performed in four porcine livers. The simulated "tumors" were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. In addition, color duplex ultrasound showed clear signals indicating for a sufficient liver perfusion.Conclusion: Laparoscopic RFA requires advanced laparoscopic ultrasound skills for an accurate placement of the RFA probe. The perfused tumor-mimic model presented is a safe, easy, effective, and economic method to improve and train laparoscopic RFA skills on porcine liver tissue. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic radiofrequency ablation is safe, practicable, and combines minimally invasive surgery with the advantages of laparotomy. However, application of the laparoscopic freehand puncture is restricted because of capnoperitoneum and the consequent fixation of the needle on two different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve precision. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases. Therefore we present a new navigation tool for laparoscopic interventions. Materials and Methods: The US Guide 2000 (Ultra Guide, Tirat Hacarmel, Israel) is an independent navigation system compatible with all ultrasound machines and has six degrees of freedom. After proper evaluation of this system under operating room conditions during transcutaneous radiofrequency ablation, we used this technique in laparoscopic radiofrequency ablation. A special adapter was developed to attach the ultrasound-based navigation system to a laparoscopic ultrasound probe. After calibrating the system with an ultrasound phantom, laparoscopic navigation in a liver organ model was studied. Results: Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Anatomic landmarks in the liver could be safely reached. No interaction between the navigation system and the laparoscopic ultrasound probe or operating instruments was observed. Conclusion: Our preliminary results show the feasibility of this technique in laparoscopic radiofrequency ablation. The use of an ultrasound-based laparoscopic inline navigation system offers the possibility of out-of-plane needle placement and could combine the flexibility of freehand puncture with the accuracy of a canal for puncture. This could increase the safety and accuracy of punctures. [ABSTRACT FROM AUTHOR]

Postoperative lymphoceles after renal transplantation appear in up to 18% of patients, followed by individual indisposition, pain or impaired graft function. Therapeutic options are percutaneous drainage, needle aspiration with sclerosing therapy, or internal surgical drainage by conventional or laparoscopic approach. The laparoscopic procedure offers short hospitalisation time and quick postoperative recovery. From 1993 to 1997, 16 patients underwent laparoscopic fenestration of a post-renal transplant lymphocele, and were presented in a retrospective analysis. Three patients have had previous abdominal surgery. Following preoperative ultrasound and CT scan, 16 patients underwent laparoscopic drainage after drainage and staining of the lymphocele with methylene blue. No conversion was necessary. Mean operation time was 42 min, no intraoperative complications were seen. Oral nutrition and immunosuppression were continued on the day of surgery, and patients were discharged between the 2nd and 5th (median hospital stay 3.3 d) day after surgery. No recurrence was evident in a follow-up time of 15–54 months (median 31.4 months). Renal function remained unchanged in all patients postoperatively. [ABSTRACT FROM AUTHOR]

PURPOSE: The need for a conversion is a problem inherent in laparoscopic surgery. The present study points up the significance of conversion for the results obtained with laparoscopic colorectal surgery and identifies the risk factors that establish the need for conversion. METHOD: The study took the form of a multicentric, prospective, observational study within the Laparoscopic Colorectal Surgery Study Group. A total of 33 institutions in Germany, Austria, and Switzerland participated. The study period was 3.5 years. Cases were documented with the aid of a standardized questionnaire. RESULTS: Within the framework of the Laparoscopic Colorectal Surgery Study Group, a total of 1,658 patients were recruited to a multicenter study over a period of three and one-half years (from August 1, 1995 to February 1, 1999). The observed conversion rate was 5.2 percent (n = 86). The patients requiring a conversion were significantly heavier (body mass index, 26.5 vs. 24.9) than those undergoing pure laparoscopy. Resections of the rectum were associated with a higher risk for conversion (20.9 vs. 13 percent). Intraoperative complications occurred significantly more frequently in the conversion group (27.9 vs. 3.8 percent). The duration of the operation was significantly increased after conversion in a considerable proportion of the procedures performed. Postoperative morbidity (47.7 vs. 26.1 percent), mortality (3.5 vs. 1.5 percent), recovery time, and postoperative hospital stay were all negatively influenced by conversion, in part significantly. Institutions with experience of more than 100 laparoscopic colorectal procedures proved to have a significantly lower conversion rate than those with experience of fewer than 100 such interventions (4.3 vs. 6.9 percent). CONCLUSION: Although, of itself, conversion is not considered to be a complication of laparoscopic surgery, it is true that the postoperative course after conversion is associated with appreciably poorer results in terms of morbidity, mortality, convalescence, blood transfusion requirement, and postoperative hospital stay. The importance of experience in laparoscopic surgery can be demonstrated on the basis of the conversion rates. Careful patient selection oriented to the experience of the surgeon is required if we are to keep the conversion, morbidity, and mortality rates of laparoscopic colorectal procedures as low as possible. [ABSTRACT FROM AUTHOR]

PURPOSE: Although laparoscopic colorectal surgery is attracting ever more attention, its use for curative treatment of colorectal carcinoma in particular continues to be controversial. The present study was an attempt to analyze the results of the perioperative course, oncologic quality, and preliminary long-term results. METHOD: The data considered here were collected within the framework of a prospective, observational study initiated on August 1, 1995, and involving a total of 18 institutions in Germany and Austria. At the end of three years, the results are now being presented selectively, i.e., focusing only on abdominoperineal resection. RESULTS: A total of 116 patients underwent laparoscopic abdominoperineal resections, 98 (84.5 percent) of which were performed with curative intent. The mean operating time was 226 (confidence interval, 140-365) minutes. Seven patients (6 percent) experienced an intraoperative complication, which in more than one-half of the cases was a vascular injury involving the presacral venom plexus; the conversion rate was 3.4 percent. Postoperatively, 40 patients developed 97 complications--including those of a very minor nature--giving an overall morbidity rate of 34.4 percent. Reoperation in six patients (5.2 percent) had to be performed for an afterbleed in one-half of the cases and ileus in the other one-half. Postoperative mortality was a low 1.7 percent. In most of the curative resections, an oncologically radical operation with high transection of the inferior mesenteric artery and a complete dissection of the pelvis down to the floor was performed. The median number of lymph nodes investigated was 11.5, and there was wide fluctuation in the numbers among the individual institutions. Tumor cell dissemination occurred intraoperatively in five patients. In the meantime, 79 patients (81 percent) underwent at least one follow-up examination, the mean follow-up period being 491 days. Seven patients developed a local recurrence, and a further six patients developed distant metastases. For recurrence-free survival rate, the Kaplan-Meier estimation calculated a probability of 71 percent. CONCLUSION: Not all of the reservations about laparoscopic abdominoperineal resection, in particular with regard to resection with curative intent, have yet been eliminated. The present study does, however, show that a laparoscopic approach can in principle meet oncologic requirements of radicality and, with regard to the postoperative course, is associated with considerable benefits to the patient. [ABSTRACT FROM AUTHOR]