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Background: Laparoscopic distal gastrectomy (LDG) is a widely used minimally invasive surgery. Following LDG, Billroth-I (B-I) provides physiological reconstruction by preserving the duodenal passage but results in a high incidence of reflux esophagitis that decreases postoperative quality of life. Because of this, Roux-en-Y (R-Y) reconstruction is often considered the first choice after LDG. However, very few studies have investigated differences in physiological function between B-I and R-Y after LDG. We hypothesized that B-I would outperform R-Y in clinical and physiological outcomes, including nutrition parameters., Methods: We compared hemoglobin, ferritin, serum iron, Vitamin B12, 25(OH)-Vitamin D (V-D), body weight, and gastric emptying after LDG in patients with either B-I or R-Y reconstruction., Results: The levels of hemoglobin in the B-I group were significantly higher than that in the R-Y group at all time points later than 6 months postsurgery. The ferritin levels were significantly higher in the B-I group at all time points later than 9 months postsurgery. The concentration of serum V-D in the B-I group was significantly higher than that in the R-Y group at 1 year 6 months, 1 year 9 months, and 2 years after surgery. Gastric emptying in the R-Y group was significantly slower than in the B-I group., Conclusions: Our data indicate that B-I leads to less postsurgical iron deficiency anemia and V-D deficiency compared with R-Y reconstruction. Furthermore, gastric emptying was preserved in B-I reconstruction compared with R-Y reconstruction. In conclusion, after LDG, B-I reconstruction seems to cause fewer nutritional complications than R-Y reconstruction.

Laparoscopic liver resection (LLR) is now performed widely, but is difficult to accomplish in some anatomical locations, such as the posterosuperior segments (S7 and S8) and caudate lobe (S1). An international survey revealed that lesions in these locations are less frequently indicated for LLR than those in other segments. Recent reports from experienced centers document several case series and present technical tips for treating such lesions. The lateral approach using intercostal (transdiaphragmatic) trocars was reported to be useful for lesions in the posterosuperior segments with a semi- to full-decubitus position. The thoracoscopic approach was also reported to be useful for lesions just under the diaphragm dome, but the tumor location and patient selection should be considered carefully because pneumoperitoneum pressure and Pringle's maneuver cannot be applied. Several case series have described the feasibility of LLR for caudate lobe lesions, with similar operative outcomes to lesions in the posterosuperior segments, but this demands technical expertise. The caudal view of laparoscopy is advantageous for approaching the caudate lobe. We conducted a systematic review to clarify the feasibility of LLR for difficult lesions and discuss its current and future status.

Background: Esophagogastrostomy after proximal gastrectomy (PG) is a simple and safe reconstruction, but it leads to a high incidence of reflux esophagitis and impairs postoperative quality of life. We have already reported gastric tube (GT) reconstruction after PG and performed it on more than 100 patients. No studies have reported long-term outcomes after PG-GT. The aim of this study was to investigate long-term outcomes, including nutrition indices, such as body weight, serum albumin, total protein, hemoglobin, and ferritin after PG, and observe recovery of upper gastrointestinal tract motility., Methods: We analyzed body weight loss and laboratory findings at our outpatient clinic at 1, 6, 12, 24, 36, 48, and 60 months postoperatively. Manometric recording was carried out at 1, 2, 3, 4, and 5 years after surgery., Results: The percentage change in body weight in the PG-GT group was significantly larger than that in the PG-JI and TG-RY groups at 2.5, 3, 4, and 5 years after surgery. The levels of hemoglobin and ferritin in the PG-GT and PG-JI groups were significantly higher than those in the TG-RY group at all time points except 6 months after surgery. In the fasted state, the phase III originated at the gastric tube was propagated to the duodenum 3 years after surgery. In the fed state, phasic contractions of the duodenum were in harmony with gastric tube contractions 3 years after surgery., Conclusions: PG-GT is the least invasive procedure, and restoration of gastrointestinal motilities in the gastric tube and duodenum may ameliorate body weight loss and nutritional status, including anemia, in patients after PG.

Background: Pheochromocytomas are rare catecholamine-producing neuroendocrine tumors. Hypertension secondary to pheochromocytoma is often paroxysmal, and patients occasionally present with sudden attacks of alternating hypertension and hypotension. Spontaneous, extensive necrosis within the tumor that is associated with catecholamine crisis is an infrequent complication of adrenal pheochromocytoma, but its pathogenesis remains unclear., Case Presentation: A 69-year-old Japanese man developed acute-onset episodic headaches, palpitations, and chest pains. During the episodes, both marked fluctuations in blood pressure (ranging from 40/25 to 300/160 mmHg) and high plasma levels of catecholamines were found simultaneously. Radiological findings indicated a 4-cm left adrenal pheochromocytoma. These episodic symptoms disappeared within 2 weeks with normalization of plasma catecholamine levels. Two months later, the patient underwent adrenalectomy. Microscopic examinations revealed pheocromocytoma with a large central area of coagulative necrosis. The necrotic material was immunohistochemically positive for chromogranin A. Granulation tissue was adjacent to the necrotic area, accompanied by numerous hemosiderin-laden macrophages and histiocytes with vascular proliferation. Viable tumor cells, detected along the periphery of the tumor, demonstrated pyknosis, and the Ki-67 labeling index was 2 % in the hot spot. No embolus or thrombus formation was found in the resected specimen harboring the whole tumor. The Pheochromocytoma of the Adrenal gland Scaled Score was 2 out of 20. The patient's postoperative course was unremarkable for > 7 years., Conclusions: Presumed causal factors for the extensive necrosis of adrenal pheochromocytoma in previously reported cases include hemorrhage into the tumor, hypotension induced by a phentolamine administration, embolic infarction, high intracapsular pressure due to malignant growth of the tumor, and catecholamine-induced vasoconstriction. In the present case, histopathological and clinical findings suggest that under conditions of chronic ischemia due to catecholamine-induced vasoconstriction, an acute infarction occurred after sudden attacks of alternating hypertension and hypotension. Over the subsequent 2 weeks, repetitive massive release of catecholamines from the infarcts into circulation likely accelerated infarction progression by causing repeated attacks of alternating hypertension and hypotension and resulted in the large necrosis. This case highlights the need for physicians to consider acute spontaneous tumor infarction accompanying episodic catecholamine crisis as a rare but severe complication of pheochromocytoma.

Background: Although laparoscopic liver resection (LLR) is now considered a standard procedure in peripheral segments, there are few reports on laparoscopic segment 1 (Sg1) resection. The aim of this study was to assess both safety and feasibility of Sg1 LLR., Methods: From 2000 to 2014, all patients who underwent LLR were identified from a prospective database. Patients with resection of Sg1 (Sg1 group) were compared with those with resection of anteroinferior segments (AI group: segments 3, 4b, 5, 6) or posterosuperior segments (PS group: segments 4a, 7, 8), in terms of tumor characteristics, surgical treatment, and short-term outcomes., Results: There were 15, 151, and 67 patients in Sg1, AI, and PS groups. Tumor size and tumor number were similar between the three groups (p = 0.139, p = 0.102). Operative time was significantly shorter in Sg1 (150 min) and AI group (135 min) compared with PS group (180 min) (p = 0.021). Median blood loss was notably higher in PS group (140 ml) compared with Sg1 group (75 ml) and AI group (10 ml) (p = 0.001). No mortality was observed in all groups. Postoperative complication rate was 20.0 % with Sg1 group, 14.6 % with AI group, and 20.9 % with PS group (p = 0.060). The rate of major complication was significantly higher in Sg1 group (13.3 %) and PS group (11.9 %) compared with AI group (4.0 %) (p = 0.042). Resection margins were clear in all Sg1 and PS group patients, whereas two (1.3 %) patients in AI group had R1 margins (p = 0.586)., Conclusion: The laparoscopic approach of isolated resection located in the caudate lobe is a feasible and curative surgical option in selected patients.

Background: Some laparoscopic gastrectomy (LG) patients are postoperatively diagnosed with locally advanced disease or lymph node metastasis. Few reports have reviewed the outcomes or validity of LG in such patients., Methods: We retrospectively compared the outcomes of LG for gastric cancer patients postoperatively diagnosed with T3 (subserosal invasion) or higher or N1 (metastasis in 1-2 regional lymph nodes), or higher disease (n = 36), with open gastrectomy (OG) for c-stage I gastric cancer patients (n = 62)., Results: D1 plus lymph node dissection was performed in all patients in the LG group. Blood loss was significantly lower in the LG group than in the OG group (P < 0.0010). The mean postoperative hospital stay duration was significantly shorter in the LG group than in the OG group (P = 0.0016). In the LG group, lymph node metastasis occurred in 1 patient, peritoneal dissemination in 2 patients, and liver metastasis in 1 patient. The 5-year survival rate did not significantly differ between the LG and OG groups (90.00 vs. 94.52 %; P = 0.6517)., Conclusions: Given the similarity in long-term outcomes between the LG and OG groups, LG is an appropriate indication for gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis.

Background: The primary aim of this study was to examine the motor activity (motility) of a gastric tube after laparoscopic-assisted proximal gastrectomy (LPG). A secondary objective was to ascertain whether a correlation exists between gastric tube motor activity and reflux esophagitis., Patients and Methods: A total of 41 patients who underwent LPG for early gastric cancer were studied. The motility of the gastric tube and the status of reflux esophagitis were evaluated. Manometric recording was performed 2 weeks and 1 year after surgery., Results: In a fasting state, the motilities of the distal gastric tube and duodenum recovered within 1 year after surgery but that of the proximal gastric tube did not recover. Improvement of the motility of the gastric tube was associated with a decreased number of patients with reflux esophagitis 1 year after surgery. In patients with reflux esophagitis, the motility of the distal gastric tube was significantly lower than that in patients without reflux esophagitis., Conclusion: After LPG, the motility of the gastric tube recovered, and the incidence of reflux esophagitis decreased with time, in parallel to recovery of gastrointestinal motility., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Our report concerns a 64-year-old man with a small-intestinal gastrointestinal stromal tumor (GIST), which was successfully treated with single-incision laparoscopic surgery (SILS). Small-bowel endoscopy detected a submucosal tumor located approximately 10 cm from the ligament of Treitz in the wall of the proximal jejunum. Contrast-enhanced computed tomography revealed a tumor (diameter, 4 cm) containing high- and low-density areas in the proximal jejunum. On 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET), the tumor demonstrated intense FDG uptake (maximum standard uptake value, 3.82), whereas it displayed high signal intensity on diffusion-weighted magnetic resonance images. No metastatic lesions were observed. The patient was diagnosed with a jejunal GIST. Wedge resection of the jejunum was performed using the SILS procedure. The tumor was histopathologically diagnosed as a low-grade malignant GIST. SILS is a useful resection technique for small-intestinal GIST.

We report on a case of ileal lipoma that prolapsed into the ascending colon and was resected by laparoscopy-assisted surgery. A 31-year-old male Japanese patient was admitted to our hospital because of hematochezia and anemia. Colonoscopy revealed a pedunculated polyp arising from the ileum. The surface was covered with slightly edematous mucosa. Abdominal computed tomography showed a low-density mass in the ascending colon. A diagnosis of pedunculated ileal lipoma with intussusception was made, and laparoscopy-assisted surgery was performed. The intussusception was reducted by resection of the lipoma. The surgical specimen was a 40 × 30 × 25 mm round tumor with a long stalk 11 cm in length. Microscopic examination of the specimen revealed ileal lipoma. Laparoscopic surgery is recommended for benign tumors of the small intestine because it is minimally invasive.

Background and Study Aims: Endoscopic submucosal dissection (ESD) is increasingly being used to resect early colorectal carcinoma, despite the technical difficulties associated with the procedure. Laparoscopic-assisted colorectal surgery (LAC) is an alternative to open surgery for colorectal cancers, and ESD was recently introduced as another alternative. In this study, we compared ESD with LAC as minimally invasive treatments for early colorectal cancer., Patients and Methods: The study included 589 patients (297 patients with colorectal intramucosal or slightly submucosal invasive cancers undergoing ESD; 292 patients with T1 colorectal cancers undergoing LAC) who were treated at National Cancer Center Hospital in Tokyo, Japan, between January 1998 and September 2008. The clinical outcomes of ESD and LAC were evaluated retrospectively and compared on the basis of data that were originally collected prospectively., Results: In the ESD group, mean tumor size was 37 mm, mean procedure time was 106 minutes, and the en bloc and curative resection rates were 87 % and 80 %, respectively. There were 14 perforations (4.7%) and 5 cases of postprocedure bleeding (1.7%); all complications were successfully managed endoscopically except for one of the perforations, which required emergency surgery. In the LAC group, mean tumor size was 20 mm, mean operation time was 206 minutes, and complications included 31 wound infections, 2 pelvic abscesses, 3 anastomotic leakages, and 1 anastomotic bleed. Stomas were necessary in 93 % of the patients who underwent LAC for rectal cancers located below the peritoneal reflection., Conclusions: ESD was associated with a lower complication rate than LAC, with favorable en bloc and curative resection rates. The safety profile and possibility of curative treatment with colorectal ESD provide advantages for the treatment of early colorectal cancers with nul risk of lymph node metastasis., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: To demonstrate the feasibility of solo laparoscopic colorectal resection (SLCR) is performed by the laparoscopist only. This study is an evaluation of the feasibility of SLCR for patients with colorectal cancer., Methodology: Fifty-one consecutive patients received SLCR from 2008 to 2009. The procedure was performed with four trocars and one laparoscopist. The short-term outcomes and complications were investigated retrospectively., Results: The median age of the patients was 67 years (range 42-81). The median operating time for SLCR was 168 minutes (range 90-268). For one patient (1.96%) conversion to open surgery was required. Anastomotic leakage developed in 1 (1.96%) patient and ileus developed in 2 (3.9%). The median postoperative hospital stay was 8 (range 6-60) days without in-hospital deaths., Conclusions: In our experience, SLCR for patients with colorectal cancer is feasible and compares favorably with the standard technique. The diminished need for human operative assistance provides significant economic and organizational benefits.

Background: Laparoscopic ligation is a difficult and advanced technique because of the limited movement of forceps under two-dimensional videoscopic view. Currently, single-port surgery is widely used and a simple method for intracorporeal ligation is required. We describe an intracorporeal slip-knot with a double-loop strand that can be used to provide security and present the experimental results obtained., Methods: A modified Eskimo bowline with a 4-0 absorbable monofilament was placed on a needle driver, and the forceps was used to grip both ends of the thread. Another forceps was used to pass the line under vessels in the abdominal cavity. The line was withdrawn from the gripping point through the preknot on the rod after it was gripped at the same point. The slip-knot was tightened, and a pushing forceps and a needle driver were used to push the knot and complete the ligation., Results: The double-loop slip-knot has a high bursting pressure compatible with that of a conventional square-to-slip knot, which is significantly higher than that of any other slip-knot. In an experimental evaluation on animal laparoscopy, residents performed complete ligations of gastric and colonic arteries and veins within 30 s after a short explanation of the procedure., Conclusion: This novel slip-knot with a double-strand loop could provide easy and secure intracorporeal ligation. This type of slip-knot has great potential for wide use in open surgery using laparoscopy. Further evaluation is required to determine its clinical applicability.

Introduction: In Japan, laparoscopic bariatric surgery has not been popular until recently because morbidly obese patients were infrequently encountered previous and Japanese health insurance does not cover this type of surgery. In 2010, the Japan Research Society for Endoscopic and Laparoscopic Treatments of Obesity undertook the first nationwide survey on laparoscopic bariatric surgery to evaluate its current status and outcomes., Methods: A mail survey was sent to the society's 64 member institutions, which included almost all institutions in Japan actively performing laparoscopic gastrointestinal surgery., Results: From 2000 to 2009, 340 laparoscopic bariatric procedures, in total, were performed in nine of the 64 institutions (14%). The most popular procedure was laparoscopic Roux-en-Y gastric bypass (LRYGB, n=147), second was laparoscopic sleeve gastrectomy (LSG, n=102), and third was laparoscopic adjustable gastric banding (LAGB, n=55). However, the number of LRYGB procedures has decreased while the number of LSG procedures has rapidly increased. Total morbidity rates were 12.2% for LRYGB, 10.9% for LAGB, and 7.8% for LSG. Percent excess weight loss was 78% at 5 years after LRYGB, 52% at 4 years after LAGB, and 68% at 2 years after LSG. Although the bariatric procedures frequently resolved or improved obesity-related comorbidities, LRYGB appears to be superior to LAGB, as was previously reported., Conclusion: The first nationwide survey of laparoscopic bariatric surgery in Japan clearly showed the current status and outcomes of this group of procedures. The Japanese results appear to be comparable to similarly undertaken surveys in Europe and the USA., (© 2011 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Blackwell Publishing Asia Pty Ltd.)

Background: In Japan, the number of obese patients with gastric cancer is increasing. This study aimed to evaluate the advantages of laparoscopically assisted distal gastrectomy (LADG) for obese patients relative to those of conventional distal gastrectomy (DG)., Methods: Between January 2004 and June 2009, a total of 197 consecutive patients with gastric carcinoma underwent curative distal gastrectomy with Billroth 1 reconstruction in the Gunma University Hospital. The patients were assigned to undergo LADG (n = 120) or DG (n = 77) according to the depth of tumor invasion and lymph node status. A body mass (BMI) of 25 kg/m(2) or higher was defined as obesity, and the amounts of blood loss, the operating time, the number of lymph nodes dissected, and the postoperative complications experienced by obese and nonobese patients were compared., Results: None of the patients in the LADG group required conversion to laparotomy. In the DG group, significantly fewer lymph nodes were retrieved from the obese patients (22.5 ± 3.4) than from the nonobese patients (31.9 ± 2.0; P < 0.05). However, among the obese patients, the number of lymph nodes retrieved did not differ significantly between the LADG and DG groups. In the LADG group, the obese patients had a longer operating time (206.6 ± 6.3 vs. 192.0 ± 3.1 min; P < 0.05) and a greater estimated blood loss (158.2 ± 24.7 vs. 101.9 ± 10.4 ml; P < 0.05) than the nonobese patients. The estimated blood loss correlated the surgical procedures and BMI. No significant difference in postoperative complications was noted between the obese and nonobese groups after each procedure., Conclusions: Relative to DG, LADG did not affect the radicality of the procedure for the obese patients, and there is no significant difference in the operating time. The estimated blood loss was significantly less for LADG than for DG. Surgeons should elect to perform LADG for obese patients with gastric cancer.

Background and Aims: The objective of this study is to compare the postoperative motility between hand-sewn end-to-end anastomosis and functional end-to-end anastomosis., Methods: Fifteen conscious dogs were divided into three groups: normal intact dog group, end-to-end anastomosis group (EE), and functional end-to-end anastomosis group (FEE). In the EE and FEE groups, the dogs underwent a transection of the jejunum 30 cm distal to the Treitz ligament and anastomosis in each method. To compare the gastrointestinal motility, the time to the appearance and the rate of propagation of interdigestive migrating motor contractions (IMC) across the anastomosis, as well as the motility index (MI) at the oral and anal sides of the anastomosis, were measured using strain gauge force transducers. Furthermore, the histological examination of intrinsic nerve fibers was evaluated., Results: The time to the appearance of propagation of IMC in the EE and FEE was not significantly different. The propagation rates of IMC in the EE and FEE completely recovered within 4 weeks of the surgery. The MI in the EE and FEE was not significantly different. In addition, no continuity of intrinsic nerve fibers across the anastomosis could be identified in either group., Conclusions: In the present study, there are no significant differences between the EE and FEE with regard to the time of the appearance and the rate of propagation of IMC. These results suggest that the effect of functional end-to-end anastomosis on postoperative motility is not different from that of hand-sewn end-to-end anastomosis.

Background: In this report, laparoscopy-assisted proximal gastrectomy (LAPG) and gastric tube reconstruction using a mini-loop retractor (MLR) is described for the treatment of early gastric cancer., Methods: Early upper gastric carcinoma with no metastasis had been diagnosed in the subjects of this study. Five surgical ports were inserted into the abdomen. The stomach was lifted to the abdominal wall side with a MLR. Three of five gastric arteries were divided using ultrasonically activated coagulating shears and ligated with ligation forceps. A fixed gastric part with MLR was properly changed according to the lymph node dissection. Reconstruction with a gastric tube (20 cm long, 3 cm wide) using a circular stapler was performed through a small incision, through which the specimen was removed., Results: Fourteen patients underwent LAPG. The mean operating time and blood loss were 202 min and 236 ml, respectively. The operations were performed without serious complications. None was changed to a laparotomy, and there were no deaths., Conclusions: This technique of LAPG and gastric tube reconstruction using MLR for the treatment of proximal early gastric cancer was simple and safe.

A 74-year-old female had repeated relapses of right lower abdominal pain; a colonoscopic examination showed a submucosal tumor of the appendix. Under provisional diagnosis of appendicitis caused by a submucosal tumor, a laparoscopic operation was performed. The laparoscopic observation did not reveal the typical finding of appendicitis. The tumor was thought to be a malignant neoplasm. The ileocecal region was excised with lymph node dissection. Macroscopically, the mass was localized in the appendix and did not infiltrate to the cecum. Histologically, the marginal zone consisted of lymphoid cells, and centrocyte-like cells were observed. Immunohistochemically, the tumor cells were positive for CD20 and CD79a and negative for CD3, CD10, and cyclin D1. The histological diagnosis was mucosa-associated lymphoid tissue (MALT) lymphoma of the appendix. Colonic MALT lymphoma is rare and rarely diagnosed before surgery. Furthermore, very few cases of the appendiceal MALT lymphoma have been reported. The laparoscopy was used in the case of a patient diagnosed with appendicitis and considered the possibility of MALT lymphoma of the appendix. We then performed an ileocecal resection, which is considered radical surgery. The present case suggests that a laparoscopic observation is helpful for the appropriate diagnosis and therapy of MALT lymphoma of the appendix.

Background/aims: Liver resection by open surgery remains the treatment of choice for hepatocellular carcinoma (HCC). However, open surgery with a large skin incision carries the possibility of liver failure in patients with advanced liver cirrhosis, because large skin incisions lead to interruption of large collateral veins. Currently, laparoscopic liver resection is preferred to avoid postoperative liver failure in these circumstances., Methodology: We describe laparoscopic treatment of three patients with a single sub glissonian HCC, using small skin incisions. The tumor lesions were located in segment 3, segment 6 and segment 8, according to Couinaud's liver anatomy on each patient. In the patient with the S8 lesion, we approached the region from the pleural cavity using a THORACO-PORT. The diaphragm was incised with a Harmonic scalpel and the tumor was removed from the pleural cavity through a 5-cm long skin incision. In the patient with S3 and that with S6 lesion, we performed mobilization of the lateral segment or the right lobe by laparoscopy. We then used a mini-retractor and Nelaton tube to bring the tumor to the subcostal region and easily performed a partial resection, which was all that could be done under the circumstances., Results: All the patients were able to start oral intake on the three postoperative days, and didn't require analgesic agent. The mean post operative stay was 8.7 days., Conclusion: in cases of hepatocellular carcinoma that require partial liver resection, a laparoscopic procedure is a reasonable approach to surgery, because of its lower invasiveness compared with conventional liver resection.

Background: In recent years, laparoscopic gastrectomy has been applied for the treatment of gastric cancer in Japan and Western countries. This report describes the short- and long-term results for patients with gastric cancer who underwent laparoscopically assisted total gastrectomy (LATG) with lymph node dissection., Methods: From September 1999 to December 2007, 20 patients underwent LATG, and 18 underwent conventional open total gastrectomy (OTG) for upper and middle gastric cancer. The indications for LATG included depth of tumor invasion limited to the mucosa or submucosa and absence of lymph node metastases in preoperative examinations. The LATG and OTG procedures for gastric cancer were compared in terms of pathologic findings, operative outcome, complications, and survival., Results: No significant difference was found between LATG and OTG in terms of operation time (254 vs 248 min.), number of lymph nodes (26 vs 35), complication rate (25% vs 17%), or 5-year cumulative survival rate (95% vs 90.9%). Differences between LATG and OTG were found with regard to blood loss (299 vs 758 g) and postoperative hospitalization (19 vs 29 days)., Conclusion: For properly selected patients, laparoscopically assisted total gastrectomy can be a curative and minimally invasive treatment for early gastric cancer.

Background: Intracorporeal suturing and knot tying are among the most difficult procedures in laparoscopic operations. An easy and inexpensive method for intracorporeal instrumental ligation with a modified laparoscopic needle driver is presented., Methods: The needle driver developed in this study has a novel mechanism that can fix the suturing thread in a hook at the distal site of the holder's jaw hinge. This hook projects out from the rod only when the jaw of the holder is open. After the needle is removed from the tissue using the grasper, the needle driver is placed under the grasper, which the surgeon manipulates by the left hand. Then the thread is hooked on the needle driver by withdrawal of the driver with the jaw opening. The tip of the needle driver is moved over the shaft of the grasper by keeping the thread on the hook. The thread is entwined during a series of crossing movements of the rods of the forceps. The short tail of the suture material is gripped and tied up as a first throw of ligation. The side edge of the jaw, used for thread cutting, is sharpened by grinding., Results: When the angle of the forceps is set at 90 degrees in the box trainer, no difference in terms of ligation time and degree of error is observed between the hook and conventional C-loop methods. In the case of the 30 degree forceps angle, the novel method is superior to the conventional method., Conclusion: The novel needle driver provides an easy and inexpensive method for performing an intracorporeal ligation, particularly in a case involving a sharp axis angle of the forceps. More clinical experience is necessary for evaluation of this method, but it has potential advantages in laparoscopic operations.

Background: Laparoscopic repair of large paraesophageal hernias (LPEH) is technically challenging, and requires advanced laparoscopic skills. We have developed a novel technique for facilitating laparoscopic repair of LPEHs safely and easily, using a Nelaton catheter., Patients and Methods: Seven patients with LPEHs were operated on through a laparoscopic approach. During surgery, the left lobe of the liver and right diaphragmatic crus were elevated using a suspended thread covered by a Nelaton catheter., Results: All patients were operated on laparoscopically using this technique. No patient required conversion to open method. The median operating time was 205 minutes and the range was from 155 to 295 minutes. No intraoperative or early complications occurred in any patient. Late complications occurred in 2 patients due to a small sliding hernia: a slipped fundoplication in 1 patient, and a gastric ulcer in the other., Conclusions: In conclusion, laparoscopic repair of LPEH is a challenging procedure that requires wide experience in laparoscopic gastroesophageal surgery. Further refinement for this operation may be necessary.

Open gastric surgery in elderly patients is associated with higher morbidity and mortality rates than those reported among younger individuals. Therefore, minimally invasive surgery may have a larger impact on the elderly compared to the younger age group. The objective of this study was to evaluate the experience of laparoscopy-assisted distal gastrectomy (LADG) in patients with early gastric cancer and compare the results in patients 70 years of age and older to those in patients younger than 70 years of age. From January 1998 to October 2004, a total of 103 patients underwent LADG. Of these patients, 30 who were older than 70 years were compared with 73 who were younger. Preoperative co-morbidity, operative results, postoperative outcomes, and survival were analyzed. Furthermore, as a standard control of this study, we reviewed 54 distal gastrectomy cases with open surgery (open distal gastrectomy; ODG) in the same term with the same background factors, categorized into elder (n = 16) and younger (n = 38). The mean age of the elderly patients was 75 years in the LADG group. A significantly higher proportion of elderly patients had concurrent diseases in both groups. Blood loss was significantly less in the elderly than in younger patients undergoing LADG, and it was less in the LADG group than in the ODG group. The overall 5-year survival rates in the LADG group were not significantly different between elderly and younger patients. Laparoscopy-assisted distal gastrectomy is a safe and effective treatment for early gastric cancer in the elderly. Therefore, chronological age alone should not be considered a contraindication in selecting patients for LADG.

Crohn's disease can involve any part of the gastrointestinal tract. Although good conservative treatment is given as soon as possible, most patients with this disease will eventually require surgery. We encountered a case of Crohn's disease associated with anemia which we treated with laparoscopic-assisted ileectomy. The postoperative course was satisfactory. The most important characteristic of Crohn's disease, fat wrapping and extending over the serosal surface toward the antimesenteric border, was observed in the ileum, distinguishing the disease and pinpointing the lesion accurately. This surgical method has an advantage over open surgery in that the recovery time is shorter and incisions are smaller, allowing easier surgery in the future, shortening the patient's hospital stay, and improving the patient's quality of life.

Background: Laparoscopic assisted gastrectomy is being reported increasingly as the treatment of choice for early gastric cancer. However, no reports concerning the prognosis of patients who have undergone laparoscopic assisted distal gastrectomy (LADG) for early gastric cancer or data comparing the results to those obtained after open gastric surgery are yet available., Methods: A retrospective study was performed comparing laparoscopic assisted and open distal gastrectomies for early gastric cancer. Eighty-nine patients who underwent LADG were compared to 60 who underwent conventional open distal gastrectomy (DG) in terms of pathologic findings, operative outcome, complications, and survival., Results: There were no significant differences between LADG and DG in operation time (209 vs 200 minutes), complication rate (9% vs 18%), and 5-year survival rate (98% vs 95%). There were differences between LADG and DG with regard to blood loss (237 vs 412 mL), number of lymph nodes (19 vs 25), postoperative stay (17 vs 25 days), and the duration of epidural analgesia (2 vs 4 days) ( P < .05 each)., Conclusions: For properly selected patients, LADG can be a curative and minimally invasive treatment for early gastric cancer.

Local resection of the stomach is suitable for the treatment of submucosal tumors (SMT). However, it cannot be easily performed laparoscopically on tumors located near the esophagogastric junction. We have developed a new technique, which is called transgastric tumor-everting resection. To identify the location of the SMT laparoscopically without an oral endoscope, an Indiana ink mark was made prior to the operation. The SMT was everted from the gastrotomy and held by the Mini Loop Retractor II. The gastric mucosa could be observed from gastrotomy, allowing us to confirm that the staple line would not cause deformity of the esophagogastric junction. The lesion was then resected, and the gastrotomy was closed simultaneously using the Endo-GIA Universal. This technique is easy, safe, and useful for the laparoscopic resection of gastric SMTs located on the greater curvature or anterior wall of the fornix, near the esophagogastric junction.

The dislodgement of a laparoscopic port during surgery is a common problem in patients with thin abdominal walls, especially children. In this paper, we report a new technique and a simple device to fix a laparoscopic port. The device consists of an O-ring and connecting threads that are tied to the ring at two points. The connecting thread is passed though the port's cannula, and a trocar is set in the cannula beforehand. The port with the inner trocar is placed into the abdominal cavity, and the trocar is removed. The ring is brought into the abdominal cavity with a laparoscopic forceps through the cannula. After the tip of the forceps has been passed through the ring in the abdominal cavity, the thread connected to the ring is withdrawn, and the ring is fixed on the cannula by anchoring the thread on the port extracorporeally. Such a device was used to fix a total of 95 ports during 12 laparoscopic colectomies, 7 gastrectomies, 19 cholecystectomies, 2 appendectomies, and 1 resection of Meckel's diverticulum. Four children were among these cases. Not a single port slipped off, even in cases involving infants and obese patients. No complications relating to use of this device were observed. The new stabilizing device is simple, cost effective, and useful for prevention of the dislodging of various types of conventional ports, especially in the case of infants.

We report a case of a patient who underwent three-dimensional arterial computed tomography, color Doppler sonography and laparoscopic splenectomy for splenic artery aneurysm. Helical computed tomography revealed a splenic artery aneurysm, 3.0 x 1.8 cm in diameter. Color Doppler sonography reveals a weak pulsatile flow from the aneurysm. Surgical treatment is indicated for such cases since approximately 10% of these aneurysms tend to rupture which thus results in fatal hemorrhaging. As a result, a laparoscopic splenectomy was performed. According to our experience, three-dimensional computed tomography and color Doppler sonography can be performed for the arterial and venous information with less invasion than angiography and a laparoscopic splenectomy for splenic aneurysm can be performed which is safer and less invasive than conventional open procedure.

Laparoscopy-assisted gastrectomy has been increasingly reported as the treatment of choice for early gastric cancer. However, there is little information regarding the benefits of laparoscopy-assisted distal gastrectomy (LADG). LADG and conventional open distal gastrectomy (DG) for early gastric cancer were compared in terms of operative outcome, recovery of bowel function, complications, and changes in body weight. Thirty-four patients underwent LADG for early gastric cancer. These patients were compared with 31 patients who underwent DG during the same period. For estimating gastrointestinal motility recovery, 20 radiopaque markers were inserted into the duodenum during surgery, and abdominal X-rays were taken daily until all markers were seen in the ascending colon. Age, gender, and histologic differentiation of the lesions were matched. The LADG group required a significantly longer operative time and the dissection of fewer lymph nodes. Postoperative hospital stay and the occurrence of postoperative complications (ileus) were significantly shorter and less frequent in the LADG group. The LADG group showed a more rapid recovery of gastrointestinal motor function compared with the DG group during the early postoperative period. Body weight 24 months after LADG was about 100% of pre-illness weight, but no further weight change was encountered in the DG group. For selected patients with early gastric cancer, LADG with lymphadenectomy can provide a rapid recovery and good quality of life without compromising the cure rate.

We report a case of a paraesophageal hernia, which was successfully treated with laparoscopic surgery after a natural history of eight years. Eight years before surgery only the fundus of the stomach was included in the hernia sac. At surgery, although the gastroesophageal junction and fundus were found in their normal positions, the distal half of the stomach and the omentum were pulled into the thorax, which demonstrated an organoaxial gastric volvulus. As the omentum tightly adhered to the top of the hernia sac and there was no tight adhesion between the stomach and hernia sac, the omentum could serve as the lead point for the gastric volvulus. This patient was successfully treated with laparoscopic surgery and is presently in good condition without any recurrence of the hernia.

Background: In recent years, laparoscopic gastrectomy has been applied to the treatment of gastric cancer in Japan. However, there are few reports of laparoscopic or laparoscopically assisted total gastrectomy in the treatment of gastric cancer because of the difficulty of the surgical technique. Laparoscopically assisted total gastrectomies with jejunal interpositions were performed on four patients with early gastric cancer located in the upper portion of the stomach., Methods: Four surgical ports were inserted into the abdomen. The stomach was lifted to the abdominal wall using newly developed retraction tubes. Gastric arteries were divided using ultrasonically activated coagulating shears and ligated with ligation forceps. Following these steps, a total gastrectomy reconstruction was performed by jejunal interposition through a small transverse laparotomy. An esophagojejunostomy and a jejunoduodenostomy were made with circular staplers., Results: The mean operating time and blood loss were 246 min and 236 ml, respectively. The operations were performed without serious complications. All patients were pain free and ambulatory after the laparoscopically assisted total gastrectomy, and the mean postoperative hospital stay was 16 days., Conclusion: We successfully performed laparoscopically assisted total gastrectomies in a relatively short period of time. When patients are carefully selected, the laparoscopic procedure can be curative and minimally invasive as a treatment for early gastric cancer.

Background: To extend the usefulness of laparoscopic operations, a secure and easy method for the ligation of large vessels is needed. Herein we describe a novel ligation forceps that can be used as a ligature carrier and knot pusher., Methods: A 2-0 suture thread with a knot already tied near one end is hooked in the upper jaw of a novel ligation forceps. After the lower jaw is passed under the vessel or cystic duct, the forceps is closed. When one end of the thread is withdrawn, the knot is trapped in the indentation built into the lower jaw; the ligature is then passed under the pedicle. An extracorporeal ligation can then be performed continuously by the same forceps., Results: The origins of large vessels were ligated safely and easily with this device during 65 laparoscopic procedures (four total colectomies, 12 colectomies, and 49 gastrectomies). Following temporary hemostasis of accidental bleeding with clamping forceps, ligation hemostasis can also be performed using this instrument., Conclusion: This novel ligation forceps permits the secure ligation of vessels or a cystic duct without the need for another device. The proposed method is both easy and inexpensive.

Background: A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported., Methods: Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision., Results: The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated., Conclusion: A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.

A 64-year-old man was admitted to Gunma University Hospital because of gastroesophageal reflux disease and hiatus hernia. Endoscopic examination showed a linear ulcer and mucosal redness in the lower esophagus. Gastrointestinal contrast study revealed a large esophageal hiatal sliding hernia. Laparoscopic Nissen fundoplication was then performed. Short gastric vessels were divided and lesser omentum was ablated with laparosonic coagulating shears, and the fundus of the stomach was used to construct the wrap around the esophagus. Three hundred and sixty degree fundoplication was undertaken using four sutures to secure the wrap. The patient is well and is currently free from reflux symptoms. Laparoscopic Nissen fundoplication is effective in the control of gastroesophageal reflux in the patient with hiatus hernia. This case report demonstrates that the use of laparosonic coagulating shears is effective for the division of the short gastric vessels.

We report the case of a massive paraesophageal hiatal hernia with gastric volvulus which presented with the symptom of a precordial sense of pressure for over two years, which was successfully treated with laparoscopic surgery. The patient is presently in good condition, without any recurrence of either the hiatal hernia or other symptoms one year after surgery. This approach is considered to be a safe and effective procedure, and it also provides for rapid recovery from the operation.

Esophageal dissection under laparoscopic monitoring is performed during total esophagectomy to treat patients with cervical esophageal carcinoma. Using this technique, a safe esophageal dissection can be made from the surrounding mediastinal tissues. Some of the disadvantageous consequences of a blunt dissection, including the blind maneuver, may thus be prevented and various intraoperative and postoperative complications may be avoided.

The location of a small lesion must be precisely identified during laparoscopic surgery. A gamma probe that is usually used for navigating sentinel lymph nodes was evaluated for its usefulness in locating small gastrointestinal lesions (14 gastric and 10 colonic). A total of 2 mCi of a Tc(99m)-labeled rhenium colloid was injected endoscopically around a tumor 16 h prior to surgery. During operation, the abdominal cavity was scanned using a handheld gamma probe (Navigator GPS, Tyco HealthCare, Norwalk, CT, USA). In all cases, the injection site was identified as the highest spot in the abdominal cavity, with 2585 counts per second on average (range, 910-8800 counts per second). The highest count in a lymph node was 637 per second on average. The gamma probe is a useful tool for identifying small gastrointestinal lesions during open and laparoscopic operations. [ABSTRACT FROM AUTHOR]