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This study investigated whether parameters derived from hand motions of expert and novice surgeons accurately and objectively reflect laparoscopic surgical skill levels using an artificial intelligence system consisting of a three-layer chaos neural network. Sixty-seven surgeons (23 experts and 44 novices) performed a laparoscopic skill assessment task while their hand motions were recorded using a magnetic tracking sensor. Eight parameters evaluated as measures of skill in a previous study were used as inputs to the neural network. Optimization of the neural network was achieved after seven trials with a training dataset of 38 surgeons, with a correct judgment ratio of 0.99. The neural network that prospectively worked with the remaining 29 surgeons had a correct judgment rate of 79% for distinguishing between expert and novice surgeons. In conclusion, our artificial intelligence system distinguished between expert and novice surgeons among surgeons with unknown skill levels.

Background: This study aimed to determine the effect of fibrin glue and polyglycolic acid (PGA) felt on prevention of pancreatic fistula (PF) after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis., Methods: Fifty consecutive patients were enrolled in this prospective study. Twenty-three patients underwent laparoscopic splenectomy with a fibrin sheet (fibrin sheet group). The sealing ability of each treatment was evaluated by an ex vivo pressure test model. Based on the results from ex vivo experiments, 27 patients received prophylaxis using fibrin glue and PGA felt (PGA with fibrin group). The primary endpoint was the incidence of PF., Results: Significantly more (5, 22%) patients developed PF in the fibrin sheet group than in the PGA with fibrin group (0%, P = .037)., Conclusions: Our new application of fibrin glue and PGA felt is an effective prophylactic procedure for preventing development of PF after laparoscopic splenectomy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Laparoscopic and open surgical skills differ distinctly from one another. Our institute provides laparoscopic surgical skills training for currently active surgeons throughout Japan. This study was performed to evaluate the effectiveness of our 2-day standardized laparoscopic surgical skills training program over its 10-year history., Methods: We analyzed the data on trainee characteristics, outcomes of skills assessments at the beginning and end of the program, and self-assessment after 6 months using a questionnaire survey., Results: From January 2004 to December 2013, 914 surgeons completed the 2-day training program. Peaks in postgraduate years of experience occurred at years 2, 8, and 17. Suturing and knot tying times were significantly shorter at the end than beginning of the program (p < 0.001). However, the numbers of misplaced and loose sutures, maximum misplacement distance, and number of injuries to the rubber sheet were significantly higher at the end of the program (p < 0.001). A questionnaire at 6 months post-training revealed significant improvements in the overall skills and forceps manipulation (p < 0.0001) and a significantly shorter mean operation time for laparoscopic cholecystectomy (p < 0.001)., Conclusion: Our 2-day training program for active Japanese surgeons is thus considered to be effective; however, continued voluntary training is important and further outcomes assessments are needed.

Purpose: This study aimed to identify detailed differences in laparoscopic surgical processes between expert and novice surgeons in a training environment and demonstrate that surgical process modeling can be used for such detailed analysis., Methods: Eleven expert surgeons each of whom had performed [Formula: see text] laparoscopic procedures were compared with 10 young surgeons each of whom had performed [Formula: see text] laparoscopic procedures, and five medical students. Each examinee performed a specific skill assessment task. During tasks, instrument motion was monitored using a video capture system. From the video, the corresponding workflow was recorded by labeling the surgeons' activities according to a predefined terminology. Activities represented manual work steps performed during the task, described by a combination of a verb (representing the action), a tool, and the involved structure. The results were described as the number of occurrences (times), average duration (seconds), total duration (seconds), minimal duration (seconds), maximal duration (seconds), and occupancy percentage (%)., Results: The terminology for describing the processes of this task included 10 actions, six tools, four structures, and three events for each hand. There were 63 combinations of different possible activities; significant differences in 12 activities were observed between the expert and novice groups (young surgeons and medical students). The expert group performed the task with fewer occurrences and shorter duration than did the novice group in the left hand., Conclusions: We identified differences in surgical process between experts and novices in laparoscopic surgical simulation. Our proposed method would be useful for education and training in laparoscopic surgery.

Introduction: We evaluated the differences in instrument manipulation skills between expert laparoscopic surgeons and novices., Methods: Six expert surgeons who had performed more than 500 laparoscopic surgeries and one skilled instructor at Kyushu University Training Center for Minimally Invasive Surgery, and 20 medical students who had experienced no laparoscopic surgery were enrolled. A new skill assessment task was designed using zippers on an unstable, mobile platform in a box trainer. The examinees were asked to close the zippers, while trying to avoid moving the platform. The path lengths of the tips of the instruments and of the platform were measured, and the performance time was also recorded. Surgical skill score was calculated from the correlation between the path lengths of the instruments and that of the platform, in addition to the performance time., Results: The path lengths of the tips of both instruments and of the platform were significantly shorter in the experts than in the novices (all p < 0.05). The performance time was also significantly shorter for experts than novices (p < 0.05). The surgical skill score was significantly higher for experts than novices (p < 0.01)., Conclusion: The differences in the instrument manipulation skills between expert laparoscopic surgeons and novices could therefore be evaluated using our surgical skill scoring system.

Introduction: Traditionally, laparoscopy has been based on 2-D imaging, which represents a considerable challenge. As a result, 3-D visualization technology has been proposed as a way to better facilitate laparoscopy. We compared the latest 3-D systems with high-end 2-D monitors to validate the usefulness of new systems for endoscopic diagnoses and treatment in Thailand., Methods: We compared the abilities of our high-definition 3-D endoscopy system with real-time compression communication system with a conventional high-definition (2-D) endoscopy system by asking health-care staff to complete tasks. Participants answered questionnaires and whether procedures were easier using our system or the 2-D endoscopy system., Results: Participants were significantly faster at suture insertion with our system (34.44 ± 15.91 s) than with the 2-D system (52.56 ± 37.51 s) (P < 0.01). Most surgeons thought that the 3-D system was good in terms of contrast, brightness, perception of the anteroposterior position of the needle, needle grasping, inserting the needle as planned, and needle adjustment during laparoscopic surgery. Several surgeons highlighted the usefulness of exposing and clipping the bile duct and gallbladder artery, as well as dissection from the liver bed during laparoscopic surgery. In an image-transfer experiment with RePure-L®, participants at Rajavithi Hospital could obtain reconstructed 3-D images that were non-inferior to conventional images from Chulalongkorn University Hospital (10 km away)., Conclusion: These data suggest that our newly developed system could be of considerable benefit to the health-care system in Thailand. Transmission of moving endoscopic images from a center of excellence to a rural hospital could help in the diagnosis and treatment of various diseases., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Background: Bariatric surgical procedures are becoming a standard treatment for morbid obesity in many western countries and in some Asian countries., Aim: The aim of the current study was to evaluate the efficacy and safety of the initial 30 cases of bariatric surgical procedures performed for morbid obesity at a single institution in Japan., Materials and Methods: From March 2012 until September 2014, 30 bariatric surgical procedures were performed for morbid obesity at a single medical center (Kyushu University Hospital) in Japan., Results: All of the operations procedures were planned laparoscopic procedures, and none required conversion to laparotomy. There were no perioperative or postoperative mortalities. Postoperative complications occurred in 3 patients: 1 patient developed an intra-abdominal abscess, 1 patient experienced temporary food intolerance, and 1 patient developed small bowel obstruction. The excessive body weight reduction rates after surgery at 1 month, 3 months, 6 months, and 1 year post-surgery were 26.1%, 39.2%, 41.7%, and 51.2%, respectively. The mean body mass index (BMI) at the same time points were 38.3%, 36.4%, 35.5%, and 31.4%, respectively. Eighteen patients had type II diabetes mellitus (T2DM). The mean preoperative fasting blood glucose levels were 169 ± 37 mg/dL. Following surgery, the blood glucose levels at 3, 6 and 12 months were 113 ± 12, 115 ± 22, and 110 ± 19, mg/dL, respectively. The preoperative HbA1c percentage was 7.9 ± 0.5. Following surgery, the HbA1c percentages at 3, 6, and 12 months were 6.9 ± 0.5, 6.2 ± 0.9, and 5.9 ± 0.6, respectively., Conclusions: Bariatric surgical procedures are effective and safe for the treatment of morbid obesity. Our results indicate that the mechanism of improvement of diabetes and related diseases following bariatric surgical procedures is not simply as a result of calorie restriction and weight reduction.

Background: The purpose of this study was to develop a new objective assessment system for the suture ligature method employed in the laparoscopic intestinal anastomosis model. Suturing skills were evaluated objectively using this system., Methods: This study compared 17 expert surgeons, each of whom had performed >500 laparoscopic procedures, with 36 novice surgeons, each of whom had performed <15 laparoscopic procedures. Each examinee performed a specific skill assessment task using an artificial model that mimics living tissue, which is linked with the Suture Simulator Instruction Evaluation Unit. The model used internal air pressure measurements and image processing to evaluate suturing skills. Five criteria were used to evaluate the skills of participants., Results: The volumes of air pressure leak in the expert and novice groups were 21.13 ± 6.68 and 8.51 ± 8.60 kPa, respectively. The numbers of full-thickness sutures in the expert and novice groups were 2.94 ± 0.24 pairs and 2.47 ± 0.77 pairs, respectively. Suture tensions in the expert and novice groups were 60.99 ± 11.81 and 80.90 ± 16.63 %, respectively. The areas of wound-opening in the expert and novice groups were 1.76 ± 2.17 and 11.06 ± 15.37 mm(2), respectively. The performance times in the expert and novice groups were 349 ± 120 and 750 ± 269 s, respectively. Significant differences between the expert and novice groups for each criterion were observed. The acceptable range of values for each criterion except for the number of full-thickness sutures was statistically defined by the performance of the expert group., Conclusions: Our system is useful for the quantitative assessment of suturing skill in laparoscopic surgery. We believe that this system is a useful tool for training and assessment of laparoscopic surgeons.

Introduction: This study presents the design of a novel single port laparoscopic surgery robot that is actuated by plate-spring-driven mechanisms with high force transmission and a larger workspace. Many ongoing studies aim to develop robotic single port laparoscopic surgery platforms due to the potential advantages in terms of a short recovery period and fewer postoperative scars. Most of these investigations of single port access have focused on resolving the inconvenient maneuverability of manual single port laparoscopic surgery. However, drive mechanism structures are another requirement., Materials and Methods: Most of the existing robotic platforms cannot transmit sufficient force, as many of them use wire-driven mechanisms, which are prone to mechanical deformation that also negatively affects the accuracy of the end effector. In addition, even the best-known laparoscopic surgical robot system has instruments with a limited workspace for single port laparoscopic surgery. Therefore, the purpose of this study was to propose a novel robotic single port laparoscopic surgery platform that uses plate springs to transmit higher forces during tissue handling., Results and Conclusion: Compared to wire- or link-driven mechanisms, the plate-spring mechanism provided surpassing force transmission, with >14 N force transmission achieved, which enables most laparoscopic surgery with single port access. In addition, the high degree of freedom structure of the proposed design permitted an expanded workspace, which might be the most competitive characteristic among the single port systems reported to date.

Background: Metacognition is the knowledge about one's own methods of perceiving, remembering, thinking, and acting. This study determined the significance of metacognitive skills in laparoscopic surgery with the aim of applying the findings in a laparoscopic surgery training program., Material and Methods: Eighteen medical students with no experience in laparoscopic surgery (novice group) and eight expert surgeons who had each performed >100 laparoscopic surgeries (expert group) were enrolled. The examinees in each group performed an evaluation task using a virtual reality simulator and answered questions about the task., Results: The longest performance times, longest path lengths, and most frequent tissue damage occurred at 135° in the novice group and at 180° in the expert group. The greatest recognition of task difficulties, impatience, and irritation occurred at 135° in the novice group and at 180° in the expert group. There were statistically significant correlation coefficients between the instrument path length and task difficulty (metacognition) at 135° (R = 0.74, p = 0.03) and 180° (R = 0.79, p = 0.02) in the expert group, but there were no significant correlations in the novice group., Conclusion: We elucidated the significance of metacognitive skills in laparoscopic surgery. A training program should include recognition feedback systems.

Background: The number of operations performed by a surgeon may be an indicator of surgical skill. The hand motions made by a surgeon also reflect skill and level of expertise. We hypothesized that the hand motions of expert and novice surgeons differ significantly, regardless of whether they are familiar with specific tasks during an operation., Methods: This study compared 11 expert surgeons, each of whom had performed >100 laparoscopic procedures, and 27 young surgeons, each of whom had performed <15 laparoscopic procedures. Each examinee performed a specific skill assessment task, in which instrument motion was monitored using magnetic tracking system. We analyzed the paths of the centers of gravity of the tips of the needle holders and the relative paths of the tips using two mathematical methods of detrended fluctuation analysis and unstable periodic orbit analysis., Results: Detrended fluctuation analysis showed that the exponent in the function describing the initial scaling exponent (α1) differed significantly for experts and novices, being close to 1.0 and 1.5, respectively (P < 0.01). This indicated that the expert group had a greater long-range coherence with an intrinsic sequence and smooth continuity among a series of motions. Likewise, unstable periodic orbit analysis showed that the second period of unstable orbit was significantly longer for experts in comparison with novices (P < 0.01). This demonstrates mathematically that the hands of experts are more stable when performing laparoscopic procedures., Conclusions: Objective evaluation of hand motion during a simulated laparoscopic procedure showed a significant difference between experts and novices., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Laparoscopic devascularization of the upper stomach and splenectomy (Dev+Sp), is technically difficult in patients with portal hypertension because of enlarged collateral vessels and spleen. This report presents the efficacy and safety of hand-assisted laparoscopic (HALS) Dev+Sp., Methods: Ten patients underwent HALS Dev+Sp as a treatment for esophagogastric varices between 2005 and 2012 (HALS group). A vessel-sealing system was used for devascularization of vessels. An autosuture device was applied to dissect the splenic hilum and the left gastric and enlarged short gastric vessels. The operative and postoperative data were compared between patients who previously underwent laparoscopic Dev+Sp (LAP group, n = 9) and conventional Dev+Sp (OP group, n = 10) between 2001 and 2008., Results: The mean operative time was 328, 336, and 245 min (P < 0.05) and the mean blood loss was 1786, 981, and 250 mL (P < 0.05) in the OP, LAP, and HALS groups, respectively. Laparoscopic surgery was converted to HALS in one patient and to open surgery in three patients. There were no conversions in the HALS group. There was no significant difference in the cumulative recurrence rate and bleeding rate in the groups., Conclusion: HALS Dev+Sp is a feasible and effective surgery in patients with portal hypertension., (© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

The occurrence of traumatic abdominal wall hernia secondary to blunt trauma is uncommon, and laparoscopic repair of such hernias is very rare. A 53-year-old man, who had sustained injuries to his right thigh and right abdomen 8 months previously, visited a hospital because of a bulge in the right lateral abdomen. An abdominal computed tomography scan revealed a rupture in the lateral abdominal muscle and herniation of the cecum into the subcutaneous space. Accordingly, delayed traumatic abdominal wall hernia was diagnosed, which was successfully repaired laparoscopically. Thus, a laparoscopic tension-free mesh repair was safely and effectively performed for delayed traumatic abdominal wall hernia.

Purpose: In pediatric endoscopic surgery, a limited view and lack of tactile sensation restrict the surgeon's abilities. Moreover, in pediatric oncology, it is sometimes difficult to detect and resect tumors due to the adhesion and degeneration of tumors treated with multimodality therapies. We developed an augmented reality (AR) navigation system based on preoperative CT and MRI imaging for use in endoscopic surgery for pediatric tumors., Methods: The patients preoperatively underwent either CT or MRI with body surface markers. We used an optical tracking system to register the reconstructed 3D images obtained from the CT and MRI data and body surface markers during surgery. AR visualization was superimposed with the 3D images projected onto captured live images. Six patients underwent surgery using this system., Results: The median age of the patients was 3.5 years. Two of the six patients underwent laparoscopic surgery, two patients underwent thoracoscopic surgery, and two patients underwent laparotomy using this system. The indications for surgery were local recurrence of a Wilms tumor in one case, metastasis of rhabdomyosarcoma in one case, undifferentiated sarcoma in one case, bronchogenic cysts in two cases, and hepatoblastoma in one case. The average tumor size was 22.0±14.2 mm. Four patients were treated with chemotherapy, three patients were treated with radiotherapy before surgery, and four patients underwent reoperation. All six tumors were detected using the AR navigation system and successfully resected without any complications., Conclusions: The AR navigation system is very useful for detecting the tumor location during pediatric surgery, especially for endoscopic surgery., (Crown Copyright © 2013. All rights reserved.)

Background: The recent development of open magnetic resonance imaging (MRI) has provided an opportunity for the next stage of image-guided surgical and interventional procedures. The purpose of this study was to evaluate the feasibility of laparoscopic surgery under the pneumoperitoneum with the system of an open MRI operating theater., Methods: Five patients underwent laparoscopic surgery with a real-time augmented reality navigation system that we previously developed in a horizontal-type 0.4-T open MRI operating theater., Results: All procedures were performed in an open MRI operating theater. During the operations, the laparoscopic monitor clearly showed the augmented reality models of the intraperitoneal structures, such as the common bile ducts and the urinary bladder, as well as the proper positions of the prosthesis. The navigation frame rate was 8 frames per min. The mean fiducial registration error was 6.88 ± 6.18 mm in navigated cases. We were able to use magnetic resonance-incompatible surgical instruments out of the 5-Gs restriction area, as well as conventional laparoscopic surgery, and we developed a real-time augmented reality navigation system using open MRI., Conclusions: Laparoscopic surgery with our real-time augmented reality navigation system in the open MRI operating theater is a feasible option.

Performing laparoscopic surgery requires several skills, which have never been required for conventional open surgery. Surgeons experience difficulties in learning and mastering these techniques. Various training methods and metrics have been developed to assess and improve surgeon's operative abilities. While these training metrics are currently widely being used, skill evaluation methods are still far from being objective in the regular laparoscopic skill education. This study proposes a methodology of defining a processing model that objectively evaluates surgical movement performance in the routine laparoscopic training course. Our approach is based on the analysis of kinematic data describing the movements of surgeon's upper limbs. An ultraminiaturized wearable motion capture system (Waseda Bioinstrumentation system WB-3), therefore, has been developed to measure and analyze these movements. The data processing model was trained by using the subjects' motion features acquired from the WB-3 system and further validated to classify the expertise levels of the subjects with different laparoscopic experience. Experimental results show that the proposed methodology can be efficiently used both for quantitative assessment of surgical movement performance, and for the discrimination between expert surgeons and novices.

The case was a 50 years old female, with history of multiple previous surgeries including living donor liver transplantation for primary biliary cirrhosis, pancreatoduodenectomy for carcinoma in the duodenal papilla Vater, revision of Roux-en-Y anastomosis for intractable cholangitis due to short Roux limb. She was hospitalized this time for decompensated liver cirrhosis due to recurrent cholangitis, with apparent hypersplenism and risky esophageal varices. After a few session of endoscopic treatment for esophageal varices, we applied total laparoscopic splenectomy for hypersplenism in a patient with multiple surgical histories, for seeking better surgical field for safety. The surgery was completed as planned preoperatively under good surgical field.

Background: We recently experienced 10 patients with cirrhosis who underwent laparoscopic splenectomy. A portion of these patients underwent dissection with a flexible endoscope in the peritoneal cavity. This pilot study mainly focused on the technical aspects and immediate results., Methods: From November 2009 to September 2010, 10 patients with cirrhosis and hypersplenism were entered into this pilot study. They were indicated to undergo laparoscopic splenectomy to treat portal hypertension and to facilitate initiation and completion of either interferon therapy for liver cirrhosis or anticancer therapy for hepatocellular carcinoma. To dissect the upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen, a flexible single-channel endoscope was introduced into the peritoneal cavity simultaneously with the use of a rigid laparoscope. Dissection with the flexible endoscope in the peritoneal cavity was performed using an insulation-tipped electrosurgical knife through the channel of the flexible endoscope., Results: The flexible endoscope offered a magnified operative view, a water-jet lens cleaner, and a powerful lavage and suction capability. The upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen were easily seen, and dissection of these critical regions was smoothly conducted with articulation of the tip of the flexible endoscope, even in patients with splenomegaly. No patient experienced major intraoperative complications or required conversion to open surgery., Conclusions: Dissection with a flexible endoscope in the peritoneal cavity may be an effective tactic for laparoscopic megasplenectomy, and significant implications for pure natural orifice translumenal endoscopic surgery have been raised. Although future randomized controlled prospective studies are needed to confirm these findings, surgeons might find this to be a typical example of an appropriate strategy for high-risk patients.

Background: IL28B and ITPA genetic variants are associated with the outcome of pegylated-interferon and ribavirin (PEG-IFN/RBV) therapy. However, the significance of these genetic variants in cirrhotic patients following splenectomy has not been determined., Methods: Thirty-seven patients with HCV-induced cirrhosis who underwent laparoscopic splenectomy (Spx group) and 90 who did not (non-Spx group) were genotyped for IL28B and ITPA. The outcome or adverse effects were compared in each group. Interferon-stimulated gene 15 (ISG15) and protein kinase R expression in the spleen was measured using total RNA extracted from exenterate spleen., Results: Sustained virological response (SVR) rate was higher in patients carrying IL28B major genotype following splenectomy (50% vs 27.3%) and in patients carrying minor genotype in the Spx group compared to non-Spx group (27.3% vs 3.6%, P < 0.05). Pretreatment splenic ISG expression was higher in patients carrying IL28B major. There was no difference in progression of anemia or thrombocytopenia between patients carrying each ITPA genotype in the Spx group. Although splenectomy did not increase hemoglobin (Hb) level, Hb decline tended to be greater in the non-Spx group. In contrast, splenectomy significantly increased platelet count (61.1 × 103/μl vs 168.7 × 103/μl, P < 0.01), which was maintained during the course of PEG-IFN/RBV therapy., Conclusions: IL28B genetic variants correlated with response to PEG-IFN/RBV following splenectomy. Splenectomy improved SVR rate among patients carrying IL28B minor genotype and protected against anemia and thrombocytopenia during the course of PEG-IFN/RBV therapy regardless of ITPA genotype.

Purpose: This study investigated the postoperative quality of life (QOL) after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) in comparison to laparoscopy-assisted distal gastrectomy (LADG)., Methods: Twenty-one patients with early-stage gastric cancer underwent minimally invasive LADG (n = 12) or LAPPG (n = 9). Demographic and cancer-related data were obtained retrospectively from medical records. QOL was assessed using a 13-item questionnaire and the Japanese edition of the Gastrointestinal Symptom Rating Scale, which were mailed to patients twice postoperatively. Body weight and hemoglobin levels were measured at the same time., Results: Early upper abdominal pain was rated as significantly worse with LAPPG than with LADG at the first checkup (1.4 vs. 1.0, P = 0.02) but not at the second checkup (1.3 vs. 1.0, P = 0.07). There was a trend toward less body weight loss in the LAPPG patients in comparison to the LADG patients. The serum hemoglobin levels of LAPPG patients at the second checkup showed significantly higher than LADG patients (13.3 vs. 11.6 g/dL, P < 0.05)., Conclusions: LAPPG and LADG produce similar QOL in patients. Trends toward less body weight loss and improved anemia in LAPPG patients may therefore become more pronounced in future studies that have adequate number of the patients and longer follow-up periods.

Purpose: In endoscopic surgery, limited views and lack of tactile sensation restrict the surgeon's abilities and cause stress to the surgeon. Therefore, an intra-operative navigation system is strongly recommended. We developed an augmented reality (AR) navigation system based on preoperative CT imaging. The purpose of this study is to evaluate the usefulness, feasibility, and accuracy of this system using laparoscopic splenectomy in children., Methods: Volume images were reconstructed by three-dimensional (3D) viewer application. We used an optical tracking system for registration between volume image and body surface markers. The AR visualization was superimposed preoperative 3D CT images onto captured laparoscopic live images. This system was applied to six cases of laparoscopic splenectomy in children. To evaluate registration accuracy, distances from the marker position to the volume data were calculated., Results: The operator recognized the hidden vascular variation of the splenic artery and vein, accessory spleen, and pancreatic tail by overlaying an image onto a laparoscopic live image. The registration accuracy of six cases was 5.30 ± 0.08, 5.71 ± 1.70, 10.1 ± 0.60, 18.8 ± 3.56, 4.06 ± 1.71, and 7.05 ± 4.71., Conclusion: This navigation system provides real-time anatomical information, which cannot be otherwise visualized without navigation. The registration accuracy was acceptable in clinical operation.

Background and Aim: We intended to determine whether laparoscopic splenectomy (Lap-Sp) contributes to treatment with interferon therapy in hepatitis C virus (HCV)-cirrhotic patients with thrombocytopenia caused by hypersplenism., Methods: From December 2004 to August 2008, 100 cirrhotic patients (54 men and 46 women) underwent Lap-Sp for a clinical application of interferon therapy. All the patients were Child-Pugh class A or B with thrombocytopenia (average platelet count, 56 × 10(3) /mm(3)). The HCV genotype was type 1 in 80 patients and type 2 in 20 patients., Results: Pure laparoscopic or hand-assisted laparoscopy was performed in 78 and 22 patients, respectively, without mortality. Conversion to open surgery was not required in any of the patients. The platelet counts improved (mean platelet count 172 × 10(3) /mm(3) 1 month after surgery) and interferon (IFN) therapy was started in 97 patients. In this study period, 36 patients obtained a sustained virologic response. Eight patients discontinued IFN therapy because of depression, neutropenia or other reasons., Conclusions: Lap-Sp permits most patients with HCV cirrhosis and hypersplenism to receive sufficient IFN therapy. Therefore, Lap-Sp can become a strong supportive surgery for cirrhotic patients who require antiviral therapy., (© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)

Background: This study aimed to evaluate whether laparoscopic splenectomy (Lap-Sp) contributes to the completion and curability of combined peginterferon and ribavirin (peg-IFN + RIB) therapy for cirrhotic patients with pancytopenia due to hypersplenism., Methods: From December 2004 to September 2007, 21 patients underwent Lap-Sp before treatment with peg-IFN + RIB. All the patients were Child-Pugh class A or B with a mean platelet count of 5.7 x 10(4)/mm(3) and a mean leukocyte count of 2,830/mm(3). The hepatitis C virus (HCV) genotype was 1b for 18 patients and 2b for 3 patients. Of the 21 patients, 17 had a viral load exceeding 100 KIU/ml, and 4 had a load of less than 100 KIU/ml., Results: All the patients underwent Lap-Sp without severe complications. The average hospital stay was 12.7 days (range, 6-23 days). Platelet counts increased from a mean of 5.7 +/- 2.2 x 10(4)/mm(3) preoperatively to 19.6 +/- 7.6 x 10(4)/mm(3) postoperatively and remained above 7.0 x 10(4)/mm(3) during the subsequent peg-IFN + RIB therapy. The full course of therapy was completed for nine patients, with five obtaining a sustained virologic response and one obtaining a biologic response. The five patients who obtained a sustained virologic response had either HCV type 2b or 1b with a low viral load (<100 KIU). At this writing, treatment is ongoing for the remaining 12 patients., Conclusions: Laparoscopic splenectomy allows patients with HCV cirrhosis and hypersplenism to receive full-dose peg-IFN + RIB therapy. Patients with HCV, genotype 2 or 1b and a low viral load, and hypersplenism may be good candidates for Lap-Sp.

Background and Aims: To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma., Methods: Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri- and post-intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti-cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra-arterial chemotherapy, and transarterial chemoembolization., Results: All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications., Conclusion: Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.

Background/aims: Recently, partial splenic arterial embolization (PSE) has become a supportive intervention for cirrhotic patients with hypersplenism in the administration of interferon therapy. However, relapsed thrombocytopenia is often observed in patients following PSE. This study aimed to report the clinical efficiency of laparoscopic splenectomy as a salvage treatment for relapsed thrombocytopenia following PSE., Methods: From 2005 to 2009, 6 patients with prior PSE treatment underwent laparoscopic splenectomy. We reviewed the surgical method of laparoscopic splenectomy and the peri- and postoperative outcomes., Results: Laparoscopic splenectomy effectively provided sufficient increases in patient platelet counts. In all patients, laparoscopic splenectomy was performed safely with no significant complications despite PSE-associated dense adhesion to the diaphragm and/or retroperitoneal attachments., Conclusion: Laparoscopic splenectomy provides a sufficient increase in patient platelet counts in relapsed thrombocytopenia following PSE. Therefore, laparoscopic splenectomy appears to be a superior supportive therapy for the treatment of thrombocytopenia in cirrhotic patients., (Copyright © 2010 S. Karger AG, Basel.)

Education and training to maintain medical safety are very important within clinical settings. We have established a training center for endoscopic surgery and we regularly hold a unique training course, which focuses on the development of fundamental skills. One hundred and ninety-four surgeons who participated in our training course were divided into four groups according to their experience in performing laparoscopic procedures. Group 1: 0-19 laparoscopic procedures (n=44). Group 2: 20-49 laparoscopic procedures (n=53). Group 3: 50-99 laparoscopic procedures (n=46). Group 4: more than 100 laparoscopic procedures (n=55). All subjects underwent evaluation for "Lifting & Grasping" using a virtual reality (VR) simulator, LapSim, before and after the training course. The mean efficiency score, time to completion and tissue damage after training were significantly improved after the training as compared with before training. Before training, subjects with greater experience had better scores. However, the only significant difference in the score was between the low experience group and greatest experience group. After training, the score increased in all groups compared with that before training, and there was no significant difference between groups. This study demonstrates the feasibility of using a VR simulator to assess fundamental skills for endoscopic surgery after training. We found that the scores for the task were associated with the level of experience of the surgeons.

Background: A laparoscopic splenectomy in patients who previously underwent living-donor liver transplantation (LDLT) is thought to be technically difficult because of the presence of severe adhesions and splenomegaly. This report documents the efficacy and safety of a hand-assisted laparoscopic splenectomy (HALS) for hypersplenism in patients after LDLT., Methods: Five patients underwent HALS for hypersplenism after LDLT between 1999 and 2007. The medical records of those patients were retrospectively evaluated., Results: The mean operative time was 237+/-12 minutes. The mean blood loss was 229+/-100 mL and the mean weight of excised spleen was 461+/-46 g. There was no conversion to open surgery. The number of platelets and leukocytes were significantly increased after surgery. No major complications were observed except for a patient who suffered paralytic ileus postoperatively. The mean hospital stay after the operation was 16.7+/-2.5 days., Conclusions: HALS for patients after LDLT is a feasible and safe procedure. This technique can thus become a standard procedure after LDLT.

Background/purpose: The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension., Methods: From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed., Results: There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively., Conclusions: With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Chronic portosystemic encephalopathy (CPSE) resulting from portosystemic shunts (PSS) is a devastating clinical problem. When CPSE is refractory to medical treatment, occlusion of the PSS should be considered. We report a case of CPSE due to a huge paraumbilical vein shunt that was successfully treated with laparoscopic disconnection. A 54-year-old woman diagnosed with liver cirrhosis was referred to our department for treatment of hepatic encephalopathy. She had repeatedly experienced episodes of disturbance of consciousness, and had hyperammoniemia refractory to medical treatment. Computed tomography showed a huge patent paraumbilical vein connected to the systemic circulation through the round ligament. Laparoscopic disconnection of the paraumbilical vein shunt was performed. The postoperative course was uncomplicated and there has been no recurrence of hepatic encephalopathy in the 2 years since, nor has there been a need for further medical treatment. We believe this is the first case report of CPSE treated laparoscopically, and it demonstrates that laparoscopic disconnection of PSS, especially paraumbilical vein shunts, can be a safe and effective procedure to treat CPSE.

Two female patients, 65 and 61 years old, respectively, suffering from a recurrent rectal prolapse underwent laparoscopic rectopexy. Our modified method using an ultrasonically activated scalpel (Harmonic Scalpel) and a laparoscopic suturing device (Endo Stich) both shortened and simplified the operation. The operation times were 140 minutes and 120 minutes, respectively. Neither of the patients demonstrated either intraoperative complications or recurrence of the prolapse during the 24-month follow-up. Our procedure using these new instruments could be performed simply, safely, and in a short time, without the use of a mesh prosthesis.

Background/aims: Laparoscopic splenectomy is now increasingly being performed. However, controversy remains regarding the effectiveness of a laparoscopic splenectomy for patients with portal hypertension., Methodology: Seventy-three patients with portal hypertension who underwent a laparoscopic splenectomy from February 1992 until October 2000 were reviewed and the effectiveness of the procedures for portal hypertension was evaluated. Forty-two patients had esophagogastric varices and twenty had a concomitant hepatocellular carcinoma. The indications for surgery were bleeding tendency due to thrombocytopenia (n = 40), difficulty in receiving treatment for hepatocellular carcinoma due to thrombocytopenia (n = 18), and sclerotherapy-resistant esophagogastric varices (n = 15)., Results: A laparoscopic splenectomy was successfully performed in all the patients. The rate of conversion to conventional open surgery was 9.6% (7/73). The mean operative time was 210.1 +/- 101.9 minutes, and the estimated blood loss was 374.7 +/- 352.4 mL. There were no cases of mortality, and morbidity was encountered in 11.0% of patients. The increase in the platelet count correlated significantly to the spleen weight (P < 0.001). The platelet count had been maintained at over 10 x 10(4)/mm3 for over three years. Eighteen patients with hepatocellular carcinoma successfully underwent treatment for hepatocellular carcinoma after surgery and no recurrence of esophagogastric varices was encountered., Conclusions: A laparoscopic splenectomy resulted in the successful secondary treatment of hepatocellular carcinoma and esophagogastric varices. Portal hypertension was not a contraindication. A laparoscopic approach is therefore the procedure of choice for a splenectomy in portal hypertension.

Laparoscopic abdominal surgery is considered a low-risk procedure for postoperative complications because of reduced surgical stress and earlier mobilization. We report two patients who experienced pulmonary embolism following laparoscopic surgery; one patient underwent umbilical hernia repair and the other cholecystectomy. Although pulmonary embolism is indeed rare after laparoscopic surgery, early detection and early treatment are determinative factors for a good prognosis. Therefore, medical caregivers must remember that pulmonary embolism can be a critical complication after laparoscopic surgery and preventive measures should be employed for high-risk subjects.

Background: Laparoscopic splenectomy has been demonstrated to be technically feasible and safe for the treatment of hematologic diseases., Methods: The study comprised 64 consecutive patients with chronic immune thrombocytopenia purpura (ITP) who were admitted to our hospital from 1992 to 2000 and underwent laparoscopic splenectomy. Forty-one consecutive patients with ITP who underwent open splenectomy performed at the same hospital by the same surgical team between 1986 and 2000 were selected as the control group., Results: We performed laparoscopic splenectomies for ITP, hereditary spherocytosis (HS), malignant lymphoma, autoimmune hemolytic anemia, and cryoglobulinemia. Laparoscopic surgery as compared with open surgery in ITP revealed a significantly lower pain medication requirement, an earlier resumption of oral intake, and a shorter hospital stay, but a longer operative time. During the present study (range: 3.8-80 months), the cumulative rate of nonrecurrence was 67.9% at 5 years after surgery, which was similar to the rate for the previous open splenectomy., Conclusions: Laparoscopic splenectomy is considered to be a suitable alternative therapeutic modality in the treatment of hematologic diseases.

Liver cirrhosis is a critical factor contributing to morbidity and mortality in abdominal surgery, because patients with cirrhosis have a particularly high risk of developing bleeding, infection, and ascites. Laparoscopic appendectomy (LA) recently has gained a lot of attention around the world; however, comparisons between the benefits of LA and those of conventional open appendectomy (OA) for patients with liver cirrhosis have yet to be sufficiently compiled. In the present retrospective study, 40 patients with liver cirrhosis who were diagnosed with acute appendicitis before surgery underwent an appendectomy (OA in 25 patients and LA in 15 patients). This study focused on the operative time, amount of postoperative pain, use of analgesics, the restart of a normal diet, number of complications, length of hospital stay, and cost-effectiveness of the procedure in such patients. The amount of postoperative pain and the length of hospital stay were significantly smaller in the LA group. The mean values of the serum C-reactive protein on postoperative days 1, 3, and 7 were significantly less in the LA group. The number of wound infections and wound bleeding was also less in the LA group. The difference in the total cost of hospitalization was not significant. The cost of the operation was greater in the LA group than in the OA group, whereas the hospitalization cost in the LA group was less than that in the OA group. The results of this study suggest that LA may be superior to OA for the treatment of postoperative pain and postoperative complications for patients with liver cirrhosis. Long-term follow-up studies are still necessary, however, to determine any possible decrease in the number of late complications.

Two cases undergoing a laparoscopic splenectomy for the treatment of a splenic artery aneurysm are herein reported. This lesion is relatively rare. Surgical treatment is indicated for such cases since approximately 10% of these aneurysms tend to rupture which thus results in fatal hemorrhaging. Both cases demonstrated aneurysms measuring more than 2 cm in diameter based on the ultrasonography, computed tomography and celiac angiography findings and, as a result, a laparoscopic splenectomy was thus prophylactically performed. This procedure is the preferred technique for high risk patients, such as those with chronic renal failure, as observed in case 1, since patients can be spared the disadvantages of undergoing a laparotomy.

Background: The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices., Study Design: Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints., Results: The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months)., Conclusions: The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.

In chronic idiopathic thrombocytopenic purpura (ITP), the two main therapeutic choices are steroid treatment or splenectomy. The adult form of ITP is described as a disease found primarily in young adults, with a female predominance. Treatment with steroids effects a complete response in less than 30% of patients, whereas splenectomy is successful in more than 60% of patients who undergo it. The minimal access afforded by laparoscopic splenectomy is considered highly desirable for these patients. The purpose of this study was to compare the clinical benefits of a laparoscopic splenectomy with those of conventional open surgery for patients with ITP. From 1968 to 1993, splenectomy was performed on 51 patients: 10 operations done laparoscopically and 41 performed conventionally. Complications, postoperative pain, recovery, and hospital charges were then compared. Laparoscopic splenectomy involved minimal incisions, and a significantly lower frequency of analgesia was required for postoperative abdominal pain (1.3 vs. 3.3); hospital stay was shorter (8.2 vs. 20.1 days) (p < 0.005). Operative time was significantly longer for the laparoscopic surgery (249.2 vs. 99.8 min) (p < 0.0001), but blood loss was less (176.0 vs. 511.7 g) (p < 0.01). No intraoperative or postoperative major complications occurred with the laparoscopic procedures, compared with 46.3% with conventional surgery. Finally, the total hospital costs were lower with laparoscopic splenectomy, especially for postoperative care (p < 0.05). A laparoscopic splenectomy may well be considered the surgical treatment of choice for patients requiring a splenectomy in view of both quality of life and economy.

A technique for laparoscopic splenectomy is described. The patient is placed in the right semidecubitus position and pneumoperitoneum is prepared. The splenic artery and vein are exposed near the hilum, using a laparoscopic ultrasonic dissector. The larger vessels are doubly ligated, and the spleen is resected and maneuvered into a nylon surgical sack; the sack is removed through a 2-cm incision along the midaxillary line. This procedure has been used for four patients requiring splenectomy for benign disease, and the outcome has been entirely satisfactory for all concerned.

Devascularization of the lower esophagus and the upper stomach is one method of treating patients with clinically significant gastric varices. We describe a new method of laparoscopically-assisted devascularization which has been applied in seven patients with esophagogastric varices. Three of the seven patients had an episode of gastric variceal bleeding, and the remaining four had moderate to large gastric varices with red color signs. The operative procedure was carried out without pneumoperitoneum by using an ordinary forceps and laparoscopic instruments through a small skin incision (3-5 cm); the abdominal wall was elevated with a U-shaped retractor. The operative field was obtained by laparoscopic and direct vision illuminated by laparoscopic light. The procedure time ranged from 100 to 180 minutes with minimal blood loss (70-320 g). No complications were encountered. All patients could be discharged within one week; postoperative pain was minimal and all patients returned to work early. Follow-up (mean 11.4 months) showed no recurrence of gastric varices although, due to an incomplete procedure in two cases, two patients were treated additionally by endoscopic injection of histoacryl.

In a 48-year-old Japanese man there was an uncontrollable and recurrent bleeding from a gastric ulcer and laparoscopic surgery was done. Two cannulae were placed in the gastric cavity through the abdominal wall and suture ligation of the bleeding vessel at the posterior wall of the stomach was done under video-visual control with endoscopic guidance. The bleeding ceased, complications were nil, and he remains well. This article reports on surgery done to repair uncontrollable, recurrent bleeding from a gastric ulcer. Two cannulae were placed in the gastric cavity through the abdominal wall and suture of the vessel at the posterior wall of the stomach was done with videovisual control and endoscopic guidance. This approach is concluded to have supplied minimal-access surgery, cost effectiveness, early discharge, less pain, and doctor-patient satisfaction.

A clear field of vision during laparoscopic cholecystectomy was attained by using a newly designed retractor which elevates the abdominal wall and does not require high-pressure CO2 infusion into the peritoneal cavity. As the abdominal cavity is continuously ventilated, smoke from the cauterization is suctioned off through openings in the middle part of the retractor. There is no interference with placement of ports.