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Background: Creation of a J pouch is the gold standard surgical intervention in the treatment of chronic ulcerative colitis (UC). Pouchoscopy prior to ileostomy takedown is commonly performed. We describe the frequency, indication, and findings on pouchoscopy, and determine if pouchoscopy affects rates of complications after takedown. Methods: All UC or indeterminate inflammatory bowel disease patients with a J pouch were retrospectively evaluated from January 1994 to December 2014. Cases were defined as having routine (asymptomatic) pouchoscopy after pouch creation but before ileostomy takedown. Controls were defined as having no pouchoscopy or pouchoscopy on the same day as that of takedown. Results: The study included 178 patients (81.5% cases, 18.5% controls). Fifty two percent of pouchoscopies were reported as normal. Common abnormal endoscopy findings included stricture (35%), pouchitis (7%), and cuffitis (0.7%). Length of stay during takedown hospitalization was shorter for cases than controls (3 vs. 5 days; p = 0.001), but neither short- nor long-term complications were statistically different between cases and controls. Abnormalities on pouchoscopy were not predictive for short-term complications (p = 0.73) or long-term complications (p = 0.55). Routine pouchoscopy did not delay takedown surgery in any of the included patients. Conclusions: Routine pouchoscopy may not be necessary prior to ileostomy takedown; its greatest utility is in patients with suspected pouch complications.

It is unclear whether intensive surveillance protocols have resulted in a decreased incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD). To determine the prevalence and characteristics of IBD associated high-grade dysplasia (HGD) or CRC that was undetected on prior colonoscopy. This is a single-center, retrospective study from 1994 to 2013. All participants had a confirmed IBD diagnosis and underwent a colectomy with either HGD or CRC found in the colectomy specimen.The undetected group had no HGD or CRC on prior colonoscopies. The detected group had HGD or CRC identified on previous biopsies. Of 70 participants, with ulcerative colitis (UC) (n = 47), Crohn’s disease (CD) (n = 21), and indeterminate colitis (n = 2), 29% (n = 20) had undetected HGD/CRC at colectomy (15 HGD and 5 CRC). In the undetected group, 75% had prior LGD, 15% had indefinite dysplasia, and 10% had no dysplasia (HGD was found in colonic strictures). Patients in the undetected group were more likely to have pancolitis (55 vs. 20%) and multifocal dysplasia (35 vs. 8%). The undetected group was less likely to have CRC at colectomy (25 vs. 62%). There was a trend toward right-sided HGD/CRC at colectomy (40 vs. 20%; p = 0.08). In addition, 84% of the lesions found in the rectum at colectomy were not seen on prior colonoscopy in the undetected group. The prevalence of previously undetected HGD/CRC in IBD found at colectomy was 29%. The high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.

Background Currently reported natural orifice transluminal endoscopic surgery (NOTES) procedures in animals have been done in heterogeneous milieus ranging from nonsterile to sterile procedures, with mixed results, including no infection in those performed in nonsterile settings. Objective To establish the potential frequency of infection during NOTES, comparing sterile to nonsterile approaches. Setting Survival experiments on sixteen 50-kg pigs. Design and Interventions From pilot data (100% infection frequency after nonsterile procedures), sample size (8 animals in each group) was calculated by using a power of 95% and an alpha risk of 0.05. The animals were randomly assigned to two groups: In the transgastric peritoneoscopy study group, liver and ovarian biopsies were performed with sterile overtubes, endoscopes, and accessories and the use of preoperative intravenous antibiotics and antiseptic gastric lavage. In the nonsterile (control) group, the same procedures were performed with nonsterile endoscopes and accessories without the use of gastric lavage and preoperative antibiotics. Complete transmural closure of the transgastric access site was made in all animals. After a 1-week survival time, all animals were killed for necropsy, which included Gram staining and peritoneal cultures. Main Outcome Measurements Intraperitoneal infection on necropsy. Results All necropsies revealed intraperitoneal infection (abscesses, fibrinopurulent exudates, and adhesions) in the control group (frequency of infection 100%). Peritoneal bacterial culture grew various aerobic and anaerobic organisms. No gross or bacteriological evidence of infection was seen in the sterile group (frequency of infection 0%, P value= Limitations Animal experiments. Conclusion Nonsterile conditions invariably lead to intraperitoneal infection. Aseptic techniques during NOTES can prevent intra-abdominal infection. Future studies will determine which infection prevention steps are mandatory and which can be omitted during NOTES procedures.

We have shown previously that abdominal insufflation with CO(2) increases serum levels of IL-10 and TNFalpha and increases survival among animals with lipopolysaccharide (LPS)-induced sepsis, even after a laparotomy. We demonstrated previously that the effect of CO(2) is not from changes in systemic pH, although the peritoneum is locally acidotic during abdominal insufflation with CO(2) even when systemic pH is corrected. We hypothesized that acidification of the peritoneum via means other than CO(2) insufflation would produce alterations in the inflammatory response similar to those associated with CO(2) pneumoperitoneum.In total, 42 rats were randomized into 7 groups (n = 6): 1) LPS only, 2) anesthesia control, 3) helium pneumoperitoneum, 4) CO(2) pneumoperitoneum, 5) buffered mild acid lavage, 6) buffered strong acid lavage, and 7) buffered strong acid lavage + helium pneumoperitoneum. Animals received anesthesia with vaporized isoflurane (except the LPS-only group) and their respective abdominal treatment (pneumoperitoneum and/or lavage) for 30 min followed immediately by stimulation with systemic LPS (1 mg/kg, IV). Blood was harvested via cardiac puncture 60 min after LPS injection, and serum levels of IL-10 and TNFalpha levels were determined by enzyme-linked immunosorbent assay.Mean peritoneal pH decreased (P.05) after CO(2) pneumoperitoneum, buffered strong acid lavage, and buffered strong acid lavage + helium pneumoperitoneum, and it decreased (P = .1) after helium pneumoperitoneum alone and buffered mild acid lavage. IL-10 levels were increased (P.01), and TNFalpha levels decreased (P.001) among animals with acidic peritoneal cavities compared with animals with pH-normal peritoneal cavities. Decreasing peritoneal pH correlated with both increasing IL-10 levels (r = -.465, P.01) and decreasing TNFalpha levels (r = 0.448, P.01). Among animals with peritoneal acidosis, there were no differences in levels of IL-10 or TNFalpha regardless of insufflation status (P.05 for both cytokines).Acidification of the peritoneal cavity whether by abdominal insufflation or by peritoneal acid lavage increases serum IL-10 and decreases serum TNFalpha levels in response to systemic LPS challenge. The degree of peritoneal acidification correlates with the degree of inflammatory response reduction. These results support the hypothesis that pneumoperitoneum-mediated attenuation of the inflammatory response after laparoscopic surgery occurs via a mechanism of peritoneal cell acidification.

Pancreatic duct stenting remains an attractive strategy to reduce the incidence of pancreatic fistulas following pancreaticoduodenectomy (PD) with encouraging results in both retrospective and prospective studies. We performed a prospective randomized trial to test the hypothesis that internal pancreatic duct stenting reduces the development of pancreatic fistulas following PD. Two hundred thirty-eight patients were randomized to either receive a pancreatic stent (S) or no stent (NS), and stratified according to the texture of the pancreatic remnant (soft/normal versus hard). Four patients were excluded from the study; in three instances due to a pancreatic duct that was too small to cannulate and in the other instance because a total pancreatectomy was performed. Patients who randomized to the S group had a 6-cm-long segment of a plastic pediatric feeding tube used to stent the pancreaticojejunostomy anastomosis. In patients with a soft pancreas, 57 randomized to the S group and 56 randomized to the NS group. In patients with a hard pancreas, 58 randomized to the S group and 63 randomized to the NS group. The S and NS groups for the entire study population, as well as for the subgroup of high-risk patients with soft pancreata, were similar as regard to demographics, past medical history, preoperative symptoms, preoperative procedures, and intraoperative data. The pancreatic fistula rate for the entire study population was 9.4%. The fistula rates in the S and NS subgroups with hard pancreata were similar, at 1.7% and 4.8% (P = 0.4), respectively. The fistula rates in the S and NS subgroups with soft pancreata were also similar, at 21.1% and 10.7% (P = 0.1), respectively. A nonstatistically significant increase in the pancreatic fistula rate in the S group persisted after adjusting for the operating surgeon and technical details of the operation (e.g., anastomotic technique, anastomotic orientation, pancreatic duct size, and number of intra-abdominal drains placed). In patients with soft pancreata, 63% percent of the pancreatic fistulas in stented patients required adjustment to the clinical pathway (including two deaths), compared to 47% of the pancreatic fistulas in patients in the NS group (P = 0.3). Internal pancreatic duct stenting does not decrease the frequency or the severity of postoperative pancreatic fistulas.

Laparoscopic surgery preserves the immune system and has anti-inflammatory properties. CO2 pneumoperitoneum attenuates lipopolysaccharide (LPS)-induced cytokine production and increases survival. We tested the hypothesis that CO2 pneumoperitoneum mediates its immunomodulatory properties via stimulation of the cholinergic pathway.In the first experiment, rats (n = 68) received atropine 1 mg/kg or saline injection 10 min prior to LPS injection and were randomization into four 30-min treatment subgroups: LPS only control, anesthesia control, CO2 pneumoperitoneum, and helium pneumoperitoneum. In a second experiment, rats (n = 40) received atropine 2 mg/kg or saline 10 min prior to randomization into the same four subgroups described previously. In a third experiment, rats (n = 96) received atropine 2 mg/kg or saline 10 min prior to randomization into eight 30-min treatment subgroups followed by LPS injection: LPS only control; anesthesia control; and CO2 or helium pneumoperitoneum at 4, 8, and 12 mmHg. In a fourth experiment, rats (n = 58) were subjected to bilateral subdiaphragmatic truncal vagotomy or sham operation. Two weeks postoperatively, animals were randomized into four 30-min treatment subgroups followed by LPS injection: LPS only control, anesthesia control, CO2 pneumoperitoneum, and helium pneumoperitoneum. Blood samples were collected from all animals 1.5 h after LPS injection, and cytokine levels were determined by enzyme-linked immunosorbent assay.Serum tumor necrosis factor-alpha (TNF-alpha) levels were consistently suppressed among the saline-CO2 pneumoperitoneum groups compared to saline-LPS only control groups (p0.05 for all four experiments). All chemically vagotomized animals had significantly reduced TNF-alpha levels compared to their saline-treated counterparts (p0.05 for all), except among the CO2 pneumoperitoneum-treated animals. Increasing insufflation pressure with helium eliminated differences (p0.05) in TNF-alpha production between saline- and atropine-treated groups but had no effect among CO2 pneumoperitoneum-treated animals. Finally, vagotomy (whether chemical or surgical) independently decreased LPS-stimulated TNF-alpha production in all four experiments.CO2 pneumoperitoneum modulates the immune system independent of the vagus nerve and the cholinergic pathway.

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

Carbon dioxide (CO(2))-pneumoperitoneum is known to favorably modify the systemic immune response during laparoscopic surgery. The presented studies were designed to determine whether treating animals with CO(2) abdominal insufflation before undergoing a lipopolysaccharide (LPS)-contaminated laparotomy would serve as "shock prophylaxis" and thus improve survival and attenuate cytokine production. Rats were randomized into five groups: CO(2)-pneumoperitoneum, helium-pneumoperitoneum, anesthesia control, laparotomy/LPS control, and LPS only control. Animals in the first four groups all received a laparotomy and a lethal dose of LPS. Immediately preceding their laparotomy, animals in the pneumoperitoneum groups received a 30-minute pretreatment of abdominal insufflation with either CO(2) or helium. The anesthesia control group received a 30-minute pretreatment of isoflurane. Animal mortality was then recorded during the ensuing 72 hours. Subsequently, a similar protocol was repeated for measurements of cytokines. CO(2)-pneumoperitoneum increased survival at 48 hours compared with LPS control (P.05), and decreased interleukin-6 plasma levels at 2 hours (P.05). Abdominal insufflation with CO(2) before the performance of a laparotomy contaminated with endotoxin increases survival and attenuates interleukin-6. The beneficial immune-modulating effects of CO(2)-pneumoperitoneum endure after abdominal insufflation. CO(2)-pneumoperitoneum pretreatment may improve outcomes among patients undergoing gastrointestinal surgery who are at high risk for abdominal fecal contamination.

Paragangliomas of the organ of Zuckerkandl are rare tumors with only several case reports noted in the literature. Synchronous paraganglioma occur sporadically, and on occasion, in association with several genetic syndromes. Paraganglioma of the organ of Zuckerkandl with synchronous carotid body paraganglioma is described herein. Traditionally, surgical resection of abdominal paraganglioma involved an exploratory laparotomy. In this manuscript, we describe one of the first reported laparoscopic resections of this tumor and review the literature on multiple paragangliomas and their associated genetic syndromes.

We have shown that the inflammation-attenuating effects of CO2 pneumoperitoneum during laparoscopy are not due to changes in systemic pH. However, acidification of peritoneal macrophages in an in vitro CO2 environment has been shown to reduce LPS-mediated cytokine release. We tested the hypothesis that the peritoneum is locally acidotic during abdominal insufflation with CO2deven when systemic pH is corrected. Rats (n = 20) were anesthetized and randomized into two groups: continued spontaneous ventilation (SV) or intubation and mechanical ventilation (MV). All animals were then subjected to abdominal insufflation with CO2. Mean arterial pH among SV rats decreased significantly from baseline after 15 and 30 minutes of CO2 pneumoperitoneum (7.329→7.210→7.191, P < 0.05), while arterial pH among MV rats remained relatively constant (7.388→7.245→7.316, P = NS). In contrast, peritoneal pH dropped significantly from baseline and remained low for both groups during CO2 abdominal insufflation (SV 6.74 → 6.41 → 6.40, P < 0.05; MV 6.94 → 6.45 → 6.45, P < 0.05). In a second experiment, rats (n = 10) were randomized to receive abdominal insufflation with either CO2 or helium. Abdominal insufflation with helium did not significantly affect peritoneal pH (7.10 → 7.02 →6.95, P = NS), and the decrease in pH among CO2-insufflated animals was significant compared with helium-insufflated animals (P < 0.05). Peritoneal pH returned to baseline levels in all groups within 15 minutes of desufflation in both experiments. A significant local peritoneal acidosis occurs during laparoscopy which is specifically attributable to the use of CO2 and which is independent of systemic pH. These data provide additional evidence that localized peritoneal acidosis is central to the mechanism of CO2-mediated attenuation of the inflammatory response following laparoscopic surgery.

BACKGROUND: The dawn of laparoscopic surgery and the telecommunications revolution have given birth to the field of telesurgery. METHODS: Even now, surgery is being performed over great distances to bring expert surgical care to physically isolated patients with otherwise limited healthcare access. RESULTS: As technical obstacles are eliminated in the future, telesurgery will extend the reach of military surgeons to patients at sea and on the battlefield, and astronauts will undergo procedures performed by earthbound interventionalists. Just as the Internet has revolutionized the way everyday consumers shop, eventually, telesurgery may transform surgical care, as patients may stay in their local hospitals and simply "dial up" the best telesurgeon for their specific operation. Telesurgical teams have now formed to refine technical approaches to telesurgery, study the effects of telesurgery on human task performance, and establish telesurgery networks around the world. CONCLUSIONS: While some legitimate social, political, and economic issues remain as impediments to the routine practice of telesurgery, there is now no question that telesurgery will play a role in the delivery of surgical care in the twenty-first century.

Background Peritoneal absorption of CO2 during abdominal insufflation in laparoscopy may disrupt the acid-base equilibrium and alter the physiological response to stress. Current nonventilated rodent models of laparoscopy do not manage the CO2 load of pneumoperitoneum, but ventilated surgical rodent models are invasive (tracheotomy) and may independently induce the inflammatory response. Materials and methods A comprehensive rodent model of laparoscopy was developed. Rats were randomized to receive anesthesia alone, anesthesia plus CO2 pneumoperitoneum, or anesthesia plus CO2 pneumoperitoneum with videoendoscopic intubation and mechanical ventilation. Arterial blood-gas analysis was performed at baseline and after 30 min of intervention. Results Baseline pH, pCO2, and HCO3− arterial blood gas parameters were normal for all rats. After 30 min, pCO2 and pH changed slightly but remained normal among rats receiving anesthesia alone (pCO2 = 46.5 ± 1.9; pH = 7.365 ± 0.009) whereas animals receiving anesthesia plus CO2 pneumoperitoneum that were dependent on spontaneous respiration for ventilation developed significant hypercarbic acidosis (pCO2 = 53.2 ± 1.9, P Conclusions CO2 pneumoperitoneum induces significant hypercarbic acidosis in nonventilated rats. Noninvasive endotracheal intubation is feasible in the rat with videoendoscopic assistance. Our noninvasive rodent model of laparoscopic surgery controls for anesthesia- and capnoperitoneum-related acid-base changes and provides an environment in which the biological response to pneumoperitoneum can be studied precisely.

Introduction The “Nintendo” surgery revolution, which began in 1987, has impacted every surgical specialty. However, our operating rooms remain isolated worlds where surgeons use awkward, primitive, rigid instruments with suboptimal visualization. We need “smart instruments,” “smart technology,” and “smart imaging.” Is surgical robotics the answer? Methods We provide an analysis of current surgical technology and skills, propose criteria for what the next generation of surgical instruments and technology should achieve, and then examine the evolution and current state of surgical robotic solutions, assessing how they answer future surgical needs. Finally we report on the U.S. Military's early experience with surgical robotics and the lessons learned therein. Results Current surgical robotic technology has made remarkable progress with miniaturization, articulating hand-imitating instruments, precision, scaling, and three-dimensional vision. The specialty-specific early clinical applications reviewed are promising, but they do have limitations. Surgical robotics offers enormous military application potential. Needed future refinements are identified, including haptics, communications, infrastructure, and information integration. Conclusions Laparoscopic surgery is a transition technology, constrained by instrument, equipment, and skill limitations. Surgical robotics or, more properly, computer-assisted surgery may be the key to the future. The operating room of the future will be an integrated environment with global reach. Surgeons will operate with three-dimensional vision, use real-time three-dimensional reconstructions of patient anatomy, use miniaturized minimally invasive robotic technology, and be able to telementor, teleconsult, and even telemanipulate at a distance, thus offering enhanced patient care and safety.

OBJECTIVES Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to urologic training and the care of patients in remote regions. The multiple arms and three-dimensional vision of the da Vinci robotic system provide a platform conducive to long-distance telementoring and telesurgery. Whereas prior telesurgical efforts have used dedicated lines for information transmission, the public Internet offers a less expensive alternative. It was the intent of this study to test the validity of using the da Vinci system in urologic telesurgery, and to conduct telerobotic nephrectomies using the public Internet. METHODS We performed four right nephrectomies in porcine models using the da Vinci robotic system. Telementoring and telesurgical approaches were used, with resident surgeons operating a console adjacent to the swine, while attending surgeons simultaneously operated a second console at distances of 1300 and 2400 miles from the operating room. RESULTS All four procedures and both telementoring and telesurgical models were successful. Round-trip delays from 450 to 900 ms were demonstrated. Blood loss was minimal, and there were no intraoperative complications. CONCLUSIONS This study represents the first use of the da Vinci Surgical System in urologic telesurgery and the first successful telesurgical nephrectomy in an animal model.

Importance High-dose glucocorticoids (GCs) are routinely given to surgical patients with a history of GC exposure to prevent perioperative acute adrenal insufficiency, but this practice is not well supported. Objective To evaluate the variability of perioperative GC dosing among patients with inflammatory bowel disease (IBD) undergoing major abdominal surgery. Design, Setting, and Participants This was a retrospective study of 49 patients with IBD undergoing colorectal surgery at a single institution between July 2010 and August 2011. Data on patient comorbidities, intraoperative risk factors, surgical site infections, and 30-day readmission rates were prospectively collected from the National Surgical Quality Improvement Program. Preoperative GC exposure at the time of the index admission and perioperative GC therapy during admission were collected by review of the medical records. Patients were divided into 3 groups at the time of surgery: (1) 1 week or more of prior GC exposure, not receiving maintenance therapy (n = 15); (2) currently receiving budesonide (n = 10); and (3) currently receiving oral prednisone (n = 24). Main Outcomes and Measures Perioperative GC exposure was the main outcome. Qualitative comparisons of perioperative exposure stratified by preoperative GC exposure were done. A multivariate logistic regression analysis was performed to determine significant differences in surgical site infection and 30-day readmission rates among patients with and without perioperative GC exposure. Results Overall, 38 of 49 patients (78%) received perioperative GCs; intraoperative GCs were administered to 35 of 49 patients (71%), and 33 of 49 patients (67%) received postoperative GCs. Patients received intraoperative and postoperative GCs, respectively, as follows: 8 patients (53%) and 7 (47%) in group 1, 7 (70%) and 3 (30%) in group 2, and 20 (83%) and 23 (96%) in group 3. The median intraoperative GC dose was 100 mg (range, 50-267 mg of hydrocortisone or hydrocortisone equivalent for dexamethasone); the median total postoperative GC dose for the first 5 days after surgery was 485 mg (range, 50-890 mg of hydrocortisone or hydrocortisone equivalent for prednisone). The median duration of postoperative GC administration was 3 days for group 1, 6 days for group 2, and 7 days for group 3. No statistically significant difference in surgical site infection and 30-day readmission rates was detected in the GC exposure vs no-exposure groups. Conclusions and Relevance Perioperative GC dosing among patients with IBD undergoing colorectal surgery is highly variable even within a single center. Additional studies are needed to define the risk of postoperative adrenal insufficiency and establish standardized practices for perioperative GC therapy, which may have the benefit of reducing GC overuse.

Objective This study provides the first objective assessment of a complete patient population undergoing laparoscopic cholecystectomy in the steady state. The authors determined the frequency of complications, particularly bile duct, bowel, vascular injuries, and deaths. Summary Background Data This retrospective study, conducted for the Department of Defense healthcare system by the Civilian External Peer Review Program, is the second complete audit of laparoscopic cholecystectomy. Data were collected on 9130 patients undergoing laparoscopic cholecystectomy between January 1993 and May 1994. Methods The study sample consisted of clinical data abstracted from the complete records of 9054 (99.2%) of the 9130 laparoscopic cholecystectomies performed at 94 military medical treatment facilities. Results Of 10,458 cholecystectomies performed in the Military Health Services System, 9130 (87.3%) were laparoscopic and 1328 (12.7%) were traditional open procedures. Seventy-six medical records were incomplete; however, there was sufficient data to determine mortality and bile duct injury rates. Of the remaining 9054 cases, 6.09% experienced complications, including bile duct (0.41%), bowel (0.32%), and vascular injuries (0.10 percent). The mortality rate was 0.13%. Access via Veress technique was used in 57.6% and Hasson technique in 42.4% of patients. Intraoperative cholangiograms were performed in 42.7% of the cases with a success rate of 86.2%. Eight hundred ninety-two (9.8%) patients were converted to open cholecystectomies. Conclusions In the steady state, despite an increase in the percentage of laparoscopic cholecystectomies performed for nonmalignant gallbladder disease, there continues to be minimal complications and low mortality.

OBJECTIVE: This study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. SUMMARY BACKGROUND DATA: This is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. METHODS: The study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. RESULTS: Of the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. CONCLUSIONS: The frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.

Background Closure of the transgastric access to the peritoneal cavity is a critical step in natural orifice transluminal endoscopic surgery (NOTES). Objective To perform a direct comparison of the histological healing post clips and threaded tags (T-tags) closure after transgastric NOTES procedures. Setting: Design and Intervention Twelve survival porcine experiments. After standardized endoscopic gastric wall puncture, balloon-dilation, and transgastric peritoneoscopy, closure of the gastric wall was performed with either clips or T-tags. Necropsy at 14 days was performed for histological evaluation of 2-mm interval transversal cross sections of the gastrotomy site. Main Outcome Measurements Histological healing of the gastric wall opening. Results Endoscopic closure of the gastrotomy was successfully achieved in all 12 animals, followed by an uneventful 2-week clinical follow-up. Transmural healing was seen in 3 (75%) animals after clip closure compared with only 1 (12.5%) in the group with T-tag closure ( P = .06). Gastric wall muscular bridging was observed in 4 (100%) animals with clip closure compared with only 1 (12.5%) in the group with T-tag closure ( P = .01). Limitations Animal model with short-term follow-up. Conclusions Endoscopic clip closure results in a layer-to-layer transmural healing of the gastric wall. In contrast, T-tag gastric wall plication impairs gastric layer bridging. These findings might guide the future design of new endoscopic devices and techniques for gastrotomy closure after NOTES procedures.

Background and study aims: Minimizing the invasiveness of operations by using natural orifice transluminal endoscopic surgery (NOTES) may reduce adhesion formation. The aim of the study was to compare rates of adhesion formation after peritoneoscopy with liver biopsy by laparotomy, laparoscopy, and transgastric NOTES. Materials and methods: Experimental comparative survival study, at a university hospital. using 18 female pigs weighing 35 - 40 kg. Peritoneoscopy with liver biopsy was randomized to one of three groups: laparotomy, laparoscopy, and transgastric NOTES. Preoperative, operative, and postoperative care was standardized. Main outcome measures were: (i) survival and complication rates; (ii) assessment of adhesion formation using the Hopkins Adhesion Formation Score at necropsy (day 14). Results: 100 % of pigs with laparotomy and 33.3 % with laparoscopy had adhesions compared with 16.7 % who underwent transgastric NOTES. Documented adhesion bands totals for each group were: transgastric NOTES 1; laparoscopy 4; laparotomy 17. Median adhesion formation scores were: laparotomy 2.5 (range 2 - 4), compared with laparoscopy 0.0 (0 - 2), and transgastric NOTES 0.0 (0 - 1) ( P < 0.001). Spearman coefficient analysis revealed that correlation between adhesion scores assigned by two investigators was excellent (r = 0.99, P < 0.001, 95 % confidence interval [CI] 0.9978 - 0.9996). Conclusions: Although this was a short-term study, with a low number of animals, it showed that transgastric NOTES and laparoscopy are associated with statistically significantly lower rates of adhesion formation than open surgery when peritoneoscopy with liver biopsy is performed. Incidence and severity of adhesions were lowest with transgastric NOTES.

“Robotic surgery” originated as an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted by the medical community. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote telepresence manipulators” because available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon. For example, in laparoscopic surgery, the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from the use of current robotic devices, whereby the surgeon sits at a console, typically in the operating room but outside the sterile field, directing and controlling the movements of one or more robotic arms. Although the surgeon still maintains control over the operation, the control is indirect and effected from an increased distance. This definition of robotic surgery encompasses micromanipulators, remotely controlled endoscopes, and console-manipulator devices. The key elements are enhancements of the surgeon’s abilities—be they vision, tissue manipulation, or tissue sensing—and alteration of the traditional direct local contact between surgeon and patient.

Background Ventral hernia repair is currently performed via open surgery or laparoscopic approach. Objective To develop an alternative ventral hernia repair technique. Setting Acute and survival experiments on twelve 50-kg pigs. Design and Interventions An endoscope was introduced transgastrically into the peritoneal cavity. An abdominal wall hernia was created through a 5-mm skin incision followed by a 5-cm-long incision of the abdominal wall muscles and aponeurosis. A hernia repair technique was developed in 3 acute experiments. Then animals were randomized into 2 groups. In the experimental group (5 animals) Gore-Tex mesh was transgastrically attached to the abdominal wall, repairing the previously created abdominal wall hernia. In the control group (4 animals), the hernia was not repaired. In both groups, the endoscope was then withdrawn into the stomach, and the gastric wall incision was closed with T-bars. The animals survived for 2 weeks and were then euthanized. Main Outcome Measurement The presence of ventral hernia on necropsy. Results In the control group, the ventral hernia was present on necropsy in all animals. In the experimental group, the ventral hernia was easily repaired, with no evidence of hernia on necropsy. In the first animal in the experimental group, necropsy revealed infected mesh. After this discovery, we used sterilized cover for mesh delivery and did not find any signs of infection in 4 subsequent study animals. Limitation The study was performed in a porcine model. Conclusions Transgastric ventral hernia repair is feasible, technically easy, and effective. It can become a less invasive alternative to the currently used laparoscopic and surgical ventral hernia repair.

Carbon dioxide (CO(2)) pneumoperitoneum alters the inflammatory response in animal models of sepsis. The spleen is a key organ in inflammation and its removal was predicted to modify this effect.The acute phase inflammatory response to lipopolysaccharide (LPS) challenge in male rats was examined for the effects of splenectomy (spx) and the technique of removal (open or laparpscopic). A series of experiments compared LPS-only controls with LPS injection 2 or 9 days following open spx, lap CO2 spx, open sham, or lap CO2 sham. The method of splenectomy was studied by randomization to control, open spx, lap CO2 spx, lap helium (He) spx, or lap air spx with LPS challenge on postoperative day 2. Serum levels of tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (INF-gamma) and, interleutin (IL) 10 were collected at multiple time points, assayed by commercial enzyme-linked immunosorbent assay, analyzed by analysis of variance.Levels of TNF-alpha at 1.5 were significantly lower following open sham than following lap sham (p0.05). Splenectomy drastically reduced INF-gamma and TNF-alpha levels compared to controls (p0.05) on postoperative day 2. No method of spx preserved TNF-alpha or INF-gamma responses. Recovery of TNF-alpha response on day 9 was delayed in the spx groups.Splenectomy dramatically reduces TNF-alpha and INF-gamma responses to LPS challenge, although by different mechanisms. Pneumoperitoneum-mediated modulation of the septic inflammatory response is partially dependent on the spleen.

We report results from a single surgeon’s 10-year team experience with laparoscopic total abdominal colectomy. We review our series, which includes a large subgroup of ill, high-risk patients with acute colitis requiring urgent surgery. From 1993 to 2003, we performed 65 laparoscopic total abdominal colectomies. All patients referred for total abdominal colectomy were offered the laparoscopic approach. We prospectively collected the following data on all patients: demographics, surgical indications, preoperative status, duration of surgery, intraoperative blood loss, operative complications, length of stay, subsequent operations, patient satisfaction, and lessons learned from our team experience. Preoperative diagnoses included ulcerative colitis (n = 55), Crohn’s colitis (n = 3), colonic inertia (n = 4), and familial adenomatous polyposis (n = 3). Among the patients with inflammatory bowel disease, 70% of cases were performed on ill patients, refractory to medical management, requiring urgent surgery. This subgroup was managed with laparoscopic total abdominal colectomy and Brooke ileostomy, with ileoanal pouch anastomosis deferred. Operative times were long, ranging from 6 to 11 hours. Mean intraoperative blood loss was 200 ml. Mean length of stay was 4.3 days and ranged from 2 to 13 days. There were no conversions to open surgery and there were no deaths. Complications occurred in 12% of patients and included intra-abdominal abscess (n = 2), wound infection (n = 3), stoma stenosis (n = 1), and incisional hernia (n = 2). Postoperative patient satisfaction was high. Subsequent operations, including restorative proctectomy, were also performed laparoscopically. Laparoscopic total abdominal colectomy is technically challenging and requires a team approach but offers patients significant benefit in length of stay and surgical recovery. This operation can be effectively used with minimal morbidity in difficult, ill patients requiring urgent surgery.

Anesthetics attenuate cytokine production in various models of endotoxic shock. Few studies have shown the effect of anesthetics on the ultimate end-point, death. The literature suggests Isoflurane can inhibit the onset but not the progression of the inflammatory cascade. Thus, we hypothesize that Isoflurane will increase survival of rats receiving a lethal dose (LD50) of bacterial lipopolysaccharide (LPS) and that this protective effect requires that Isoflurane be given before the endotoxic insult. The effect of Isoflurane on mortality was studied by inducing sepsis using the LD50 of LPS in male Sprague-Dawley rats. Rats were fasted and then randomized into 4 groups: Isoflurane 2 h before LPS, Isoflurane and LPS simultaneously, or Isoflurane 2 h after LPS. All 3 groups received 30 min of Isoflurane 2%. The fourth group received LPS alone without any durable exposure to Isoflurane. Rats were observed for survival. Isoflurane pretreatment increased survival by 30% compared to LPS alone and was significantly better compared to simultaneous or posttreatment (P < 0.011). Rats that received Isoflurane simultaneously with or after LPS had 20% less survival then rats in the LPS alone group. Isoflurane is recognized as having potent anti-inflammatory effects. These effects can significantly increase survival in the rat model of sepsis. The protective effect of Isoflurane necessitates administration prior to the inflammatory insult. The use of Isoflurane may be useful in critical care patients who face a profound septic risk such as burn victims. Download full-size image

Introduction. CO 2 pneumoperitoneum is known to have beneficial immune effects in laparoscopic surgery. However, the effects of CO 2 pneumoperitoneum preconditioning on the immune response to conventional surgery are unknown. The purpose of this study was to determine if CO 2 pneumoperitoneum preconditioning would reduce the cytokine response to lipopolysaccharide (LPS) sepsis and laparotomy. Materials and Methods. Thirty-two rats ( n = 8) were randomized into four groups: CO 2 pneumoperitoneum, helium pneumoperitoneum, anesthesia control, and laparotomy/LPS only control. The first three groups received 30 min of preconditioning with their respective treatments followed by laparotomy for another 30 min. Simultaneously to laparotomy, rats received intraperitoneal Escherichia coli LPS (1 mg/kg). The laparotomy/LPS only control group received no preconditioning. In a second experiment, 40 rats ( n = 10) were subjected to the same conditions described above but with the laparotomy being closed immediately following LPS injection. Blood samples for serum cytokine assays were collected via cardiac puncture from all animals 2 h following LPS injection. Results. Compared to laparotomy/LPS only control, plasma levels of IL-6 were depressed 30% by anesthesia preconditioning, 55% by He-pneumoperitoneum preconditioning, and 84% by CO 2 -pneumoperitoneum preconditioning. In the second experiment, IL-6 levels were depressed 8.9% by anesthesia-preconditioning, 9.6% by He-pneumoperitoneum, and 49% by CO 2 -pneumoperitoneum compared to laparotomy/LPS only control. Conclusions. CO 2 pneumoperitoneum preconditioning down regulates subsequent serum IL-6 expression in response to LPS-induced sepsis even in the setting of a laparotomy. Furthermore, the immune modulating effects of CO 2 pneumoperitoneum endure for a number of hours following abdominal insufflation regardless of the duration of open peritoneal exposure to the ambient environment. CO 2 pneumoperitoneum preconditioning may protect the critically ill surgery patient from the inflammatory response associated with sepsis and surgical celiotomy.