Technical Progress in Single-Incision Laparoscopic Cholecystectomy in Our Initial Experience

Single-incision laparoscopic cholecystectomy (SILC) has rapidly spread throughout the world because of its low invasiveness and because it is a scarless procedure. Various surgical methods of performing SILC are present in each institute; however, it is necessary to develop a standardized procedure that we can perform safely, such as the conventional 4-port laparoscopic cholecystectomy (LC). The SILC experiment in our institute was started by use of the commercial SILS Port and changed from a 3-port method via an umbilicus to a 2-port method to improve some problems. Although none of the conversions to conventional 4-port LC and also none of the complications such as bile duct injury occurred in each method, the 2-port method functioned best and was also economical. However, it is most important to adopt strict criteria and select the patients suitable for SILC to demonstrate SILC safety same as 4-port LC

A Non-Randomized Comparative Study of Laparoscopy-Assisted Pancreaticoduodenectomy and Open Pancreaticoduodenectomy

Background/Aims: Laparoscopic surgery for periampullary disease is still a challenging operation. The aim of this study was to compare the perioperative outcomes of patients undergoing conventional pancreaticoduodenectomy (PD) with the outcomes of those undergoing laparoscopy-assisted PD. Methodology: A retrospective analysis was conducted on 51 consecutive patients who underwent laparoscopy-assisted or open PD for periampullary disease. Results: There were no significant differences in the preoperative demographic or clinical data of the two study groups. Although there were no significant differences in the operative time between the two study groups, blood loss in the laparoscopy-assisted PD group was significantly smaller than that in the open PD group. There were no significant differences in the occurrence of postoperative complications between the two groups. Conclusions: Laparoscopy-assisted PD is a feasible and safe surgical procedure that provides the advantages expected from a minimally invasive surgery including less blood loss

Minimally invasive surgical necrosectomy for infected walled-off necrosis using endoscopy with the flexible overtube technique : A case report

Background: Minimally invasive surgery with a step-up approach is essential for treating infected walled - off necrosis (WON) which has a high mortality rate. Percutaneous endoscopic necrosectomy with a flexible overtube which has various advantages is performed in our institution. We herein introduce safety and easy percutaneous endoscopy with flexible overtube technique for minimally invasive surgical necrosectomy.Case presentation: The patient was placed in the supine position and tilted to the right lateral side. The skin was incised 8cm according to the situated percutaneous drains. Following the tract of the drain, the cavity of infected WON was reached in the retroperitoneum. The percutaneous drain was removed, and a flexible overtube was inserted. An endoscope was inserted through the flexible overtube. The necrosis was then crushed with saline flushing and removed by suction or forceps. A new drain was placed in the cavity to allow continuous drainage after surgery. Necrosectomy should be limited to a glimpse of normal granulation tissue, as aggressive debridement carries a risk of bleeding and/or organ injury. Using the step-up approach, endoscopy may be useful in cases of minimal residual necrosis.Conclusion: Percutaneous endoscopy with the flexible overtube technique for minimally invasive surgical necrosectomy is easy to perform and safe for treating infected WON

Single-incision laparoscopic distal pancreatectomy.

Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery, and rapidly evolving in the field of abdominal surgery. However, SILS is not a common procedure for pancreatic surgery. We describe our first experience with a SILS approach in a patient with a metastatic pancreatic tumor. We performed a SILS distal pancreatectomy (SILS-DP) using 3 trocars placed through a single port at an umbilical incision. In our case, the most important surgical technique was the stomach-hanging method to obtain a favorable laparoscopic view of the pancreas. Although SILS-DP is a safe and feasible procedure, further studies are required to determine the advantages of this procedure in comparison with the standard laparoscopic method

Combined pancreatic resection and pancreatic duct-navigation surgery for multiple lesions of the pancreas: intraductal papillary mucinous neoplasm of the pancreas concomitant with ductal carcinoma of the pancreas.

When a branch-type IPMN of the uncinate process is concomitant with ductal carcinoma of the body of the pancreas, total pancreatectomy may be recommended. However, a decrease in quality of life becomes a serious problem after total pancreatectomy because of the abolition of endocrine and exocrine pancreatic function. We proposed the combined resection, which consists of resection of the uncinate process of the pancreas with distal pancreatectomy. This surgical procedure of combined resection is most suitable for preservation of the pancreatic functions. In addition, we recommend the pancreatic duct-navigation surgery to enable us to prevent injury to the main pancreatic duct, and to dissect at the optimal cutting point of the pancreatic branch duct

Gastric wall-covering method prevents pancreatic fistula after distal pancreatectomy

Background/Aims: Pancreatic fistula is the most common complication after distal pancreatectomy. The aim of this study was to evaluate retrospectively the usefulness of a new surgical technique, the gastric wall-covering method, after distal pancreatectomy. Methodology: The study group consisted of 53 patients who underwent distal pancreatectomy. The management of the stump of the remnant pancreas was accomplished by the gastric wall-covering method (GWC group, n=20) or by conventional surgery (CS group, n=33). In the gastric wall-covering method, the cut surface of the pancreas is fixed to the posterior wall of the gastric body. Results: There were no significant differences in operating time, intraoperative blood loss, or texture of the remnant stump between the two groups. Postoperative pancreatic fistula was diagnosed in 1 patient (5.0%) in the GWC group and in 12 patients (36.4%) in the CS group (P=0.01). Conclusions: The gastric wall-covering method for the management of the pancreatic stump after distal pancreatectomy reduces the incidence of postoperative pancreatic fistula

Evaluation of Preoperative Magnetic Resonance Cholangiopancreatography in Acute Cholecystitis to Predict Technical Difficulties in Laparoscopic Cholecystectomy

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique that provides high-quality visualization of the biliary tree, including the gallbladder. This study aimed to evaluate the useful-ness of preoperative MRCP for acute cholecystitis in predicting technical difficulties during laparoscopic chole-cystectomy (LC). A total of 168 patients who underwent LC with preoperative MRCP were enrolled in this study. Patients were divided into two groups according to preoperative MRCP findings: the visualized group (n = 126), in which the entire gallbladder could be visualized; and the non-visualized group (n = 42), in which the entire gallbladder could not be visualized. The perioperative characteristics and postoperative complica-tions of the two groups were retrospectively analyzed. Operation time was longer in the non-visualized group (median 101.5 vs. 143.5 min; p < 0.001). The non-visualized group had significantly more intraoperative blood loss than the visualized group (median 5 vs. 10 g; p = 0.05). The rate of conversion to open cholecystectomy was significantly higher in the non-visualized group (1.6 vs. 9.5%; p = 0.03). In conclusion, patients in the non- visualized group showed higher difficulty in performance of LC. Our MRCP-based classification is a simple and effective means of predicting difficulties in performing LC for acute cholecystitis

Histological study of the elongated esophagus in a rat model

Background Esophageal elongation by traction suture is used in pediatric patients to manage long-gap esophageal atresia (EA). There was no histological evidence of the esophageal elongation. Here, we sought to clarify the histologic effects of traction on the esophagus by using a rat EA model simulating Foker\u27s method. Materials and methods Rats were randomly assigned into three groups (n = 5 each). The traction group underwent daily stretching of the distal segment of the esophagus. The nontraction group underwent a sham operation, and the normal group served as controls. Seven days after the operation, the distal segments of the esophagus were removed. The length and thickness were measured, and samples were stained with Ki-67, nNOS, and S-100. Results The whole length of the esophagus in the traction group was significantly longer than that in the nontraction group (P < 0.01). The thickness of esophageal mucosa and muscle tended to become thin by traction, but not significantly. The Ki-67-positive ratio of mucosa and muscle was significantly higher in the traction group (P < 0.05). There were no significant differences in Ki-67 between two segments (cardia-middle and middle-stump) in any group. Auerbach\u27s plexus was identified at all sites of elongated esophagus by nNOS and S-100 staining. Conclusions By traction, the esophagus was elongated uniformly and cell proliferation activity was promoted in all parts of the elongated esophagus in the rat EA model

Intraoperative pancreatography using an endoscopic naso-pancreatic drainage tube for the prevention of pancreatic fistula after local pancreatic resection

Background: Local pancreatic resections can avoid the unnecessary resection of the normal pancreatic parenchyma in comparison with standard pancreatic resection. However, the incidence of pancreatic fistula after local pancreatic resection is high, and still responsible for most morbidity and mortality. Methods: We reviewed 6 patients who underwent intraoperative pancreatography using an endoscopic naso-pancreatic drainage (ENPD) tube during local pancreatic resection for the prevention of postoperative pancreatic fistula. Results: One patient had injury to the main pancreatic duct during surgery, and transient pancreatic fistula of grade B occurred. In this patient, ENPD tube was left in place for the management the pancreatic fistula, resulted in a favorable outcome. Other 5 patients showed no postoperative complications including pancreatic fistula. Conclusions: Intraoperative pancreatography using ENPD tube is a simple technique and useful for the prevention of pancreatic fistula after local pancreatic resection

Laparoscopic Single-Branch Resection of the Pancreas for Intraductal Papillary Mucinous Neoplasm

Although laparoscopic pancreatic resections have become more common, laparoscopic minimally invasive and function-preserving pancreatic resections have not been widely accepted. Branch-type intraductal papillary mucinous neoplasm (IPMN) has a low-grade malignant potential and shows a favorable prognosis. In branch-type IPMN, minimal resection techniques with preservation of the pancreatic functional reserve have advantages over the more conventional pancreaticoduodenectomy. We describe herein laparoscopic single-branch resection of the pancreas for branch-type IPMN. This surgical procedure is a novel and an ideal minimally invasive method for the resection of branch-type IPMN. In addition, our endoscopic nasopancreatic drainage (ENPD) tube-guided technique is useful for precise resection of the tumor and for the prevention of pancreatic fistula