The technique of thoracoscopy. Operative endoscopy in orthopedics and traumatology. Laparoscopic organostomies and other treatments. Damage of blood vessels of the anterior abdominal wall, mesenteric blood vessels, retroperitoneal vessels during laparoscopy. Damage of internal organs of the abdominal cavity during laparoscopy. Early and long-term postoperative complications.
CONTENTS
The technique of thoracoscopy.
Operative endoscopy in orthopedics and traumatology.
Laparoscopic organostomies and other treatments.
Damage of blood vessels of the anterior abdominal wall, mesenteric blood vessels, retroperitoneal vessels during laparoscopy. Damage of internal organs of the abdominal cavity during laparoscopy.
Early and long-term postoperative complications.
THE TECHNIQUE OF THORACOSCOPY.
Video-assisted thoracic surgery (VATS) has come to be the primary operative approach for a wide variety of intrathoracic problems previously addressed through open thoracotomy. The primary uses of VATS approaches in general thoracic surgical practice today are listed in Table
Table Uses of VATS in general thoracic surgery.
• Diagnosis and management of the idiopathic complex pleural effusive
process and pleural-based masses
• Diagnosis of the peripheral indeterminate pulmonary nodule
• Diagnosis of idiopathic interstitial lung disease
• Thymectomy for myasthenia gravis and selective biopsy and/or resection of mediastinal masses
• VATS pulmonary lobectomy
• VATS management of spontaneous pneumothorax and lung volume reduction surgery for pulmonary emphysema
• VATS sympathectomy and splanchnicectomy for hyperhidrosis and pain
syndromes
• Performance of the intrathoracic dissection as a part of minimally invasive esophagectomy
• Esophagomyotomy
• Resection of esophageal diverticulum
Not all thoracic surgeons utilize the VATS approach for this entire range of intrathoracic problems. The majority of thoracic surgeons limit their use of VATS to the management of pleural pathologic conditions and wedge resection biopsy of peripheral lung lesions. Nevertheless, as experience and enthusiasm with minimally invasive surgical techniques grows, a growing number of thoracic surgeons completing their training are expanding their use of VATS. This chapter details principles of perioperative patient management, instrument needs, and basic intercostal approach strategies crucial for a successful VATS intervention.
B. Anesthesia Issues Related to VATS
VATS is usually performed under general endotracheal anesthesia. Generally speaking, the physiologic derangements that occur during VATS are the same as those encountered during open thoracic surgery. Thus, it is critical that the anesthesia team be accomplished in the standard open incisional thoracic surgical management. VATS requires ipsilateral pulmonary collapse. Without adequate collapse, pulmonary lesion localization is suboptimal and the risk of pulmonary injury significantly greater. Lung collapse may be obtained in one of several ways. 1. Occasionally, a patient with a large pleural effusion may have already sufficient collapse of the ipsilateral lung to allow pleural biopsy, breakdown of loculations, pleurodesis, and strategic chest tube placement to be done with a standard endotracheal tube. The lung rarely expands immediately after drainage of the effusion. a. It is important to examine the airway first to ensure that lung collapse is not due to bronchial obstruction. If central main stem bronchial obstruction is encountered, VATS should not be undertaken until airway obstruction has been over-come through endoluminal laser, stenting, or brachytherapy.
2. We believe that double-lumen endotracheal tube intubation is required for almost all VATS interventions, and this is the technique used by most surgeons.
3. An endotracheal bronchus blocking approachmay be considered in lieu of a double-lumen tube if the anesthesia and thoracic surgical team have experience with this approach. This approach is often satisfactory, but occasional difficulty with lung isolation will be seen among patients with a short right main stem bronchus. It is imperative that the thoracic surgeon evaluate the adequacy of the posi-tioning the double-lumen tube or bronchus blocker. We also recommend a second bronchoscopic evaluation by the surgeon and anesthesia team after lateral posi-tioning of the patient for the VATS procedure to ensure that the endotracheal tube or blocker has not become malpositioned during patient transfer. Carbon dioxide insufflation is generally not used for VATS interventions. The exception is VATS to accomplish thoracodorsal sympathectomy for hyper-hidrosis or upper extremity pain syndromes.
Patient Positioning for VATS
Most VATS interventions are accomplished in a near full lateral decubitus position. We tend to lean the patient slightly backward to provide additional access to the anterior intercostal spaces, which are wider. Access through these anterior spaces may reduce the risk of intercostal neurovascular or rib injury and resulting acute and chronic pain. Exceptions to this generally lateral positioning approach occur for VATS thymectomy and thoracodorsal sympathectomy. For thymectomy we prefer to approach the patient from the right side at 45 to 60 degrees from the supine. This gives better access to the anterior mediastinum, by allowing gravity to produce dependent displacement of the collapsed lung. For VATS bilateral sympathectomy, we prefer to place the patient in a supine position with a roll beneath the shoulders and perform the bilateral intervention without repositioning of the patient. The operating table is established in a sharp reverse Trendelenburg position for VATS sympathectomy to allow for dependent displacement of the lungs during the apical thoracic VATS dissection.
For patients who are approached through a lateral decubitus position, ensure that the midsection is at the central break of the operating table. This allows flexing of the table to further open the intercostal spaces and to displace the patient’s hip so that manipulation of instrumentation and videothoracoscopic camera unit is not impeded by it. We also establish the operating table in a reversed Trendelenburg position after lateral positioning of the patient to take advantage of gravity in overcoming the effects of the ipsilateral cephalad diaphragmatic displacement seen during contralateral single-lung ventilation. A wide surgical preparation with anterior exposure to include the breast is important. This ensures the anterior disposition of the patient positioning, which is often forgotten in favor of the positioning and preparation that have been used for a posterolateral thoracotomy. Again, we stress that the positioning commonly used for posterolateral thoracotomy will result in inferior operative dexterity and the potential for increased postoperative pain syndromes.
VATS Instrumentation
VATS requires superior video-optics and intracavitary illumination.
A variety of companies have developed three-chip video cameras that provide excellent visibility and image definition. Table lists the basic instrumentation.
1. We prefer to use an “operating thoracoscope” for most of our VATS interventions. These 10-mm-diameter scopes have an inline 5-mm biopsy channel and a prismatic visual optic configuration that allows for a 45-degree offline orientation of the eyepiece–camera connection. With this scope, single intercostal access VATS can be readily accom-plished for the biopsy, evaluation, and treatment of simple idiopathic pleural problems (i.e., pleural-based masses and simple pleural effu-sions). Since most VATS interventions are also conducted under open atmospheric conditions, the open biopsy channel also allows for an air entry site during intrathoracic suctioning, preventing a closed-space vacuum that can instantaneously result in expansion of the lung. For VATS sympathectomy and with smaller individuals, we routinely use 5-mm direct-viewing thoracolaparoscopes. In the case of thoracodor-sal sympathectomy, we limit the intercostal access to two 5-mm sites. One is used for the scope–camera and the other is used for an endo-surgical “duck bill” grasper and hook cautery suction device.
2. Trocar protection of the thoracoscope is another important instrument-related concern. For the most part, we choose reusable metal “ports” to protect the smudging of the optics during introduction into the chest. We will use a second port to protect the entry of the 10-mm endo-scopic stapling device during the conduct of VATS wedge resection and lobectomy. Beyond these two trocars, we usually rely upon direct instrument entry through the sites of intercostal access. These trocar ports are not sealed and are open to the atmosphere. Two closed-system 5-mm disposable trocars are used during the VATS thoracodorsal sym-pathectomy, as this intervention is accomplished using a closed-chest preparation with low pressure (5–10 mm) carbon dioxide insufflation.
3. Appropriate hand instrumentation also is required for a successful VATS intervention.
a. We will commonly use regular open surgical hand instrumenta-tion during VATS. Long Metzenbaum scissors and long “Univer-sity of
b. The Landreneau “mashers”are a hybrid form of VATS and laparoscopic instrumentation incorporating the coaxial “feel” of standard hand instrumentation and the ability to traverse the inter-costal space through small trocars access (Starr Medical,
Table Basic instrumentation for VATS.
• “Three-chip” endoscopic video camera and high-definition television monitor
• Operating thoracoscope (with 5-mm biopsy channel)
• Three standard-length ringed forceps
• Suction-irrigation system
• Endoscopic hook cautery (
• Standard electrocautery unit with extended tip for application through intercostal access site
• Landreneau “Masher” set
• Bulbed syringe (60 ml)
• Standard Metzenbaum scissors (10–12 in.)
•
• Standard-sized and pediatric Yankour metal suckers
• Standard 28-French chest tubes (straight and right angled) and closed drainage system agement of complex esophagogastric disorders. We have found these tools to be particularly useful during the conduct of VATS wedge resection and VATS.
Once the location of the pulmonary lesion has been determined the “masher” clamp can be approxi-mated beneath the proposed parenchymal margin of resection to permit estimation of the safety and adequacy of the site of the staple line. The lung parenchyma is grasped and effaced beneath the lesion with the “masher,” and this is followed by introduction of the endoscopic stapling device along this line of proposed resection, estimated with the aid of the tissue compression by the “masher” forceps. These “masher” tools are also useful for the examination of the lung and for the performance of VATS lobectomy, as they give the surgeon the ergonomic “feel” of standard surgical tools and thus provide the proprioceptive feedback that the surgeon is familiar with. c. In addition to the instrumentation mentioned, we recommend a good 10-mm suctioning and irrigation system (Davol, subsidiary of CR Bard,
E. Intercostal Access Strategies for Frequently Performed VATS Procedures
Although individual patient anatomic variation and peculiar location of intrathoracic lesions may require some thought to determine the most appro-priate intercostal access, the following basic intercostal access strategies we what we generally recommend for frequently performed VATS procedures. Additional information for more complex procedures is given in the chapters that follow.
1. Idiopathic Loculated Extensive Pleural Effusion Three sites of intercostal access are usually established in the anterior axil-lary, midaxillary, and posterior axillary lines. These are established approxi-mately in the fifth, seventh, and eighth intercostal spaces, respectively. We usually start with the midaxillary seventh intercostal space access and work from there to obtain the remaining sites of access necessary to accomplish the procedure. Not infrequently, a fourth site of access is established in the midaxillary line at the third or fourth intercostal space to break down complex loculated processes or perform pulmonary decortication.
We have almost always been successful in managing such pleural problems when using this three- to four-intercostal-access approach. Pleural biopsy, evac-uation of the effusion, pleurodesis, and decortication can usually be accomplished without problem. On rare occasion, conversion to thoracotomy is necessary to accomplish decortication. The three lower intercostal access sites will also be used for chest tube placement tube at the end of the VATS procedure.
2. Empyema and Contained Hemothorax
Empyema and contained hemothorax are pleural processes frequently asso-ciated with dense, broad pleural adhesions between the lung and the chest wall. In contradistinction to the management described earlier for more diffuse pleural fluid problems, it is critical to establish the initial intercostal access squarely in the middle of the fluid collection to prevent lung injury at the site of unsuspected adhesion. Once the principal cavity has been entered and its anatomic extent appreciated, other sites of intercostal access are established under direct thora-coscopic visibility. Dense adhesions are left undisturbed unless significant pul-monary restriction is present. Strategic chest tube placement is established under videoscopic guidance.
3. VATS Wedge Resection Biopsy of Indeterminate
Interstitial Lung Disease
The use of VATS for the diagnosis of interstitial lung disease has for the most part made elective “open lung biopsy’ an obsolete term. There is the potential for misuse of VATS when biopsy of diffuse interstitial infiltrates is needed for the ventilator-dependent patient in the intensive care unit. The primary advantage of VATS over limited anterolateral thoracotomy for lung wedge biopsy is in reducing perioperative morbidity for the “walking and talking” patient and in allowing for a panoramic assessment of the lung for directed biopsy in the setting of heterogeneous interstitial lung inflammation. When the patient is already on the ventilator and the pulmonary infiltrates are diffuse, the simplicity of a small inframammary thoracotomy approach with the avoidance of double-lumen intubation appears to be the most prudent course. First, study the computed tomography scan closely to determine the principal target area of pathology. Evaluation of the volume of the ipsilateral pleural cavity is necessary because it is common for this volume to be reduced owing to the restrictive nature of the patient’s disease. This reduced lung volume may alter the intercostal access site decisions for the patient. The initial site of inter-costal access is usually in the midaxillary line at the seventh intercostal space. This location usually allows for the best panoramic image of the lung and pleural space. A second site of intercostal access is usually at the anterior axillary line near the inframammary crease. This is the usual site of introduction of the endoscopic mechanical stapling device used for pulmonary wedge resection. We are often able to accomplish wedge resection with these two intercostal sites only when an operating thoracoscope is used. The lung parenchyma can be grasped through the biopsy channel of the scope while the stapling device is applied from the other intercostal access site. More commonly, we will establish a third inter-costal access site at the midaxillary line in the fourth intercostal space. This fourth intercostal space site usually establishes access near the confluence of the major and minor pulmonary fissures on the right and at the midpoint of the pulmonary fissure on the left. The ringed sponge forceps (minus the sponge) can be introduced through this intercostal access site to grasp the lung in the area of representatively diseased parenchyma for the proposed wedge resection. At the completion of the VATS wedge resection, a single chest tube is posi-tioned through the lower midaxillary line seventh interspace access site. The chest tube is connected to the standard underwater seal drainage system with intentions to remove the tube in the recovery room if there is no air leak, excessive drainage, or chest roentgenographic abnormality.
4. VATS for the Management of Spontaneous Pneumothorax
VATS has become the preferred approach for the surgical management of recurrent spontaneous pneumothorax. In our clinical practice we continue to utilize primary chest tube evacuation of first-time pneumothoraces. We are quick to move ahead with definitive VATS management if a persistent air leak or incomplete expansion of the lung is present in the setting of a properly positioned and functional chest tube. VATS management is routinely recommended for the recurrence of pneumothorax without intervening chest tube placement, if clinically safe and appropriate. We routinely use three sites of intercostal access for this VATS intervention. An initial site of access is usually at the sixth or seventh intercostal space in the midaxillary line. A second site of access is at the third intercostal space in the midaxillary line at the axillary hairline. This is used for introduction of the ringed forceps to grasp and examine the apical segment of the lung and the superior segment of the lower lobe. After identification of the area of bullous disease, preparation for wedge resection of the lung to completely encompass the area of involvement is made. As is the case with lung wedge biopsy for interstitial lung disease, we prefer to utilize an anterolateral site of intercostal access at or near the level of the inframammary crease (usually at the fourth or fifth inter-costal space). The interspace is usually wide here and the line of stapler appli-cation ideal for this wedge resection procedure. If no definitive area of bullous disease is discernible, we will perform a wedge of the apical segment the upper lobe and also perform an apical pleurectomy to reduce the known postoperative recurrence reported in this setting. A single 28-French chest tube is introduced and secured through the lower axillary line access and positioned near the apex of the chest. Underwater seal drainage is employed for 2 to 3 days to enhance the likelihood of pleural symphysis.
The role of video-assisted thoracic surgery (VATS) for pretreatment staging of intrathoracic malignancies continues to evolve. As with other malignancies, precise staging allows more accurate prediction of survival, treatment planning, evaluation of results of therapy, exchange of information among cancer centers, and investigation of newer therapies. Preoperative staging of lung cancer can be achieved by the use of imaging modalities such as computed tomography (CT) and positron-emission tomogra-phy (PET). These techniques however, do not provide histologic confirmation of tumor involvement and may underestimate or overestimate the true extent of tumor extension. Surgical staging for lung cancer was pioneered by Carlens and Pearson, who established mediastinoscopy as an important diagnostic tool for the preoperative assessment of lung cancer patients. Lymph node metastases have been shown to be an important predictor of survival in lung and esophageal cancer patients, and their detection may allow prospective selection of patients who might benefit from neoadjuvant or pre-operative chemotherapy or radiotherapy. Because treatment strategies and prog-noses vary depending on the stage at the time of presentation, the need for more complete and accurate pathologic staging has become more clearly defined. Accurate staging of thoracic malignancies typically begins with noninvasive techniques; however, definitive diagnosis and final staging still depend on patho-logic specimens. Although noninvasive techniques (including percutaneous and endobronchial procedures) have been used and continue to improve, many patients still have suboptimal clinical staging compared with final pathologic staging, resulting often in poor results of surgical therapy. Until recently, the final determination of the true pathologic stage was made by direct surgical explo-ration at the time of the intended resection. With the introduction and refine-ments in minimally invasive techniques, most thoracic malignancies caow be accurately diagnosed and staged with minimal morbidity before definitive therapy. This chapter summarizes the recent experience with thoracoscopy in the staging of intrathoracic malignancies, with emphasis on lung and esophageal cancer.
Lung Cancer
From the perspective of the thoracic surgeon, the primary issue in the care of patients with non–small cell lung cancer (NSCLC) is a determination of the stage of their disease. Stage determines the treatment patients will receive and their prognoses. Lung cancer staging often requires both noninvasive and invasive procedures to assess the extent of tumor involvement. Accurate preoperative staging is mandatory for a proper selection of patients to be included in a neoadjuvant treatment protocol. This allows proper clinical stratification to standardize inclu-sion criteria, which leads to valid and reproducible posttreatment results. Unnec-essary thoracotomies are avoided by identifying unresectable disease. The current staging system for NSCLC in large part centers on the size of the primary tumor (T) and on presence or absence of metastatic involvement of hilar and mediastinal lymph nodes (N).
1. Cervical mediastinoscopyremains the primary diagnostic approach for the evaluation of paratracheal and high subcarinal lymphadenopa-thy associated with a presumed or known lung cancer. Adenopathy located in the aorticopulmonary window, anterior mediastinum, or low subcarinal plane, however, is difficult or impossible to access through standard cervical mediastinoscopy, although accessible through an extended cervical mediastinoscopy.
2. The role of VATS is still limited but provides specific information often not obtainable by other diagnostic modalities. Currently, mostcenters do not perform routine VATS staging in patients with NSCLC and is reserved for patients with cytologically negative pleural effu-sion or patients with inferior mediastinal lymphadenopathy. VATS is particularly useful to do the following:
a. Evaluate suspected contralateral lung metastases
b. Exclude pleural effusion in otherwise operable patients
c. Stage lymph node stations not easily accessible by medi-astinoscopy; these include the subaortic (aortopulmonary window), nodes (level 5), paraortic (ascending aorta or phrenic) nodes (level 6), posterior subcarinal (level 7) nodes, parae-sophageal (level 8) nodes, and pulmonary ligament nodes (level 9)
d. Provide a panoramic exploration of the entire surface of the lung and pleura
e. Employ as a first step on patients with undiagnosed peripheral lung nodules associated with lymphadenopathy
Esophageal Cancer
Most patients with esophageal cancer have a dismal prognosis, as most lesions are found to be full thickness (T3, T4) or to involve lymph nodes (N1) at the time of diagnosis. In the
Technique of VATS Staging Generally, VATS staging for lung cancer is done on the side of involvement. Sampling of regional lymph nodes and inspection of pleural surfaces and superficial parenchyma can be performed on either side. Right thoracoscopy allows sampling of peritracheal, periesophageal, subcarinal, and inferior pulmonary ligament nodes. When aortic invasion or aortopulmonary window lymph node involvement must be ruled out, a left thoracoscopy is performed.
1. The patient is intubated with a single-lumen endotracheal tube.
2. First, perform a standard bronchoscopic examination of the main airways and lobar and segmental orifices.
3. Exchange the tube for a double-lumen endotracheal tube to achieve
selective left lung ventilation. Confirm accurate positioning of the tube by bronchoscopic examination.
4. With the patient in full left lateral decubitus position, place the first trocar (
5. Insert the thoracoscope and place two to three additional working ports (
6. Inspect all pleural surfaces for any evidence of tumor implant or effu-sion. If effusion is present, aspirate and collect it for cytopathologic analysis.
7. Retract the lung anteriorly through the anterior port, incise the medi-astinal pleura overlying the trachea or esophagus and continue the incision inferiorly to the level of the carina or inferior pulmonary vein. This incision can be carried down to the level of the inferior pulmonary ligament to include dissection of lymph nodes in this area.
8. Dissect meticulously with a grasper and harmonic scalpel to sample individual lymph nodes at each lymph node station. Take special care when working in the plane behind the right main stem bronchi and carina to avoid injury to the airway.
9. On the right, thorough sampling of the lower paratracheal lymph nodes on the right may be facilitated by dividing the azygos arch with a vas-cular endoscopic stapler. To allow sampling of the inferior pulmonary ligament node, divide the ligament with electrocautery or harmonic scalpel with the patient in steep Trendelenburg position.
10. Before partially mobilized lymph nodes are excised completely, use an endoscopic clip applier to secure the vascular pedicle. Meticulous hemostasis is important to avoid troublesome bleeding from the bronchial arteries and aortoesophageal branches.
11. Retrieve individual lymph nodes from the chest utilizing the cut finger of a surgical glove and label these appropriately. If necessary, mobilize the primary tumor to assess local invasion into surrounding structures.
12. At the end of the procedure, infiltrate the intercostal nerves with bupi-vacaine 0.25% and a place single chest tube posteriorly and superiorly toward the apex of the chest cavity. Gently allow the lung to reexpand and close the incisions in two layers.
13. The patient is then extubated in the operating room and a chest-x-ray obtained in the recovery room.
E. Technique of Laparoscopic Staging for
Esophageal Cancer
1. Position, prepare, and anesthetize the patient as for exploratory laparoscopy. We prefer the Hasson cannula to the closed insertion of a Veress needle. Carefully evaluate patients who have had abdominal procedures for alternative sites of placement of the initial port for establishing pneumoperitoneum. The Hasson trocar (
2. Establish pneumoperitoneum and insert the laparoscope. The use of a high-resolution 10-mm, oblique-viewing laparoscope maximizes lighting and increases visual field and access to most areas of the peri-toneal cavity.
3. Perform a thorough exploration of the abdomen, with special attention to the following.
a. Carefully survey the hepatic, diaphragmatic, peritoneal, and omental surfaces for any evidence of tumor implants. These will appear as dense nodules, clearly distinguishable from the liver parenchyma and the shiny translucent appearance of the peri-toneum or fatty surface of the omentum. Small occult metastases at these locations are not uncommon for esophageal cancer. These implants should be sampled if encountered, placing additional trocars for graspers and biopsy forceps.
b. Place a 5-mm trocar in a mirror-image location with the first trocar. Then place bilateral subcostal 5-mm trocars at the anterior axillary line.
c. If desired, place a liver retractor through a trocar inserted under laparoscopic guidance just below the edge of the liver to elevate the left lobe and expose the diaphragmatic hiatus.
d. Aspirate any ascitic fluid and send it for cytologic examination.
e. A laparoscopic ultrasound probe can also be utilized through a 10-mm port to examine the superior aspect of the liver for occult metastases. While certain ultrasonic features may be suggestive of malignancy, no ultrasonic image can confirm malignant versus benign hepatic parenchymal disease. In these situations, ultrasound-guided percutaneous biopsy is required.
f. After adequate examination of the peritoneal cavity and the liver parenchyma, attention is turned to evaluating the perigastric and celiac lymph nodes.
g. Divide the lesser omentum with the ultrasonic shears and retract the lesser curvature of the stomach laterally to the patient’s left.The lymph nodes are then readily visualized and subjected to biopsy, utilizing the harmonic scalpel to achieve hemostasis.
h. Additional lymph nodes may be encountered along the angle of His and splenic hilum and can be sampled if desired.
i. Place each lymph node in a cut finger of a glove for retrieval from the abdominal cavity through the 11-mm port. Take care to avoid injury to the stomach and vascular structures.
j. After achieving hemostasis, withdraw the retractor and instru-ments and close the port sites in the usual fashion.
Esophagectomy has traditionally been performed by open methods. Recently, a review of mortality following esophagectomy in the United States showed that mortality rates ranged from 8% to as high as 22% depending on institutional experience and surgeon volume. Results from experienced centers specializing in esophageal surgery demonstrate better outcomes but still include significant morbidity, mortality rates in excess of 5%, and hospital stays frequently greater than 10 days. In an effort to lower morbidity, our group at the University of Pittsburgh Medical Center has developed a minimally invasive approach to esophageal resection. Our early experience with minimally invasive esophagectomy (MIE) was limited to patients with Barrett’s high-grade dysplasia or small tumors. This has evolved and now includes most patients with resectable esophageal cancer after evaluation with positron-emission tomography (PET), endoscopic ultrasound (EUS), and computed tomography (CT) including those with limited nodal involvement. Neoadjuvant chemoradiation is not a contraindication for a mini-mally invasive approach. If the EGD, EUS, or CT scan findings suggest gastric extension, T4 local extension, or possible metastases, we perform a staging laparoscopy or a thoracoscopy or both. We perform an on-table esophagogas-troduodenoscopy (EGD) to make a final assessment of the tumor’s location and the gastric conduit’s suitability for reconstruction. If there is histologic evidence of node-positive disease and the patient is a candidate for chemotherapy, we encourage participation in a neoadjuvant trial. In our recent report of 222 patients undergoing MIE in a single institution, we reported a shorter hospital stay, lower mortality rate, and more rapid recovery to full activity compared with the results of most open series. A prospective, multicenter trial is now under way to more rigorously assess the results of MIE in our own institution and others with sig-nificant minimally invasive surgical expertise (Eastern Cooperative Group Trial E2202). In addition to esophageal carcinoma, we have successfully performed MIE for other esophageal disorders including end-stage achalasia, lymphoma, perforation, and tracheoesophageal fistula.
Placement for Thoracic Phase of Operation
The surgeon stands on the right and the assistant on the left. After completion of the esophagogastroduodenoscopy, the patient is intubated with a double-lumen tube for single-lung ventilation. An arterial line and a urinary catheter are inserted. The thoracic phase of the operation is performed first. The right lung is deflated as soon as the patient is placed in a left lateral decubitus position. Optimal port placement is crucial to facilitate the technical aspects of the esophageal dissection and mobilization. Place a 10-mm port at the eighth or ninth intercostal space, anterior to the mid axillary line, and pass the thoracoscope. Place a 5-mm port at the eighth or ninth intercostal space, posterior to the posterior axillary line, for the ultrasonic coagulating shears (U.S.Surgical,
Thoracoscopic Esophageal Mobilization
1. Gently retract the lung anteriorly with the fan retractor to expose the inferior pulmonary ligament.
2. Begin the esophageal dissection by dividing the pulmonary ligament up to the inferior pulmonary vein using the ultrasonic shears coagulator.
3. Divide the mediastinal pleura overlying the esophagus to the level of the azygos vein, preserving the pleura intact above the vein, to the level of the thoracic inlet, This may help seal the plane around the gastric tube at the thoracic inlet, preventing potential extension of a cervical leak into the mediastinum.
4. Circumferentially dissect the azygos vein. Divide it with a vascular stapler (Endo-GIA II; U.S. Surgical,
5. Next, circumferentially mobilize the esophagus with lymph node dissection from the diaphragm up to 1 to
6. Place a Penrose drain around the esophagus to facilitate traction and exposure. As the esophageal mobilization proceeds toward the thoracic inlet, keep the dissection plane near the esophagus to avoid trauma to the membranous trachea and recurrent laryngeal nerves.
7. Near the diaphragm, take care to avoid violating the peritoneum, which would result in difficulty in maintaining adequate pneumoperitoneum during the abdominal portion of the procedure. Prior to moving to the laparoscopic port, the entire thoracic esophagus and surrounding lymph nodes should be mobilized.
8. Insert a single 28-French-chest tube through the lower, anterior thora-coport and infiltrate the intercostal nerves with 1 to 2 mL of 0.5% bupi-vacaine with epinephrine at each interspace. Gently inflate the right lung and check the membranous airway for potential air leaks.
9. Withdraw the ports and scope and close the incisions.
Gastric Mobilization and Tubularization
1. Turn the patient to the supine position with the neck slightly turned to the right, with the patient prepped and draped from chin to pubic symphisis and laterally down to the posterior axillary lines.
2. With the surgeon standing on the right and the assistant on the left, insert five abdominal ports utilizing a similar approach as for laparoscopic fundoplication. In general, these ports are placed slightly lower toward the umbilicus compared with our antireflux surgery ports.
3. Insufflate the abdomen and maintain an intra-abdominal pressure of
6 to
4. Insert the camera and explore the abdomen for evidence of metastatic disease.
5. Place the patient in steep reverse Trendelenburg position.
6. Retract the left lobe of the liver upward to expose the esophageal hiatus, using a Diamond flex retractor (Genzyme, Tucker, GA) held in place with a self-retaining system (Mediflex, Velmed, Wexford, PA).
7. Divide the gastrohepatic ligament with the endoshears above the hepatic branch of the vagus nerve.
8. Dissect the right crus of the diaphragm, taking care to preserve the phrenoesophageal membrane to avoid entry into the mediastinum and loss of pneumoperitoneum, which would lead to pneumothorax and technical difficulties.
9. Begin gastric mobilization by dividing the gastrocolic omentum
10. Divide the short gastric vessels using the ultrasonic coagulating shears taking care to avoid injury to the spleen. Clip and divide larger branches.
11. Next, retract the stomach superiorly and divide the left gastric artery and vein using the Endo-GIA stapler with a vascular load.
12. Dissect the left crus of the diaphragm to complete the hiatal mobilization.
13. Mobilize the first portion of the duodenum. Performing a full Kochermaneuver of the duodenum is usually not necessary.
14. Next, perform a pyloroplasty, using the ultrasonic shears to open the pylorus for a distance of approximately
15. Construct the gastric tube constructed by dividing the stomach with the
16. Minimize manipulation and trauma to the tubularized stomach during its mobilization.
17. Next, attach the most cephalad portion of the gastric tube to the divided esophageal and gastric specimen using two figure-of-eight Endo-sutures.
18. An additional superficial stitch may be placed on the anterior gastric tube to facilitate orientation and to prevent twisting as the tube isguided into the mediastinum to the neck.
21. With the stomach fully mobilized and prepared for delivery into the mediastinum, divide the phrenoesophageal membrane and partially incise the right and left crura to avoid gastric tube outlet obstruction. Take care to maintain orientation of the greater curvature towards the left crus.
Cervical Esophagogastric Anastomosis
1. Make 4- to 6-cm horizontal incision just above the suprasternal notch.
2. Continue careful dissection along the anterior border of the stern-ocleidomastoid muscle. Identify the tracheoesophageal groove and encircle the esophagus with a Penrose drain.
3. To avoid injury to the left laryngeal recurrent nerve, no retractors are placed.
4. The degree of neck dissection is minimal owing to the high intra-thoracic dissection performed well into the thoracic inlet during the thoracoscopic portion of the case. Generally, this plane is very easily entered, and we then pull up the Penrose drain that was left around the esophagus and pushed up into the inlet during the last video-assisted thorncic surgery step. This facilitates delivery of the mobilized esoph-agus into the neck.
5. Divide the cervical esophagus after applying the autopursestring device and pull the esophagogastric specimen out of the neck incision. The autopursestring device is used only if we are planning to perform the anastomosis with the end-to-end device. There are many options for neck anastomosis, but end-to-end anastomosis (EEA) has proved to be a good option in our experience. We do believe the esophagus should be divided quite high, just below the cricopharyngeus. This high division minimizes any residual Barrett’s mucosa and also tends to leave the anatomosis lying very high and near the cervical neck incision. Other anastomotic techniques may leave additional length to the cervical esophagus, and if excessive length is left at this point, the anastomosis tends to lie well into the thoracic inlet. Owing to the thoracoscopic mobilization of most of the mediastinal pleura, leaks in this location tend to drain into the chest.
6. As traction is applied to the specimen in the neck, the assistant guides the gastric tube in proper orientation into the mediastinum and into the neck. Separate the specimen from the gastric tube and remove it from the field. Inspect the gastric tube for ischemia or vascular congestion.
7. The anastomosis is then constructed. In most cases, as stated above, we use the EEA,
8. Next a nasogastric tube is passed from above and guided into the gastric tube to a point near the lower chest. Resect the open tip of the fundus with the Endo-GIA II stapler and copiously irrigate the area with warm antibiotic solution. Next, reinsufflate the abdomen and apply gentle downward traction on the pyloroantral area to reduce any redundant gastric tube to the abdomen. Perform this pull only until the assistant at the neck observes the tube beginning to be pulled down at the level of the anastomosis. Taking care to preserve the right orientation of the gastric tube at the diaphragmatic hiatus, place three tacking sutures to prevent subsequent thoracic herniation.
a. Place one stitch between the left crus and the stomach just ante-rior to the greater curve arcade.
b. The second stitch is placed on the right side of the gastric tube between the area just above the right gastric vessels and the right crus.
c. The third stitch is placed anteriorly between the stomach and the diaphragm.
9. Inspect the incisions for hemostasis and close them.
Early Complications
1. Cervical anastomotic leak
a. Cause and prevention.Ischemia and necrosis of the proximal part of the gastric tube will cause breakdown and leakage of the cervical anastomosis. Careful manipulation and atraumatic grasping of the stomach are of utmost importance to prevent this com-plication. Prior to performing the esophagogastric anastomosis, the gastric tube should be thoroughly inspected, and ischemic or necrotic tissue must be resected. In our recent experience, exces-sive narrowing of the gastric tube to less than
b. Recognition and management. Presence of erythema and drainage at the neck wound suggests a cervical leak. Intrathoracic extension must be ruled out. Generally, we perform a barium esophagogram to assess the path of the leak and the requirement for drainage. Open drainage of the neck wound is indicated, and if extension of the leak into the right chest occurs, additional drainage procedures may be required.
Gastric tube necrosis
a. Cause and prevention. Inadequate vascularization of the stomach secondary to venous congestion or poor arterial blood supply can cause necrosis of the gastric tube. Technical considerations to prevent this complication include preservation of the right gastric vessels and preservation of the right gastroepiploic arcade during dissection of the gastrocolic ligament. Twisting of the gastric tube as the conduit is brought up to the neck must be avoided by direct laparoscopic inspection. In the postoperative period, hemodynamic stability must be maintained to achieve adequate gastric perfusion. Nasogastric decompression prevents distention of the stomach and venous congestion. Construction of a narrow conduit may impair vascularization of the stomach.
b. Recognition and management. A protracted course with hemodynamic instability should raise suspicion for gastric tube necrosis. If major necrosis is confirmed, takedown of the anastomosis may be required, with return of the gastric tube to the abdomen and construction of a cervical esophagostomy.
Mediastinal abscess
a. Cause and prevention. Downward extension of a cervical anastomotic leak or a missed gastric perforation can cause a mediastinal abscess. Careful gastric mobilization and intraoperative recognition and repair of a perforation will avoid this problem. Prevention of a cervical leak is as described earlier. In addition, construction of a wider gastric tube (providing more bulk at the thoracic inlet), preservation of the mediastinal pleura above the azygos vein, and a very high anastomosis just below the level of the cricopharyngeus muscle may prevent mediastinal contamina-tion if a cervical anastomotic leak does occur.
b. Recognition and management. Fever, leukocytosis, and the presence of a cervical leak suggest the possibility of a mediastinal abscess. Confirmation by CT mandates drainage by right tho-racoscopy or thoracotomy.
Recurrent laryngeal nerve injury
a. Cause and prevention.Inadvertent injury or excessive traction of the recurrent laryngeal nerve can be avoided by gentle blunt and sharp dissection of the cervical esophagus. Retractors should not be used. Care is taken to stay near the esophagus during its mobilization, as the dissection proceeds toward the thoracic inlet.
b. Recognition and management. Hoarseness, dysphagia, or aspiration suggests injury to the recurrent nerve. Laryngoscopy confirms the diagnosis. Treatment options include observation and vocal cord injection with polytetrafluoroethylene (Teflon).
Chylothorax
a. Cause and prevention.Dissection of the posterior esophagus in the area of the thoracic duct, which can lead to a thoracic duct leak, can be prevented by the liberal use of endosurgical clips.
b. Recognition and management.Persistent and unexpected large chest tube drainage should raise suspicion. Initially, treatment is conservative by closed drainage and diet. If this is unsuccessful, surgical intervention is indicated.
Right main stem bronchi injury
a. Cause and prevention. While dissecting at the level of the subcarinal nodes, care is taken to stay near the esophagus and continous attention must be paid to avoid injuring the main stem bronchi.
b. Recognition and management. Injury to the airway can be identified by direct visualization at the time of surgery or postoperatively by the presence of an air leak. Conservative management or operative repair is indicated.
Bleeding
a. Cause and prevention. To date we have not had bleeding complications. The ultrasonic coagulating shears save time and avoid the tedium of clipping and dividing, or tying. The left gastric vessels are safely and rapidly divided using the endoscopic stapling device with a vascular load. No clips are placed on the gastric side of the short gastric vessels to avoid potential displacement during the gastric pull-through. Care is taken to clip any aortoesophageal vessels posteriorly during mobilization of the esophagus.
b. Recognition and management. Clinical evidence of bleeding requires identification of the source of bleeding. Conservative or surgical management is indicated.
Late Complications
1. Delayed gastric emptying
a. Cause and prevention.In our early experience, two patients who had an initial pyloromyotmy developed persistent delayed gastric emptying (DGE) requiring pyloroplasty with good results. There-fore, pyloroplasty is now part of our standard MIE. DGE has also been caused by obstruction of the gastric tube at the level of the crura. Therefore, we partially divide the right and left crura routinely. We place tacking sutures between the gastric tube and the diaphragm to prevent hiatal herniation.
b. Recognition and management. Contrast studies confirm the diagnosis and level of obstruction. Pyloric dilatation or reoperation will be necessary to relieve the obstruction.
Anastomotic stricture
a. Cause and prevention.Avoidance of cervical anastomotic leaks.
b. Recognition and management. Presence of progressive dysphagia confirmed with barium swallow. Strictures resolve with endoscopic balloon dilation.
Sympathectomy
1. Indications
Thoracodorsal sympathectomy is primarily used today for the surgical man-agement of intractable facial blushing/sweating, upper extremity hyperhidrosis (hand and axilla), vasospastic disorders of the hand, and upper extremity pain syndromes (causalgia). The video-assisted thoracic surgery (VATS) approach to thoracodorsal sympathectomy is preferred because it combines limited incisional morbidity with exceptional videoscopic exposure of the upper thoracic sympa-thetic chain. The extent of sympathectomy required depends upon the anatomic involve-ment of the syndrome. We recommend a T2-T3 sympathectomy for facial manifestations. We primarily perform a T3 sympathectomy for patients with palmar hyperhidrosis and vasospastic disorders of the hand (Raynaud’s syndrome, Beurger’s syndrome). Axillary hyperhidrosis and/or bromidism willlead us to include the T4 ganglia with the T3 sympathectomy. For upper extrem-ity chronic pain syndromes (causalgia), we recommend a T2 through T4 ganglionectomy. The clinical results of VATS thoracodorsal sympathectomy vary depending upon the nature of the problem being addressed. Good results are consistently seen in over 90% of patients approached for palmar hyperhidrosis. Improvement is also consistently seen for patients undergoing sympathectomy for vasospastic syndromes. The long-term benefits of thoracodorsal sympathectomy for axillary symptoms are less consistent; however, most series report long-term benefit in greater than 70% of patients. The most variable results with thoracodorsal sympathectomy are seen among patients approached for chronic pain (causalgia) syndromes. Results vary from one third to over 70% of patients benefiting from sympathectomy. In this latter group, it is appreciated that the benefit may be longer to mature clinically than for other syndromes and also that delay in the diagnosis and treatment of the disorder lessens the general effectiveness of lympathectomy.
2. Operative Approach for VATS
Thoracodorsal Sympathectomy
a. Position the patient supine.
b. After general anesthesia and double-lumen endotracheal tube intubation have been accomplished, place a roll between the patient’s shoulders. We usually have both arms extended laterally to ensure adequate exposure to the anterior chest and axilla.
c. Bronchoscopically confirm proper position of the endotracheal tube.
d. Prep and drape the entire chest axilla and inner aspect of the upper arms within the operative field. Radial arterial pressure monitoring is not usually necessary. Place the operating table in a 45-degree reverse Trendelenburg position to allow the lung to fall away from the operative field. e. We usually begin a bilateral VATS intervention on the right side but will start on the left if that is the patient’s dominant upper extremity. We routinely utilize two sites of intercostal access. The operating table is rolled away from the surgeon to enhance operating space and for improved dexterity with the endosurgical instrumentation. Sealed laparoscopic ports (
Complications
a. The primary complication associated with thoracodorsal sympathec-tomy is injury to the stellate ganglion resulting in “Horner’s syndrome” of varying degrees. In most series, the incidence of partial or full Horner’s syndrome is reported to occur in less than 1% of patients after sympathectomy.
b. The development of “compensatory” truncal hyperhidrosis involving the small of the back, groins, and periumbilical area is noted in over one half of patients. This is usually a mild phenomenon; however, it may be considered significant in a minority of patients.
Splanchnicectomy
1. Indications and Results
Chronic upper abdominal pain resulting from chronic pancreatitis or infiltrating carcinoma of the stomach, gastroesophageal junction, or pancreas is a difficult management problem. A number of surgical investigators have seen a benefit from splanchnic denervation. The VATS approach is particularly suited for this intervention. The anatomic variability of the intrathoracic splanchic nerves is becoming increasingly appreciated. It is now recognized that an extensive pleurotomy over the course of the T4 through the T12 levels is important to ablate the fibers of the greater splanchnic nerve (usually T6–T9 but sometimes ranging to T4), the lesser splanchnic nerve (usually T10–T11) and the least splanchnic nerve (T10–T12). Less than satisfactory results with splanchnicec-tomy may be explained by incomplete ablation of the full extent of the thoracic splanchnic innervation. The splanchnic nerve communication to the celiac plexus involved with pancreatic, perinephric, and gastric innervation is predominantly left sided. Accordingly, the left chest is usually approached first to accomplish VATS splanchnicectomy. If only partial relief of symptoms is obtained following the left VATS approach, and the residual pain is located predominantly on the right, consideration of a right-sided ablation is reasonable if the patient’s functional status allows. The addition of thoracic truncal vagotomy with thoracic splanchnicectomy has been variably advocated in the past. The theoretical benefit of vagotomy results from reduction gastric acid stimulation of pancreatic secretion and the pain associated with this stimulation. The additive benefit of this vagotomy maneuver has been hard to quantitate, and the risk of important gastric empty-ing problems related to vagal denervation of the stomach can be seen iearly a quarter of patients. Accordingly, we do not advocate the addition of transthoracic truncal vagotomy at this time. The results of spanchnicectomy have been variably good, with nearly 70% of patients noting a reduction in upper abdominal pain and requirements for narcotic pain medicine.
Technique of VATS Splanchnicectomy
a. Establish and confirm general anesthesia and double-lumen endotra-cheal tube position as noted for VATS thoracodorsal sympathectomy.
b. Place the patient in a right lateral decubitus position with a 15-degree forward tilt. The table is placed in a moderate reverse Trendelenburg position and rotated toward the right to aid in exposure to the posterior aspect of the thoracic cavity. The surgeon usually stands on the patient’s right side for the upper aspect of the splanchnicectomy and then switches to the left to continue the dissection inferiorly.
c. We presently utilize 5-mm closed endosurgical ports so that modest carbon dioxide insufflation can be accomplished for optimal lung collapse and thoracoscopic exposure of the splanchnic nerves.
d. We establish intercostal access for the 5-mm thoracoscope and camera at the seventh intercostal space in the posterior axillary line. Three other intercostal access sites are established in the midaxillary line of the third interspace (for left hand grasping tool), the fifth or sixth intercostal space midaxillary line (trumpeted suction device with hook electrocautery attachment), and the ninth intercostal space midaxillary line (for lung and diaphragmatic retraction).
e. Create an extended pleurotomy medial to the sympathetic chain, from the T4 level through the T12 level. During the conduct of this extrapleural exposure, numerous fibers will be seen coalescing from an oblique plane to form the greater, lesser, and least splanchnic nerves. All these fibers must be ablated during this extended extra-pleural dissection.
f. Postoperative tube thoracostomy drainage is employed owing to the extent of the extra-pleural dissection. This tube is usually removed within 48 hours of surgery.
Complications
Complications related to the procedure are generally like those common to other thoracoscopic explorations. Chronic intercostal pain is uncommon with the use of smaller trocar access. Patients who have not had previous surgical interventions related to their primary upper abdominal pathology appear to do better than previously operated patients. VATS splanchnicectomy seems to be a reasonable minimally invasive surgical approach to pain management of the patient with a reasonable functional status who has upper abdominal pain.
General Considerations
An indeterminate pulmonary nodule (IPN) is any radiologically described parenchymal pulmonary lesion of unknown histology that is less than
1. Benign lesions that present as IPNs include the following:
a. Intrapulmonary lymph nodes
b. Hamartomas
c. Granulomas, teratomas
d. Sarcoidosis
e. Rheumatoid nodules
f. Arteriovenous malformations, traumatic lesions
g. Congenital lesions
2. Malignant lesions include the following:
a. Primary lung cancers including non–small cell and small cell types
I. Found in approximately 35% of IPNs.
II. Predictors of malignancy include advanced age, history of cigarette smoking, increased lesion size, and nodule growth.
b. Pulmonary metastases from other primary malignancies. In patients who have previously been diagnosed with cancer, any pulmonary lesion may potentially represent metastatic disease, and solitary metastases can account for 20% of IPNs. The most common metastatic pulmonary metastases are from lung primary carcinomas followed by breast and colorectal malignancies. Obtaining tissue is often mandatory in this group as the impact on future therapeutic intervention may be great. The presence of pulmonary metastases may lead to an abandonment of a planned local procedure and initiation of systemic therapy. Alternatively, possible metastatic lung nodules proven to be benign allow more aggressive local therapies and potentially longer survival.
Diagnostic Workup
IPNs are most commonly discovered incidentally by plain chest radiograph (CXR) or computed tomography (CT) of the chest during diagnostic workup for unrelated problems. Less commonly, they are found on follow-up surveillance for prior malignancy or during screening of at-risk populations. Both CXR and chest CT have been shown to accurately predict the presence of malignancy in up to 60% of lesions based on morphologic characteristics and tissue density, though a substantial proportion of solitary pulmonary nodules remain indeterminate. Confirmatory tissue diagnosis is usually required, as the consequences of an undiagnosed malignancy are life threatening and therapies aimed at malignant conditions usually demand histological confirmation.
1. Chest X-Ray
The two findings on CXR that most heavily predict benign histology are calcification pattern and chronicity.
a. Benign calcifications are described as a diffuse, central, “popcorn,” or laminar pattern.
b. Stippled and eccentric calcifications are indeterminate, as they are seen in benign and malignant conditions.
c. The absence of growth over a 2-year time period suggests benign etiology. In patients with an IPN identified by CXR, all previous CXRs should be reviewed. No further investigation is needed if the lesion is unchanged over 2 more years or.
d. Other criteria that may be helpful include margins of lesion, size, presence of cavitations, and presence of satellite nodules, though none of these have been consistently accurate in differentiation of benign and malignant nodules.
Computed Tomography
a. Chest CT better characterizes the nodule in respect to location, surrounding structure involvement, mediastinal involvement, and additional nodule identification, and even allows staging of the liver and adrenal gland.
b. CT is more sensitive in detecting calcification within a pulmonary nodule allowing indeterminate noncalcified nodules on CXR to be further assessed for benign calcifications.
c. An irregular border on chest CT is strongly suggestive of malignancy, as 84% to 90% of spiculated lung nodules are malignant.
d. CT is also particularly helpful in detection of fat within a pulmonary nodule, another indicator of benign disease most often seen in hamartoma.
e. CT provides a much more accurate estimate of size and growth than CXR. CT is typically reliable to approximately one millimeter. Size conveys importance in malignancy risk, as the vast majority of nodules greater than
f. Contrast enhancement of the pulmonary nodule on CT provides additional prognostic information. Blood flow in malignant pulmonary nodules is increased compared with benign pulmonary nodules, and the degree of enhancement is directly related to vascularity. With sensitivity of 98% and specificity of 73%, nodules that enhance to greater than 20 Hounsfield units have been found to be predictive of malignancy, while those less than 15 Hounsfield units are characteristically benign.
Positron-Emission Tomography (PET)
PET is a newer imaging technique that uses 18-fluorodeoxyglucose (FDG) as a radiotracer taken up by active cells in glycolysis but bound within the cell. Metabolically active cells are typically neoplastic or inflammatory. A meta-analysis of the use of PET in pulmonary nodules and masses demonstrated an overall sensitivity of 96.8% in diagnosing malignancy and sensitivity of 96% in diagnosing benign nodules. Unfortunately, two barriers to PET exist. First, owing to the uptake of radiotracer into active, nonneoplastic inflammatory cells, the specificity is 77% in malignant nodules and 88% in benigodules. Second, the current resolution of PET is approximately
Magnetic Resonance Imaging (MRI)
MRI has a very limited role in the evaluation of IPNs. It may be used in patients who cannot tolerate intravenous contrast medial. Although MRI is superior to CT in the evaluation of nerve root, brachial plexus, and vertebral body involvement in some lung neoplasms, for most purposes CT is less costly and just as accurate.
Options for Management
After thorough radiologic analysis of an IPN, approximately one third of theinitial pulmonary nodules will remain indeterminate. In the management of these nodules, many factors must be considered, including the patient’s concern for definitive diagnosis, general state of health, age, smoking history, and medical history. Current options in the evaluation and management of indeterminate solitary pulmonary nodules include observation, bronchoscopy, transthoracic needle aspiration (TTNA), video-assisted thoracic surgery (VATS), and thoracotomy. Each will be considered here, with special emphasis on VATS.
Observation
As many IPNs discovered on radiology evaluation are benign, “watchful waiting” can be a reasonable option in certain clinical situations. Observation is usually favored in individuals without a tissue diagnosis but with low probability for malignancy secondary to age, smoking history, and/or tumor characteristics on imaging. Observation may also be the only option for patients who are high-risk candidates for interventions because of poor lung function or associated cardiovascular disease, regardless of their probability for malignancy. Close, responsible follow-up with serial chest CT should be the mainstay during observation of low-risk, but potentially malignant, IPNs. Though few objective data exist, current recommendations include an initial CXR with serial CT scanning at 3, 6, 12, and 24 months. A solitary pulmonary nodule should be considered benign if it remains unchanged during a 2-year period of observation, and tissue diagnosis should be pursued for nodules increasing in size or demonstrating malignant tendencies on imaging.
Tissue Diagnosis
When tissue diagnosis is required, several options exist.
a. Bronchoscopy is commonly implemented in the diagnosis of large, central, or advanced-stage lung neoplasms with mediastinal involvement, though its role in the management of IPNs is quite limited. Though it is a safe, minimally invasive procedure, a definite diagnosis is obtained in less than 10% of patients with nodules less than
b. Transthoracic needle aspiration offers tissue diagnosis through a minimally invasive outpatient procedure. Typically performed by interventional radiology with
IPNs of Unknown Etiology
VATS with thoracoscopic wedge resection is often the initial step in IPNs of unknown histology. Indications include unknowodules peripheral in location with a size greater than
Contraindications and Complications Associated with VATS
Even with localization techniques, initial VATS wedge resection approaches to IPNs more than
Indications
The most common indications for video-assisted thoracic surgery (VATS) for pleural disease are as follows:
Undiagnosed pleural effusion
Treatment of spontaneous pneumothorax
Drainage, debridement, and decortication of early empyema
Chemical and mechanical pleurodesis for benign and malignant effusions
Evacuation of traumatic and postoperative hemothorax
Biopsy of pleural-based lesion
Excision of primary lesions of the pleura
Anesthesia and Lung Isolation
1. VATS requires single-lung ventilation for facilitation of the procedure.
2. Lung isolation is achieved with a double-lumen endotracheal tube or a single-lumen tube with the selective placement of a bronchial blocker in the operative side.
4. On occasion, if the patient does not tolerate single-lung anesthesia, periods of apnea after hyperventilation will allow sufficient time to perform short diagnostic and therapeutic interventions.
5. Most patients also require electrocardiographic monitoring, pulse oximetry, arterial line, and if necessary, central venous pressure monitoring.
Patient Position and Room Setup
1. Position the patient in full lateral decubitus position with the opera-tive side up on a beanbag.
2. Protect all pressure points with gel or foam pads to protect against nerve compression or tissue ischemia.
3. The arms need to be placed in a neutral position (i.e., prayer position) to avoid hyperextension injury of neurovascular structures.
4. Place the hips of the patient aligned with the angle of the table to allow flexion at that level.
5. Elevate the head of the bed slightly (reverse Trendelenburg) to a com-fortable position for the operating team.
6. Secure the patient well to the table.
7. The surgeon generally stands in front of the patient, and the assistant and scrub nurse in the back.
8. Place the monitors at the head of the table.
Trocar Position and Choice of Thoracoscope
1. General concepts
a. Place the initial intercostals access site at a distance from the lesion to achieve a panoramic view and provide full visibility of additional instruments.
b. Avoid instrument crowding (“fencing”).
c. Avoid mirror image by positioning instruments and thoracoscope within the same 180-degree arc. That is, approach the lesion from the same general direction with instruments and camera.
2. For fluid collections, place the first port at the center of the fluid collection as x-ray and computed tomography scans. On occasion, aspiration of fluid with a small needle may aid in localizing a fluid collection.
3. For pneumothorax or general inspection of the pleural space, place the first port anteriorly and low in the hemithorax (i.e., eighth or ninth intercostal space), just in front of the anterior axillary line. This will provide a wide range of maneuvering without undue pressure on inter-costal structures.
4. When the skin incision is made (
6. The 10-mm 0- or 30-degree scope is preferred for most procedures.
7. Select optimum placement of the additional ports based on the initial assessment of the pleural space problem at hand. Most working ports can be
Performing the Exploration and Intervention
1. If fluid is present, aspirate and send it for culture, cytology, and chemical studies as necessary. A large trap will provide enough samples for most studies.
2. If the patient has a large long-standing effusion, we prefer to place a pigtail catheter the day before to drain some fluid over a few hours to decrease the risk of reexpansion pulmonary edema. The pigtail is removed at the time of VATS.
3. Perform a general inspection of the pleural space, including the diaphragm and pericardium, then take biopsy samples of any abnormal areas on the pleural or lung surfaces. Most parietal pleural biopsies can be performed with a sponge stick holder or thoracoscopic graspers.
4. Aspirate thick fluid or retained clotted hemothorax with a large-bore suction device, taking care not to injure the lung parenchyma or mediastinal structures.
5. Divide adhesions from the visceral to the parietal pleura with electro-coagulating shears to avoid troublesome bleeding, which makes visualization more difficult.
6. Disrupt fluid loculations with blunt-tipped suction devices, digital manipulation, sponge stick holder or Metzenbaum scissors. The goal is complete and adequate visualization of all structures and full mobi-lization of the lung to allow full reexpansion.
7. Early empyemas entrapping the lung can be debrided by gently strip-ping off the exudates from the surface of the lung, taking care to avoid injury to the lung and potential air leaks. Entry into the appropriate plane of dissection is at times facilitated by partially reinflating the lung with small tidal volumes.
8. Apical bullae responsible for pneumothoraces are easily accessible for resection with endoscopic gastrointestinal anastomosis stapling devices.
9. Mechanical abrasion for pleurodesis can be done with sponges, cotton-tipped applicators, electrocautery, or pleurectomy.
10. Chemical pleurodesis is achieved by insuflation of talc (3–5 g) or doxy-cycline (500 mg in 100–250 mL of normal saline solution).
11. At the conclusion of the procedure, insert a 28-French chest tube and direct it posteriorly and apically for pneumothorax or malignant effu-sions. For empyemas or hemothorax, strategically positioned, multiple large-bore (32–36 Fr) chest tubes are preferred.
12. After pleurodesis the chest tubes are connected to continuous suction (20–40 cm H2O) for 48 to 72 hours and removed after an additional 24 hours on water seal. If an air leak is present, continue suction until 24 hours after resolution of the air leak.
13. Chest tubes for drainage of empyema are typically left in place for 2 to 4 weeks. The tubes can be opened to air and connected to a drainage system after a few days if the lung remains expanded while the tube is open. These tubes can later be withdrawn a few centimeters every 2 to 3 days until removed.
Complications
1. Persistent air leak
a. Cause and prevention.This complication is usually secondary to inadvertent injury to the lung parenchyma in the process of mobilizing the lung or performing the decortication for empyema. Occasionally it is also seen after stapled resection of apical blebs in patients with emphysematous lungs. To an extent, utilizing staple line reinforcement or buttressing with GoreTex or Vicryl strips can prevent this.
b. Recognition and management.The patient will develop air bubbles in the water seal chamber of the pleural drainage system. The air leak can be graded from small to large depending on the amount of bubbles generated with quiet or forced exhalation. Most leaks are small and require only continuous suction for 2 to 3 additional days. If the air leak persists, the suction can be lowered or discontinued (water seal) as long as the lung remains expanded. Rarely a persistent air leak after a VATS procedure requires reoperation.
2. Hemorrhage
a. Cause and prevention.This complication is usually secondary to intercostal vessel injury, hilar injury, or overly aggressive pleurectomy or decortication with bleeding from the chest wall or lung parenchyma, respectively. Gentle manipulation of tissues, attention to planes of dissection, and thorough hemostasis are required to prevent this complication.
b. Recognition and management.Intrathoracic bleeding is most often recognized by excessive postoperative chest tube output. In general, over 100 mL/h for 3 or more consecutive hours requires close observation and possibly reexploration. A chest x-ray should be obtained to rule out the possibility of an underlying retained hemothorax. Persistent bleeding or a retained hemothorax is an indication for reexploration with VATS. If one is unable to resolve the bleeding with this approach, a thoracotomy may become necessary.
3. Inadequate drainage of empyema a. Cause and prevention.This is usually secondary to incomplete disruption of all loculations and failure to achieve full mobiliza-tion of the lung with creation of a unilocular pleural cavity. Gentle and meticulous disruption of all loculations should be the goal of VATS for drainage of empyema. Attention should also be directed at draining any fluid accumulated in the interlobar fissures, or paravertebral or diaphragmatic recesses. Strategic placement of large-bore, straight, and or right-angle chest tubes may decrease the incidence of this complication.
b. Recognition and management. Before concluding the VATS procedure, the surgeon should be satisfied with the accomplished results. Suboptimal results usually will require reoperation. Post-operatively, the patient may persist with fever, leukocytosis, or pleural densities representing residual undrained fluid collections. Management usually requires VATS or open thoracotomy. On occasion, administration of fibrinolytics (recombinant tissue plasminogen activator, 5–6 mg) through the chest tube may allow one to avoid reoperation.
OPERATIVE ENDOSCOPY IN ORTHOPEDICS AND TRAUMATOLOGY.
Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed to evaluate or treat many orthopaedic conditions including torn cartilage (known by doctors as “meniscus”), torn surface (articular) cartilage, ACL reconstruction, and trimming damaged cartilage.
The advantage over traditional open surgery is that the joint does not have to be opened up fully. For knee arthroscopy only two small incisions are made, one for the arthroscope and one for the surgical instruments to be used in the knee cavity. This reduces recovery time and may increase the rate of success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions. Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid leaks (extravasates) into the surrounding soft tissue, causing edema.
The surgical instruments are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments and menisci or cartilage.
It is technically possible to do an arthroscopic examination of almost every joint, most commonly the knee, shoulder, elbow, wrist, ankle, foot, and hip.
History
Professor Kenji Takagi in
Pioneering work began as early as the 1920s with the work of Eugen Bircher. He published several papers in the 1920s about his use of arthroscopy of the knee for diagnostic purposes. After diagnosing torn tissue, he used open surgery to remove or repair the damaged tissue. Initially, he used an electric Jacobaeus thoracolaparoscope for his diagnostic procedures, which produced a dim view of the joint. Later, he developed a double-contrast approach to improve visibility. He gave up endoscopy in 1930, and his work was largely neglected for several decades.
While he is often considered the inventor of arthroscopy of the knee, the Japanese surgeon Masaki Watanabe,
The first operating arthroscope was designed by them, and they worked together to produce the first high-quality color intraarticular photography. The field benefited significantly from technological advances, particularly advances in flexible fiber optics during the 1970s and 1980s.
Knee arthroscopy has in many cases replaced the classic arthrotomy that was performed in the past. Today knee arthroscopy is commonly performed for treating meniscus injury, reconstruction of the anterior cruciate ligament and for cartilage microfracturing. Arthroscopy can also be performed just for diagnosing and checking of the knee; however, the latter use has been mainly replaced by magnetic resonance imaging.
During an average knee arthroscopy, a small fiberoptic camera (the arthroscope) is inserted into the joint through a small incision, about
For osteoarthritis
Arthroscopic surgeries of the knee are done for many reasons, but it is not clear whether it is a more effective treatment for treating osteoarthritis than more conservative therapies.
A double-blind placebo-controlled study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in 2002. In this three-group study, 180 military veterans with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement with lavage, or arthroscopic lavage alone without debridement (a procedure only imitating the surgical debridement, where superficial incisions to the skin were made to give the appearance that the debridement procedure had been performed). For two years after the surgeries, patients reported their pain levels and were evaluated for joint motion. Neither the patients nor the independent evaluators knew which patients had received which surgery (thus the “double blind” notation). The study reported, “At no point did either of the intervention groups report less pain or better function than the placebo group.” Because there is no confirmed benefit for these surgeries in cases of osteoarthritis of the knee, many payors are reluctant to reimburse surgeons and hospitals for what can be considered a procedure which seems to create the risks of surgery with questionable or no demonstrable benefit.
A 2008 study confirmed that there was no long-term benefit for chronic pain, above medication and physical therapy.
Meniscal tears
One of the primary reasons for performing arthroscopies is to repair or trim a painful and torn or damaged meniscus. A torn meniscus is in a majority of cases non-symptomatic and is often difficult to diagnose. Surgery, known as arthroscopic partial meniscectomy (APM), can still be performed, and it has been the subject of a number of recent clinical trials comparing APM to exercise (physical therapy) or sham surgery. These surgeries have generally found that patients undergoing APM recover at high rates; however, differences between patients who were instead randomized to physical therapy or sham surgery are small. It is unclear which treatment is most clinically- or cost-effective.
After surgery
After knee arthroscopy there will be swelling around the knee, which can take anywhere from 7–15 days to completely settle. It is important to wait until there is no swelling before doing any serious exercise or extensive walking, because the knee will not be fully stable; extensive exercise may cause pain and in some cases cause the knee to swell more. The spread of the swell might cause serious problems.
Hip arthroscopy was initially used for the diagnosis of unexplained hip pain, but is now widely used in the treatment of conditions both in and outside the hip joint. The most common indication currently is for the treatment of femoroacetabular impingement (FAI) and its associated pathologies; however, this is by no means where it ends. Hip conditions that may be treated arthroscopically also includes labral tears, loose / foreign body removal, hip washout (for infection) or biopsy, chondral (cartilage) lesions, osteochondritis dissecans, ligamentum teres injuries (and reconstruction), Iliopsoas tendinopathy (or ‘snapping psoas’), trochanteric pain syndrome, snapping iliotibial band, osteoarthritis (controversial), sciatic nerve compression (piriformis syndrome), ischiofemoral impingement and direct assessment of hip replacement.
Arthroscopy is commonly used for treatment of diseases of the shoulder including subacromial impingement, acromioclavicular osteoarthritis, rotator cuff tears, frozen shoulder (adhesive capsulitis), chronic tendonitis, removal of loose bodies and partial tears of the long biceps tendon, SLAP lesions and shoulder instability. The most common indications include subacromial decompression, bankarts lesion repair and rotator cuff repair. All these procedures were done by opening the joint through big incisions before the advent of arthroscopy. Arthroscopic shoulder surgeries have gained momentum in the past decade. “Keyhole surgery” of the shoulder as it is popularly known has reduced inpatient time and rehabilitation requirements and is often a daycare procedure.
Arthroscopy of the wrist is used to investigate and treat symptoms of repetitive strain injury, fractures of the wrist and torn or damaged ligaments. It can also be used to ascertain joint damage caused by wrist osteoarthritis.\
Spinal arthroscopy
Many invasive spine procedures involve the removal of bone, muscle, and ligaments to access and treat problematic areas. In some cases, thoracic (mid-spine) conditions requires a surgeon to access the problem area through the rib cage, dramatically lengthening recovery time.
Arthroscopic (also endoscopic) spinal procedures allow access to and treatment of spinal conditions with minimal damage to surrounding tissues. Recovery times are greatly reduced due to the relatively small size of incision(s), and many patients are treated as outpatients. Recovery rates and times vary according to condition severity and the patient’s overall health.
Arthroscopic procedures treat
- Spinal disc herniation and degenerative discs
- spinal deformity
- tumors
- general spine trauma
Temporomandibular joint arthroscopy
Arthroscopy of the temporomandibular joint is sometimes used as either a diagnostic procedure for symptoms and signs related to these joints, or as a therapeutic measure in conditions like temporomandibular joint dysfunction. TMJ arthroscopy can be a purely diagnostic procedure, or it can its own beneficial effects which may result from washing out of the joint during the procedure, thought to remove debris and inflammatory mediators, and may enable a displaced disc to return to its correct position. Arthroscopy is also used to visualize the inside of the joint during certain surgical procedures involving the articular disc or the articular surfaces, similar to laparoscopy. Examples include release of adhesions (e.g. by blunt dissection or with a laser) or release of the disc. Biopsies or disc reduction can also be carried out during arthroscopy. It is carried out under general anesthetic.
LAPAROSCOPIC ORGANOSTOMIES AND OTHER TREATMENTS.
Background and Historical Development
Laparoscopic gastrojejunostomy is a recently adopted procedure in the history of minimally invasive surgery. Early research showed that laparoscopic gastrojejunos-tomy was technically feasible in animal models. Case presentations were first published in 1992, applying laparoscopic gastrojejunostomy to palliation of pancre-atic cancer. Initially, this proved to be a technically dif-ficult procedure reserved for experienced surgeons. Now, as surgeons are becoming increasingly comfortable with laparoscopy and as laparoscopic technology improves, the frequency of laparoscopic gastrojejunostomy has increased. Its application to different disease states has similarly expanded. Indications and Patient Selection Laparoscopic gastrojejunostomy has been applied to a wide variety of malignant and benign disorders. Palliative laparoscopic gastrojejunostomy is of special benefit to those with a short life expectancy. The most common indication is for malignant gastric outlet obstruction. Most are secondary to periampullary carci-noma, but application to gastric carcinoma, lymphoma, and metastatic lesions has proven equally successful. Benign obstructing lesions such as Crohn’s disease and
chronic pancreatitis are also amenable to laparoscopic gastrojejunostomy. Similarly, peptic ulcer disease can be managed laparoscopically. More recently, bariatric surgery has benefited from advances in laparoscopy for their gastric bypass procedures. Morbid obesity introduces multiple technical challenges that are not addressed in this chapter.
Periampullary Carcinoma
Pancreatic carcinoma is the fourth leading cause of cancer death, with an incidence of 9 per
Surgical Technique
As with all laparoscopic procedures, the patient must undergo general endotracheal anesthesia. In the case of obstructing lesions, our patients have large-bore naso-gastric tubes placed at least 24 h in advance for gastric decompression and irrigation of the obstructed stomach. Intravenous antibiotics are administered prophylactically. A urinary drainage catheter is placed at the time of operation. An increased risk of venous thromboembolic events occurs in laparoscopic surgery, related to the pneumoperitoneum. We routinely use sequential compression devices. If there is a past history of deep venous thrombosis or pulmonary embolism in a patient, we initiate heparin therapy. The patient is placed in low modified lithotomy with a slight reverse Trendelenburg. The primary surgeon is positioned between the patient’s legs with the first assis-tant at the patient’s left; an optional second assistant stands to the patient’s right. The peritoneum is insufflated via a Veress needle from a left subcostal puncture. If pre-vious abdominal surgery has been performed, an open technique is used. A 10-mm supraumbilical port is the site of entry of the 30° laparoscope. From here, planning of the subsequent ports is based on the patient’s body habitus. A fan liver retractor is placed through a right lateral port, exposing the gastroduodenal junction. At the left lateral and epigastric regions, 12-mm ports are placed for use of atraumatic graspers and a harmonic scalpel, respectively. A 10-mm port is placed at the left subcostal region where the first assistant will place a large grasper. To mobilize the stomach, we take down the gastrocolic ligament using a harmonic hook scalpel. After this is complete, a loop of jejunum is mobilized to perform the gastrojejunostomy. To do this, the midtransverse colon is elevated using atraumatic bowel graspers, identifying the ligament of Treitz. An appropriate length of jejunum is brought to the anterior wall of the stomach in an antecolic fashion. The loop must be sufficiently long to rest comfortably against the distal greater curvature of the stomach. The site of anastamosis of the jejunum is usually 15 to
Problems and Controversies
Laparoscopic gastrojejunostomy is a relatively new technique and its applications to different disease states remain unfulfilled. Problems with this technique have been primarily a function of the surgeon’s technical expertise and the patient’s underlying pathology. Laparo-scopic gastrojejunostomy is technically demanding and has not yet been widely adopted by the general surgical population. Most cases are performed by advanced laparoscopic surgeons in centers of excellence. With advanced surgical skills, improved instrumentation, and better operating room staff familiarity, this may become a readily performed laparoscopic procedure. The introduction of any laparoscopic procedure must include formal analyses of safety, efficacy, operating time, hospital stay, and quality of life. Laparoscopic gastrojejunostomy is a recent phenomenon with few case reports and no large randomized trial. The benefits of laparoscopic gastrojejunostomy lie in the presumed improvements in postoperative recovery. As with any other laparoscopic procedure, there is less bowel manipulation, less postoperative pain, earlier mobilization of the patient, and earlier oral intake. Laparoscopic gastrojejunostomy offers fewer wound and respiratory complications, a quicker alimentation time, and earlier return to normal daily activities. Operating time remains a function of the surgeon’s expertise. Studies comparing laparoscopic with open Billroth II gas-trectomies showed reduced morbidity, quicker recovery times, shorter hospital stays, and less postoperative pain. Short-term quality of life after Billroth I and II were similar. Because laparoscopic gastrojejunostomy remains a technically difficult procedure, we suggest that its use be reserved to surgeons with advanced technical skills and training in laparoscopic surgery. With regard to patient selection, laparoscopic surgery in the morbidly obese patient adds new challenges to the surgeon. We believe that except for treatment of obesity when performed by a skilled bariatric surgeon, laparo-scopic gastrojejunostomy should be contraindicated in the morbidly obese. Patients with portal hypertension and coagulation disorders are not suitable candidates. In addition, there is a relative contraindication to those who had undergone previous abdominal surgery or those who failed endoscopic biliary decompression. Laparoscopy in malignancy is controversial. Proceed-ing with palliative surgery is an option that must be dis-cussed individually between the surgeon and the patient. Laparoscopic surgery with the intent to cure raises. Gastrojejunal stapled anastamosis. Using stay sutures, a loop of jejunum is approximated with the greater cur-vature of the stomach. Gastrotomy and enterotomy are made using a harmonic hook scalpel. Two passes of the 45-mm linear stapler through the gastrotomy/enterotomy from the left lateral port ensure a 6-cm lumen. Stapled closure of gastrotomy/enterotomy is performed by approximating the two edges with a grasper. A linear stapler with the blade removed is placed through the left subcostal port to close this opening. An articulating linear stapler may be helpful to achieve awkward angles. concern for tumor seeding at the port sites. In addition, laparoscopy for malignancy presents the following prob-lems: lack of localization of the tumor, lack of tactile sensation, inadequate assessment of lymph node or liver metastases, and inadequate resection. With further expe-rience, curative resection of malignancy may become an acceptable laparoscopic procedure with improved outcomes.
Postoperative Care
The patient remains with nasogastric tube decompres-sion for at least 2 days postoperatively. Before beginning enteral nutrition, we perform an upper gastrointestinal study using water-soluble contrast to check for patency of the anastamosis and absence of leakage. Most patients are able to tolerate a diet as early as 3 to 5 days post-operatively, compared to an average 6.5 days with the conventional open technique. Hospital stay averages 7 to 10 days for malignancy, as compared to 13.3 days with conventional technique.
Complications
Few data are available for laparoscopic gastrojejunos-tomy, as there are few case reports and no large randomized trials. Among reported cases, none had oper-ative mortality; this compares to 8% to 17% average operative mortality for all cases using conventional tech-niques and a 22% operative mortality in malignancy. Morbidity for laparoscopic gastrojejunostomy varies depending on the underlying disease state and indica-tions for operation. In malignancy, postoperative mor-bidities have included trocar site bleeding, delayed gastric emptying, congestive heart failure, pneumonia, and diarrhea.With the conventional open technique in malignancy, there is 55% morbidity with 16% delayed gastric emptying. Higher incidences of wound infec-tions, chest infections, and prolonged ileus were found in the open approach when compared to the laparoscopic approach; there seems to be no difference in delayed gastric emptying. In benign disease, the conventional open technique has 25% morbidity, with 16% delayed gastric emptying. Laparoscopic gastrojejunostomy in benign disease may be complicated by retrogastric fluid collection, incisional hernia, ulcer recurrences, and diarrhea. Complications related to pneumoperitoneum and positioning in reverse Trendelenburg include decreased venous return and cardiac output, increased chance of gastric reflux and aspiration, thromboembolic events, and decreased vital capacity. The small risk of carbon dioxide embolus on insufflation of the pneumoperitoneum results in cardiac arrhythmia, hypotension, pulmonary edema, hypoxemia, and right-sided heart failure.
Results
Few prospective data have been collated on laparoscopic gastrojejunostomy. This procedure is performed in few institutions by few surgeons, and the number of patients selected annually remains small. The largest series of retrospective data for malignancy has been reported by Brune et al. This studied 16 patients who were palliatively treated for malignant gastric outlet obstruction. Laparoscopic antecolic side-to-side gastrojejunostomy was performed in an average of 126 min with no intraoperative complications. One patient was converted to open procedure due to exten-sive adhesions. One postoperative complication, that of trocar site bleeding, required intervention. Median hospital stay was 7 days. Delayed gastric emptying was observed in 19%. Median survival was 87 days. Deaths were attributed to the underlying cancer, and patients were tolerating oral intake during their remaining sur-vival time. For benign disease, Wyman et al. retrospectively studied 12 patients with gastric outlet obstruction sec-ondary to peptic ulcer disease and pyloric stenosis. These patients underwent laparoscopic truncal vagotomy and gastrojejunostomy with a median operating time of 210 min. One patient required conversion to open tech-nique. Median hospital stay was 6 days. Delayed gastric emptying was observed in 2 patients but resolved with conservative measures. All patients had a good sympto-matic outcome at up to 12 months.
Conclusion
Laparoscopic gastrojejunostomy has been a successful minimally invasive procedure, although its applications have been limited. With increasing surgical experience, long-term studies can be performed to fully elucidate the indications and outcomes of such a procedure for the general surgical population. Damage of blood vessels of the anterior abdominal wall, mesenteric blood vessels, retroperitoneal vessels during laparoscopy. Damage of internal organs of the abdominal cavity during laparoscopy. Early and long-term postoperative complications.
Laparoscopic Side-to-Side Choledochoduodenostomy
Indications and Surgical Strategies
The indications for choledochoduodenostomy include common bile duct obstruction or stasis secondary to sludge, primary or recurrent stones, multiple common bile duct stones (when these cannot be cleared by endoscopic sphincterotomy and basket extraction), and distal common bile duct obstruction secondary to chronic pancreatitis or benign distal stricture. It is mandatory that the common bile duct be at least
Surgical Technique
After induction of satisfactory general anesthesia, the patient is placed in a supine position with the legs apart.The operator usually stands between the legs or to the left of the patient. The peritoneal cavity is entered by making a small incision at the umbilicus and introducing a 12-mm trocar under direct vision; this eliminates the risk of first trocar injuries. A pneumoperitoneum is created, and a 30° or 45° laparoscope is used because we believe this affords the best view of the duodenal and common bile duct anatomy. Under direct vision, a 12-mm trocar is introduced in the left upper quadrant in the sub-costal region. Two 5-mm trocars are introduced, one in the right upper quadrant in the midclavicular line just above the umbilicus, and another more laterally at the level of the anterior axillary line. If adhesions are present, these are lysed with sharp dissection, avoiding electrocautery wherever possible. The gallbladder, common bile duct, and duodenum are clearly identified. The fundus of the gallbladder is grasped with an atrau-matic tissue grasper through the lateralmost trocar, and the gallbladder and liver are raised upward toward the right hemidiaphragm. This maneuver allows relatively easy access to, and good visualization, of the common bile duct. The peritoneum over the distal common bile duct is incised, exposing the common bile duct wall, longitudinal incision along the anterior wall of the common bile duct is made for approximately
Laparoscopic Roux-en-Y Choledochojejunostomy
Indications and Surgical Strategies
When the common bile duct is less than
Surgical Technique
Laparoscopic Roux-en-Y choledochojejunostomy is technically a very demanding and time-consuming procedure. It requires a high level of laparoscopic skill that presently precludes it from widespread adoption. The technique described here was first developed in an animal model in our laboratory and demonstrates that this operation is technically feasible. The patient positioning and operating room setup are the same as previously described for laparoscopic choledochoduodenostomy. Trocar positioning is similar, except that we use three 12-mm trocars and two 5-mm trocars. The extra 12-mm trocar allows us to use an endoscopic linear stapling device to perform the enteric anastomosis as well as transect the distal common duct. Once the 30° laparoscope is inserted, a thorough examination of the portal triad and duodenal area is carried out to see if a surgical bypass can be performed. We prefer to create the Roux-en-Y jejunal limb first. The transverse colon is raised, exposing the ligament of Treitz and the proximal jejunum. The mesentery is divided just distal to the second arcade of vessels and extended down to the third or fourth arcade, depending on the length required. Once the mesentery has been divided, an endoscopic linear stapling device is used to transect the jejunum. The peritoneum over the distal common bile duct is then incised and the bile duct is carefully dissected free from the other portal triad structures. A right-angle dissector is often helpful in this dissection. When adequate mobilization of the distal common duct has been achieved, a 30-mm linear stapler is used to divide the distal common bile duct. The staple line on the proximal common bile duct is then excised, and an end-to-side single-layer handsewn anastomosis is created to the prepared jejunal limb prolene suture on a straight needle is then passed through the abdominal wall, and seromuscular bites are taken through the proximal jejunal limb and the distal jejunum at an appropriate distance (50–60 cm) from the biliary–enteric anastomosis. This suture acts to stabilize the two jejunal limbs as well as to maintain orientation. An enterotomy is made in both jejunal limbs that is large enough to fit the jaws of the stapling device. Care must be taken to avoid twisting of the bowel, which would result in tangential stapling. A side-to-side anastomosis is created using a 45-mm endoscopic linear stapler. The enterotomy sites are then closed with either an additional application of the stapler or a hand-sewn closure. To date, there have been few reports of choledochojejunostomies, except for experimental animal models. There have beeo reported cases of Roux-en-Y choledochojejunostomy in humans, and it is too early to tell whether laparoscopic choledochojejunostomy can be carried out quickly and safely enough to usurp present treatment options, including open surgery. However, because of new developments in anastomotic devices and animal models using fibrin glue, these clinical reports will probably soon emerge. Ultimately, the final deciding factor in making this procedure useful in humans will be the surgeon who develops the expertise in intracorporeal suturing required to perform laparoscopic choledochojejunostomy in a safe, effective, and timely fashion.
DAMAGE OF BLOOD VESSELS OF THE ANTERIOR ABDOMINAL WALL, MESENTERIC BLOOD VESSELS, RETROPERITONEAL VESSELS DURING LAPAROSCOPY. DAMAGE OF INTERNAL ORGANS OF THE ABDOMINAL CAVITY DURING LAPAROSCOPY. EARLY AND LONG-TERM POSTOPERATIVE COMPLICATIONS.
Despite the many potential benefits of laparoscopic colorectal surgery, as has been reported for ileoanal reservoir surgery and other advanced colorectal surgical procedures, complications are also inevitable. Complications may be related to the laparoscopist’s experience. The learning curve specific to colorectal surgery is both steep and lengthy. Moreover, the consequences of an anastomotic leak are potentially catastrophic; hence requirements for avoidance of complications include technical precision, advanced skills, and extensive training. Many surgeons have adapted this new technology without the benefit of formal training such as within a traditional surgical residency program or fellowship. The lack of organized progressive experience coupled with the complexity of the procedure increased and intensified the resultant morbidity attributed to the laparoscopic approach.
Proper case selection and prudent judgment advocating timely conversion have become inherent and exaggerated necessities for a successful outcome. Different and unusual complications such as port site recurrences and hernias have mandated a reevaluation of this approach, not only within local quality assurance surgical forums but also by the enrollment of patients in multi-institutional prospective randomized trials. This novel procedure is associated with immense theoretical benefits in the treatment of colorectal pathology. However, extensive training, supervision, and credentialing of surgeons keen to adapt this technology are essential to surpass the difficult learning curve. Complications of laparoscopic colorectal surgery can be categorized as:
2. Attributed directly and specifically to the laparoscopic
approach
3. resulting from errors in judgment and case selection
Complications attributed to the learning curve are not surprising. Laparoscopic colectomy challenges even the most adept instrumentalist who also has an innate gift of transforming three-dimensional anatomy to the two-dimensional video screen. Laparoscopic colectomy requires extensive mobilization of a large hollow organ in multiple quadrants of the abdomen. In addition, extensive vascular control of a fat-laden mesentery requires costly instrumentation to ensure safety. Finally, a well-vascularized, tension-free circumferentially intact anastomosis must be constructed, often in a narrow pelvis. The potential for complications is undoubtedly increased as each and every new and unfamiliar step is taken.
Complications specific to the laparoscopic approach include port site hernias, port site recurrences, and pneumoperitoneum-related problems. Direct trocar-related injuries to bowel and vascular structures are not uncommon, yet are possibly avoidable. Faulty positioning, difficult exposure, and the loss of tactile sensation may predispose to complications specific to laparoscopic technology. The list includes ureteral, vascular injury, and contamination and sepsis from bowel injury. Complications resulting from poor surgical judgment are often due to inadequate case selection and the inappropriate application of this technology to treat all pathology regardless of patient outcome. No single surgical tool, procedure, or approach is universally applicable. Laparoscopy is no different; there still remains an important role for the traditional laparotomy. Other complications resulting from poor judgment stem from inappropriately prolonged operating times and reluctance to convert to a laparotomy when indicated.
The Steep and Lengthy Learning Curve Complications are in part reflective of the operating surgeon’s experience. Agachan and associates reported a progressive decrease in the complication rate at the Cleveland Clinic
The Laparoscopic Approach
Complications specific to the laparoscopic approach can be separated into those problems attributed to the use of pneumoperitoneum, trocar-related difficulties, and direct laparoscopic limitations such as faulty positioning, difficult exposure, and loss of tactile sensation. Pneumoperitoneum-Associated Complications Intraperitoneal insufflation of carbon dioxide can elevate the arterial content of carbon dioxide (CO2) by trans-peritoneal and subcutaneous absorption. Therefore, continuous capnometry is mandatory, as are blood gas measurements in prolonged cases. The CO2 gas used should be warmed to help prevent hypothermia; most healthy patients will develop only minimal hypercarbia. Patients with cardiopulmonary dysfunction can develop severe hypercarbia and acidemia, provoking numerous complications. Extensive subcutaneous emphysema sequesters large amounts of CO2, which can overwhelm the endogenous clearance mechanism and further exacerbate the respiratory acidosis. This occurrence is typical in thin-skinned, frail elderly patients with cardiopulmonary disease. This problem can be avoided by carefully anchoring the ports and having an assistant ensure port stability during the introduction and extraction of instruments through the ports. The intraabdominal pressure should be kept at 15 mmHg because higher pressures can decrease venous return. This level is especially important in volume-depleted patients, particularly after a bowel preparation. Furthermore, increased intraabdominal pressure may alter pulmonary mechanics, decreasing compliance and forcing the diaphragm cephalad. Ventilating the lower lobes for patients with obstructive pulmonary disease may be difficult and require increasing the ventilator’s inflation pressure. Trocar-Associated Complications The major risk with trocars is related to the initial blind insertion. Adherent organs and vessels within or deep to the abdominal wall may be injured. The Hasson tech-nique eliminates the complications of blind Veress needle and the initial trocar insertion; the Hasson technique is not without morbidity, as avulsion of adhesions or even enterotomy can occur. Nevertheless, the complication rate appears to be both lower and less consequential than with the closed technique. Regardless of technique of initial port placement, all subsequent trocars should be placed under direct vision, specifically avoiding the epigastric vessels. This positioning can be difficult in obese patients in whom the epigastric vessels cannot be easily transilluminated. To help decrease the chance of epigastric vessel injury, subsequent ports are placed lateral to the vessels. This position also facilitates mobilization of the right or left colon, allowing maximum distance between ports. The skin incision should be large enough and the abdomen should be fully distended, so that excessive force is not required to place the trocar. The incidence of port site hernias is probably increased secondary to frequent manipulation and dissection that is required through larger, atypically placed trocars. Thus, all defects made by trocars
Conclusion
Avoiding complications associated with the application of minimally invasive technology to colorectal disorders can be achieved in the same way that any other unfamiliar innovative technology is adapted to the surgical forum. Progressive technical experience, careful and thoughtful case selection, early conversion to laparotomy, and advances in technology will all help ensure the desired outcome.
Avoidance and Treatment of Urological Complications
The incidence of ureteral injury during open colorectal surgery has been reported to be 0.71% for colorectal procedures and as high as 3.7% for abdominoperineal resections. Laparoscopic surgery poses additional challenges for the colorectal surgeon because of the lack of tactile feedback and potential difficulties with exposure. A 0.6% to 1.6%3,4 incidence of ureteral injuries has been reported for laparoscopic gynecological procedures. Clearly, the incidence of iatrogenic urologic injury varies depending on patient selection factors such as history of radiation or the likelihood of retroperitoneal or pelvic fibrosis. The risk of iatrogenic urological injury also depends on the location of the pathology and the extent of dissection required to complete the laparoscopic procedure.
Ureteral Anatomy
Because the ascending and descending colon are, in part, within the retroperitoneal space, the ureters must be considered during their surgical dissection. The ureters course medially in the retroperitoneum posterior to the colon mesentery. The proximal to midureters are immediately lateral to the great vessels and anterior to the psoas muscle. The ureters cross the iliac vessels at their bifurcation and travel posterolaterally along the pelvic sidewall. The ureters then cross under the vas deferens, in men, and the infundibulopelvic ligament, in women, before passing under the obliterated umbilical artery and into the posterolateral aspect of the bladder where they enter via a muscular sheath. Because of the proximity of the distal ureters to the gynecological organs and rectum, most iatrogenic ureteral injuries occur to the distal one-third of the ureters, particularly in the region of the pelvic brim.
Avoidance of Ureteral Injury
The most important aspect of avoiding ureteral injury is to be aware of its possibility. Patients who are particularly susceptible to ureteral injury include those with significant retroperitoneal inflammation, such as patients with inflammatory bowel disease or pelvic abscess. Patients with infiltrative cancer or a history of abdominal or pelvic radiation are also at increased risk for iatrogenic ureteral injury. Ureteral catheters may be placed before colon surgery to aid in identifying the ureters via palpation during difficult cases. Because the ureteral catheters can be difficult to palpate laparoscopically, intraoperative manipulation of the ureteral catheters via the urethra as the retroperitoneum is inspected for motion may aid in
the identification of the ureters. If a ureter cannot be identified in the region of large bowel pathology and the risk of ureteral involvement is high, it would be prudent to identify the ureter away from the pathology and trace it into the region of involvement. Illuminated ureteral catheters may facilitate their identification but are expensive and should be reserved for particularly difficult cases. Ureteral catheters that emit infrared light are also available with an infrared laparoscopic camera system.
Recognition and Treatment of Urinary
Tract Injuries
Discovering an iatrogenic urinary tract injury intraoperatively is far preferable to discovering the problem in the postoperative period. Most clues that the urinary tract has been injured are relatively obvious, such as the sudden intraoperative onset of hematuria or insufflation of the bladder catheter drainage bag with CO2. Preoper-ative placement of ureteral catheters facilitates the intraoperative recognition of a ureteral injury by the surgeon’s direct visualization of the catheter during dis-section. In the absence of a ureteral catheter, a ureteral injury could much more easily be missed. If suspicion for a ureteral injury exists, a ureteral catheter can be placed cystoscopically at any point during the procedure and then irrigated with methylene blue or saline solution. Extravasation of irrigant should be evident. If there is any suspicion for bladder injury, the bladder catheter should be similarly irrigated with methylene blue or saline solution. If a urinary tract injury is recognized intraoperatively, steps can be taken immediately to repair the injury. If a very small ureterotomy (<1–2 mm) has been made. In the upper retroperitoneum, the ureters (arrow-heads) are anterior to the psoas muscles and posterior to the ascending and descending colon mesentery. A gravity cystogram may be performed to confirm absence of extravasation before bladder catheter removal. Patients with an initially unrecognized urinary tract injury may present with flank or abdominal pain, fever, leukocytosis, or prolonged ileus. Although unusual, post-operative oliguria or anuria could be noted if both ureters are injured. CT is a valuable tool for identifying urinary tract injury. If extravasation of contrast or a collection is seen on CT, a drain should be placed and the fluid sent for creatinine level. Other diagnostic procedures that may be performed to locate or characterize urinary tract injury include intravenous pyelography, cystography, cys-toscopy, and retrograde pyelography.
Conclusion
Urinary tract injuries are uncommon during laparoscopic or open colon surgery. However, the ureters and bladder may be injured if significant inflammation and fibrosis are present. Awareness of the possibility of urinary tract injury and steps to prevent injury, such as preoperative placement of ureteral catheters, can further reduce the incidence of such events. Intraoperative recognition is far preferable to postoperative diagnosis of a urinary tract injury. Fortunately, the urinary tract is relatively forgiving so long as the urine is diverted with an indwelling ureteral stent or a large bladder catheter during the healing process.
Placement of an indwelling ureteral stent and a retroperi-toneal drain should suffice. Larger lacerations may require the additional placement of a few small (4-0 or smaller) interrupted absorbable sutures. The closure should be transversely performed if possible so as not to compromise the diameter of the ureter. If a significant injury occurs or if the ureter is completely transected, however, reconstruction will be necessary via open or laparoscopic ureterotomy or ureteral reimplantation, depending on the site and extent of injury. The end(s) of the ureter should be debrided and spatulated, but mobi-lized no more thaecessary. The goal of any such pro-cedure is to create a watertight, tension-free anastomosis with a good blood supply to each end of the ureter. If the ureteral injury involves inadvertent ligation, the ligated segment usually should be excised and a ureterouretero-tomy performed. Placement of a drain adjacent to the anastomosis is generally recommended following such procedures. In extreme circumstances when a significant length of ureter is lost and when there is insufficient length to perform a ureteral reimplant, options include complex open reconstructive procedures such as the construction of an ileal ureter, transureteroureterostomy, autotransplantation, or nephrectomy. Such complex pro-cedures should probably not be undertaken at the time of initial ureteral injury. If a bladder injury has occurred, the bladder may be repaired in one or two layers via an open or laparoscopic approach using absorbable sutures. Care should be takeot to injure or obstruct the urethra and bladder neck or the ureters and their orifices during bladder repair.
Vascular complications are uncommon but potentially catastrophic sequelae of laparoscopic surgery. Although the term vascular injury connotes an iatrogenic breech in a vessel wall, equally significant vascular complications can result from the hemodynamic effects of pneumoperitoneum or the inadvertent introduction of
gas into the circulation. The avoidance of vascular complications during laparoscopic surgery is based on both an appreciation of vascular anatomy and a sound understanding of physiological principles related to pneumoperitoneum.
Complications Related to Venous Stasis
Risk factors for venous thromboembolism are well char-acterized and thus, measures to prevent perioperative deep venous thrombosis (DVT) have become standard. The creation of pneumoperitoneum in conjunction with laparoscopic procedures has specific implications with respect to venous stasis and the potential for thromboembolic events. Studies have demonstrated that lower extremity venous stasis occurs when intra-abdominal pressure exceeds 14 mmHg. Furthermore, a tendency toward hypercoagulability is seen in patients following pneumoperitoneum. Despite these factors which, in aggregate, would be anticipated to increase the likelihood of venous thromboembolism following laparoscopy, the incidence of clinical venous thromboembolism may, in fact, be lower than with comparable procedures per-formed by laparotomy. In this regard, in one series of more than 500 laparo-scopic colorectal procedures, no instances of DVT or pulmonary embolism were observed. Although speculative, the low incidence of venous thromboembolic events following laparoscopic colorectal surgery may relate to the placement of the patient in the Trendelenburg position during many such procedures. It is currently recommended that prophylactic measures be employed in patients at risk for DVT in whom laparoscopic surgery is being performed. Prophylaxis should include mechanical measures (pneumatic compression) supplemented by anticoagulation with heparin or low molecular weight heparin, as indicated. The use of pneumatic compression has been shown to improve venous hemodynamics dur-ing laparoscopic surgery.
Effects of Pneumoperitoneum on the Mesenteric Circulation
Experimentally, the increased abdominal pressure asso-ciated with induction of pneumoperitoneum has been shown to decrease splanchnic perfusion. The clinical implications of relative mesenteric hypoperfusion, however, are unclear as visceral ischemic manifestations are exceedingly uncommon following routine laparoscopic procedures. Richmond et al. have reported a collected series of five cases of mesenteric ischemia attributed to laparoscopy.
Gas Embolism
Gas embolism may appropriately be considered a vascular complication of laparoscopy. The rare incidence of this potentially lethal complication may be attributed to the rapid dissolution of carbon dioxide (CO2) in the blood. The introduction of large volumes of CO2into the circulation, however, can result in precipitous cardiovascular collapse. A high index of suspicion regarding CO2 embolism must be maintained when a patient develops hemodynamic instability or collapse during laparoscopy, particularly in association with bradycardia and cyanosis. Monitoring end-tidal CO2 may help confirm the diagnosis, although an increased end-tidal CO2reflecting hypercapnia is not invariably observed. In nearly two-thirds of reported cases of CO2 embolism, cardiovascular colla-pase occurred during or immediately following insufflation. In most cases inadvertent vascular cannulation with a Veress needle was suspected. In cases of gas embolism, management is directed toward immediate cessation of insufflation and release of pneumoperitoneum. The patient should be placed in the steep Trendelenburg and left lateral decubitus posi-tion. Aspiration of gas from the right atrium by central venous cannulation can be a lifesaving maneuver in such cases.
Vascular Injury Related to Veress
Needle Placement and Cannulation
The potential for direct vascular injury begins with peritoneal cannulation. Often, pneumoperitoneum is established by introduction of a Veress needle through a periumbilical incision. Injury to the aortic bifurcation or iliac vessels can occur with blind introduction of the Veress needle into the peritoneal cavity. In anatomic studies, the aortic bifurcation has been demonstrated to lie within
Veress needle injuries accounted for the preponderance of these. Injuries sus-tained during initial trocar placement are thought to
. A. Location of abdominal wall and retroperitoneal vessels relative to the umbilicus and rectus muscles.
B. The retroperitoneal mesenteric attachments of the colon. The superior mesenteric and left iliac vessels are particularly vulnerable to injury during division of the transverse mesocolon and sigmoid mesocolon, respectively. These obser-vations have led some authorities to advocate open can-nulation, as originally described by Hasson, in preference to closed cannulation. The data comparing these tech-niques, although uncontrolled, support the superiority of the former method, limiting major and potentially lethal vascular injury. Undoubtedly, the vessel most commonly injured in laparoscopic procedures is the epigastric artery. This vessel may be particularly vulnerable in laparoscopic colorectal procedures because of the proximate sites of trocar insertion used in such procedures. Injuries to the inferior epigastric artery may go unrecognized due to temporary tamponade by both the cannulae and the pneumoperitoneum. The importance of direct laparoscopic inspection of the port site on withdrawl of the can-nulae and decompression of the pneumoperitoneum to ensure proper hemostasis bears emphasis in this regard. Significant bleeding may occur in such cases into the peritoneal cavity, the preperitoneal space, or the rectus sheath. Temporary hemostasis is usually not problematic, being effected by reintroduction of a cannula. Suture control is achieved by transmural introduction of a monofilament mattress suture on a straight needle above and below the port site. In contrast to the burgeoning experience and literature relating to laparoscopic gastrointestinal and solid organ. Cross-sectional representation of rectus sheath demonstrates transabdominal mattress suture compressing the epigastric artery. The suture is removed several days after the procedure. Although anecdotal reports of aortofemoral bypass performed laparoscopically have been described, vascular techniques in laparoscopic surgery cannot be viewed as standardized. As such, it must be emphasized that, in cases of injury to major vascular structures incurred during laparoscopy, conversion to laparotomy with direct vascular control and repair is imperative in all but the most exceptional circumstances. Laparotomy will afford optimal vascular exposure and permit repair using standard techniques. In most cases, this resolution will involve direct suture repair using fine monofilament suture. In those unusual cases in which extensive disruption of the arterial or venous wall occurs, more elaborate reconstructive tehniques may be required, such as debridement and patch angioplasty or segmental resection with end-to-end anastamosis or interposition grafting. Should the latter technique be required, autogenous grafting using the greater saphenous vein or, less commonly, the hypogastric artery should be employed if the reconstruction is being performed in a contaminated field. The iliac vessels are at risk both during cannulation and during pelvic dissection. Acute compromise of the common or external iliac arteries in the absence of pre-existing atherosclerotic disease typically leads to severe limb ischemia; prompt and accurate repair of such injuries, using anatomic or extra-anatomic techniques, is essential. In contrast, prolonged attempts to salvage an injured hypogastric artery may not be justified, particularly if the contralateral internal iliac artery is intact or if proctosigmoidectomy has been performed. In such cases ligation can usually be performed without sequelae. Similarly, although repair of iliac venous injuries is preferable, if circumstances dictate, ligation is well tolerated. Swelling can be anticipated following iliac vein ligation, and the use of compression stockings can be helpful. Injury to the superior mesenteric vessels, vulnerable during mobilization and resection of the transverse colon, can have devastating consequences. This portion of the procedure may be particularly difficult when the transverse colon is foreshortened by malignant or inflammatory disease. Should injury to either the superior mesenteric artery or vein occur, precise repair with preservation of patency is imperative to prevent extensive mesenteric infarction. In contrast to spontaneous mesenteric venous thrombosis, thrombectomy should be attempted in iatrogenic superior mesenteric vein throm-bosis in an attempt to restore venous patency.
