Operative Endoscopic and Minimally Invasive Surgery 9781498708302, 1498708307, 9780429426360

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Operative Endoscopic and Minimally Invasive Surgery
 9781498708302, 1498708307, 9780429426360

Table of contents :
Content: ForewordPrefaceContributorsSECTION I: MINIMALLY INVASIVE SURGERY IN THE MODERN HEALTH CARE ENVIRONMENT1. Cost implications in minimally invasive surgeryChristopher M. Schlachta and Janet Martin2. Enhanced recovery programs in minimally invasive surgeryNicolo Pecorelli and Liane S. FeldmanSECTION II: FLEXIBLE ENDOSCOPY3. Training and privileging surgeons and gastroenterologists in endoscopyJudy Wang and Brian J. Dunkin4. Anesthetic challenges in the gastrointestinal suitesSheila Ryan Barnett5. Diagnostic upper gastrointestinal endoscopyJaclyn Weirzbicki, Adam Reid, I. Bulent Cetindag, Aman Ali, and John D. Mellinger6. Diagnostic upper endoscopy II: Endoscopic ultrasoundVaibhav Wadhwa and Douglas Pleskow7. Dilatation and stentingMatthew R. Pittman and Dean J. Mikami8. Therapeutic upper endoscopy II: Treatment of Barrett esophagusBoris Kiriazov and Vic Velanovich9. Therapeutic upper endoscopy III: Treatment of gastroesophageal refluxEdward L. Jones, Kyle A. Perry, and Jeffrey W. Hazey10. Endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection in the upper gastrointestinal tractD. Tami Yamashita and James Ellsmere11. Endoscopic procedures for morbid obesityAustin L. Chiang and Marvin Ryou12. Therapeutic upper endoscopy VI: Revisional bariatric techniques-Suturing, scleraltherapyHans F. Fuchs, Cristina R. Harnsberger, and Garth R. Jacobsen13. Therapeutic upper endoscopy VII: Management of perforations and fistulaEleanor C. Fung and Dean J. Mikami14. Therapeutic upper endoscopy VIII: Management of upper gastrointestinal bleedingRobert Gianotti and Tyler Berzin15. Diagnostic lower endoscopy IDouglas Horst16. Lower endoscopy therapeutic dilation and stentingDavid E. Beck17. Transanal endoscopic microsurgeryJohn H. Marks and Jean F. Salem18. Transanal minimally invasive surgeryJustin J. Kelly, John P. Burke, and Matthew R. Albert19. Diagnostic lower endoscopyEleanor C. Fung20. Endoscopic procedures of the pancreas for complications of pancreatitisAjaypal Singh and Andres Gelrud21. Endoscopic procedures of the biliary treeJeffrey M. Marks and Ping Pan22. Endoscopy assistance in laparoscopic techniqueMorris E. Franklin Jr. and Miguel A. HernandezSECTION III: NATURAL ORIFICE SURGERY23. Transvaginal access for natural orifice transluminal endoscopic surgeryKurt Eric Roberts and Stephanie G. Wood24. Percutaneous endoscopic gastrostomyJeffrey L. Ponsky and Avery C. Capone25. Peroral endoscopic myotomy (POEM) for achalasiaPaul Colavita and Lee L. Swanstrom26. Transvaginal cholecystectomyBill Ran Luo and Eric S. Hungness27. Transvaginal appendectomyKurt Eric Roberts and Stephanie G. Wood28. Natural orifice surgery: ColectomyChristy E. Cauley and Patricia SyllaSECTION IV: PREPARATION FOR MINIMALLY INVASIVE SURGERY29. Telementoring in minimally invasive surgeryIan Choy and Allan Okrainec30. Objective metrics in the simulation of minimally invasive surgeryYusuke Watanabe, Elif Bilgic, Amin Madani, and Melina C. Vassiliou31. Virtual reality simulation in minimally invasive surgerySuvranu De32. Training and credentialing in laparoscopy, including the Fundamental Use of Surgical EnergyMichael A. Russo, Shawn T. Tsuda, and Daniel J. Scott33. Measuring quality in minimally invasive surgeryElan R. Witkowski and Matthew M. Hutter34. How the commitment to patient safety impacts operative practice in minimally invasive surgeryEric Luedke, Dan Azagury, and John Morton35. Three-dimensional transesophageal echocardiography in minimally invasive cardiac surgeryMario Montealegre-Gallegos and Feroze Mahmood36. The impact of skills warm-up in minimally invasive surgeryJames C. Rosser, Jr., Scott Furer, and Neesha Patel37. The role of mental training in minimally invasive surgeryArmando Rosales and Raul J. Rosenthal38. The ergonomic minimally invasive surgical/endoscopy suiteH. Reza Zahiri and Adrian E. Park39. Energy sources in minimally invasive surgeryAmin Madani and Sharon L. Bachman40. Anesthesia for laparoscopy: What does a surgeon need to know?Cindy M. Ku and Stephanie B. JonesSECTION V: ACCESS AND IMAGING IN MINIMALLY INVASIVE SURGERY41. Access in minimally invasive surgeryMargaret E. Clark and Robert B. Lim42. Single port and reduced port accessBenjamin Sadowitz, Alexander Rosemurgy, and Sharona Ross43. Diagnostic laparoscopy for benign and malignant diseaseRita A. Brintzenhoff, William S. Richardson, and Dimitrios Stefanidis44. Laparoscopic ultrasound in surgeryMaurice E. Arregui and Piyush Aggarwal45. Three-dimensional printing development and medical applicationsFeroze Mahmood and Daniel B. JonesSECTION VI: MINIMALLY INVASIVE TREATMENT OF ESOPHAGEAL DISEASE46. Anatomic and physiologic tests of esophageal functionJoel M. Sternbach and Eric S. Hungness47. 360 Degrees FundoPatrick Reardon48. Laparoscopic partial fundoplicationAlex P. Nagle and Kenric M. Murayama49. Laparoscopic placement of external magnetic antireflux ringYulia Zak and Ozanan Meireles50. Laparoscopic antireflux esophageal lengthening procedureLeena Khaitan and Abel Bello51. Laparoscopic repair of paraesophageal herniaC. Daniel Smith52. Reoperative surgery after fundoplicationCarmen L. Mueller, Lorenzo E. Ferri, and Gerald M. Fried53. Laparoscopic treatment of achalasiaBrian M. Nguyen and Jonathan F. Critchlow54. Robotic approach to achalasiaAlberto S. Gallo and Santiago Horgan55. Laparoscopic treatment of esophageal diverticulaSarah E. Billmeier and Thadeus L. Trus56. Laparoscopic transhiatal esophagectomy for curative intentMoshim Kukar and Steven N. Hochwald57. Minimally invasive Ivor Lewis method for resection of esophageal cancerJohn-Paul Bellistri and W. Scott MelvinSECTION VII: MINIMALLY INVASIVE TREATMENT OF GASTRIC DISEASE58. Peptic ulcer diseaseHenry Lin59. Resection of nonadenomatous gastric tumorsJason K. Sicklick, Michele L. Babicky, and Ronald P. DeMatteo60. Laparoscopic resection for treatment of gastric cancerTsuyoshi Etoh, Hajime Fujishima, and Seigo Kitano61. The laparoscopic placement of feeding tubesJaisa OlaskySECTION VIII: LAPAROSCOPIC TREATMENT OF MORBID OBESITY62. The impact of obesity epidemic: Relationship between body mass index and 30-day mortality riskSara A. Hennessy and Bruce D. Schirmer63. Laparoscopic adjustable gastric bandingBradley F. Schwack and Jaime Ponce64. Laparoscopic Roux-en-Y gastric bypassDavid Spector and Scott Shikora65. Laparoscopic sleeve gastrectomyJihui Li, Emanuele Lo Menzo, Samuel Szomstein, and Raul J. Rosenthal66. Laparoscopic management of bariatric surgery complicationsSungsoo Park, Hana Alhomoud, Emanuele Lo Menzo, and Raul J. Rosenthal67. Laparoscopic reoperative bariatric surgeryNatan Zundel, Santiago Rodriguez, and Juan D. Hernandez68. Video-assisted thoracoscopic vagotomy for marginal ulcersCaroline Park and Sidhu Gangadharan69. Intragastric balloonAlfredo Genco and Ilaria ErnestiSECTION IX: MINIMALLY INVASIVE TREATMENT OF HEPATOBILIARY DISEASE70. Laparoscopic cholecystectomy and intraoperative biliary imagingRobert D. Fanelli, Thomas J. VanderMeer, and Brandon D. Andrew71. Laparoscopic common bile duct explorationEzra N. Teitelbaum and Nathaniel J. Soper72. Laparoscopic left hepatectomyYasushi Hasegawa and Go Wakabayashi73. Totally laparoscopic right hepatectomyDavid Fuks and Brice Gayet74. Laparoscopic hepatectomy: The Glissonian approachMarcel Autran Cesar Machado75. Ablative treatment of liver tumorsPascal R. Fuchshuber, John B. Martinie, and David A. Iannitti76. Robotic approach to hepatic resectionsSusanne Warner and Yuman Fong77. Laparoscopic staging for pancreatic malignancyAmmara A. Watkins and Mark P. Callery78. Robot-assisted minimally invasive pancreaticoduodenectomyAlessandra Storino, Tara S. Kent, and A. James Moser79. Laparoscopic pancreaticoduodenectomy (Whipple)Ruchir Puri, John A. Stauffer, and Horacio J. Asbun80. Laparoscopic distal pancreatectomyOmar Yusef Kudsi, Lerna Ozcan, and Michel Gagner81. Laparoscopic surgery of the spleenNamir Katkhouda, Vivian Pham, and Kulmeet SandhuSECTION X: MINIMALLY INVASIVE APPROACH TO ENDOCRINE DISEASE82. Laparoscopic adrenalectomyJesse D. Pasternak and Quan-Yang Duh83. Endoscopic approaches to the thyroid and parathyroid glandsHyunsuk Suh and William B. Inabnet III84. Laparoscopic resection of endocrine pancreatic neoplasmsCherif Boutros and John A. Olson Jr.SECTION XI: MINIMALLY INVASIVE APPROACH TO DISEASE OF THE GASTROINTESTINAL TRACT85. Laparoscopic treatment of diseases of the small bowelJeffrey N. Harr and Fred Brody86. Laparoscopic surgery of the appendixEric Balent and Robert B. Lim87. Laparoscopic surgery for benign disease of the colon: DiverticulitisAli Linsk Butash and Ketan Sheth88. Laparoscopic resection for carcinoma of the colonJared Wong and James Fleshman89. Laparoscopic total mesorectal excisionYuliya Yurko and Tonia M. Young-Fadok90. Laparoscopic treatment of inflammatory bowel diseaseDaniel Shouhed, Gustavo Fernandez-Ranvier, and Barry Salky91. Robotics in colon and rectal surgeryDeborah M. Nagle92. Hand-assisted colectomy techniquesPeter W. Marcello93. Minimally invasive therapies for fecal incontinenceIsacco Montroni, Claire E. Peeples, and Steven D. WexnerSECTION XII: LAPAROSCOPIC APPROACH TO INGUINAL AND ABDOMINAL WALL HERNIA94. Laparoscopic totally extraperitoneal hernia repairEdward L. Felix94A Technique of transanal-assisted colon resection and rectopexyKarl-Hermann Fuchs, Wolfram Breithaupt, Gabor Varga, Kai Neki, Rebeca Dominguez Profeta, and Santiago Horgan95. Laparoscopic transabdominal preperitoneal inguinal hernia repairBrian Jacob and Alexandra Argiroff96. Laparoscopic component separationRussell C. Kirks, Jr. and David A. Iannitti97. Biomaterial considerations in laparoscopic hernia repairBrent D. Matthews98. Laparoscopic incisional and ventral hernia repairBruce J. Ramshaw, Lisa A. Cunningham, and H. Charles Peters99. Robotic transabdominal preperitoneal inguinal hernia repairFahri Gokcal and Omar Yusef Kudsi100. Robotic ventral hernia repairFahri Gokcal and Omar Yusef Kudsi101. Laparoscopic repair of recurrent inguinal herniaBrandice Durkan and Edward H. Phillips102. Laparoscopic repair of sports herniaL. Michael Brunt103. Laparoscopic roboticsOmar Yusef Kudsi, Anthony Gonzalez, Zachary McCabe, and Ernesto DominguezSECTION XIII: THORACOSCOPY104. Thoracoscopic surgery of the mediastinum and esophagusNassrene Y. Elmadhun and Michael Kent105. Video-assisted thoracic surgery lobectomyAlessandro Brunelli and Tim BatchelorSECTION XIV: OTHER MINIMALLY INVASIVE ABDOMINAL/RETROPERITONEAL PROCEDURES106. The role of robotics in minimally invasive urologic surgeryOstap Dovirak and Andrew A. Wagner107. Laparoscopic nephrectomy for malignancyAaron Lay and Jeffrey A. Cadeddu108. Laparoscopic donor nephrectomyDaniel M. Herron109. Laparoscopic approaches to aortic vascular diseaseKonstantinos S. Mylonas and Konstantinos P. Economopoulos110. Laparoscopic median arcuate ligament releaseWilliam S. Richardson and James Wooldridge111. Minimally invasive approach to retroperitoneal collections in necrotizing pancreatitisPieter Timmerman, Marc G.H. Besselink, and Karen D. HorvathSECTION XV: PEDIATRIC LAPAROSCOPY AND ENDOSCOPY112. Pediatric laparoscopy: General considerationsSebastian K. King and Jacob C. Langer113. Laparoscopic hernia repair in childrenDavid H. Rothstein and Carroll M. Harmon114. Laparoscopic treatment of reflux in childrenSteven Rothenberg115. Laparoscopic treatment of benign gastrointestinal disease in childrenBrian T. Bucher and Gretchen P. JacksonSECTION XVI: IMAGE GUIDED SURGERY116. Surgical procedures performed in radiology suitesKinga A. Powers and Kelley Whitmer117. Augmented realityMichele Diana, Luc Soler, Stephane Nicolau, and Jacques MarescauxSECTION XVII: ESSAY ON ISSUES IN MINIMALLY INVASIVE SURGERY118. The challenges and solutions of performing minimally invasive surgery in underdeveloped environmentsRaymond R. Price and Adewale O. Adisa119. Essay: The future of robotics in minimally invasive surgeryCrystal Krause, Songita Choudhury, and Dmitry Oleynikov120. Essays on the future of endoscopic surgery: Redefining, future training, and credentialing pathwaysAurora D. PryorIndex

Citation preview

Operative Endoscopic and Minimally Invasive Surgery

Operative Endoscopic and Minimally Invasive Surgery Edited by Daniel B. Jones, MD, MS

Professor of Surgery Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts

Steven D. Schwaitzberg, MD, FACS

Professor and Chair of Surgery Jacobs School of Medicine and Biomedical Sciences The State University of New York Buffalo, New York

Art Editor Cara M. Jordan,


Provost’s Fellow in the Arts Center for the Humanities Graduate Center, City University of New York New York City, New York

CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2019 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4987-0830-2 (Pack- Hardback and eBook) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Jones, Daniel B., 1964- editor. | Schwaitzberg, Steven D., editor. Title: Operative endoscopic and minimally invasive surgery / edited by Daniel B. Jones and Steven D. Schwaitzberg. Description: Boca Raton : CRC Press, 2019. | Includes bibliographical references. Identifiers: LCCN 2018013795| ISBN 9781498708302 (pack : book and e-book : alk. paper) | ISBN 9780429426360 (e-book) Subjects: | MESH: Endoscopy--methods Classification: LCC RD33.53 | NLM WO 505 | DDC 617/.057--dc23 LC record available at https://lccn.loc.gov/2018013795 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com


Foreword xi Preface xiii Editorsxv Contributors xvii Section I  MINIMALLY INVASIVE SURGERY IN THE ­MODERN HEALTH CARE ENVIRONMENT 1 2

Cost implications in minimally invasive surgery Christopher M. Schlachta and Janet Martin Enhanced recovery programs in minimally invasive surgery Nicolò Pecorelli and Liane S. Feldman

3 7

Section II  FLEXIBLE ENDOSCOPY 3 4 5 6 7 8 9 10

11 12 13 14 15 16 17

Training and privileging surgeons and ­gastroenterologists in endoscopy Judy Wang and Brian J. Dunkin Anesthetic challenges in the gastrointestinal suites Sheila Ryan Barnett Diagnostic upper gastrointestinal endoscopy Jaclyn Weirzbicki, Adam Reid, I. Bulent Cetindag, Aman Ali, and John D. Mellinger Diagnostic upper endoscopy II: Endoscopic ultrasound Vaibhav Wadhwa and Douglas Pleskow Dilatation and stenting Matthew R. Pittman and Dean J. Mikami Therapeutic upper endoscopy II: Treatment of Barrett esophagus Boris Kiriazov and Vic Velanovich Therapeutic upper endoscopy III: Treatment of gastroesophageal reflux Edward L. Jones, Kyle A. Perry, and Jeffrey W. Hazey Endoscopic mucosal resection, endoscopic s­ ubmucosal dissection, and endoscopic full-thickness resection in the upper gastrointestinal tract D. Tami Yamashita and James Ellsmere Endoscopic procedures for morbid obesity Austin L. Chiang and Marvin Ryou Therapeutic upper endoscopy VI: Revisional bariatric techniques—Suturing, scleraltherapy Hans F. Fuchs, Cristina R. Harnsberger, and Garth R. Jacobsen Therapeutic upper endoscopy VII: Management of perforations and fistula Eleanor C. Fung and Dean J. Mikami Therapeutic upper endoscopy VIII: Management of upper gastrointestinal bleeding Robert Gianotti and Tyler Berzin Diagnostic lower endoscopy I Douglas Horst Lower endoscopy therapeutic dilation and stenting David E. Beck Transanal endoscopic microsurgery John H. Marks and Jean F. Salem

18 26 30 39 45 50 55

60 67 71 74 80 84 93 98

vi Contents 18 19 20 21 22

Transanal minimally invasive surgery Justin J. Kelly, John P. Burke, and Matthew R. Albert Diagnostic lower endoscopy Eleanor C. Fung Endoscopic procedures of the pancreas for ­complications of pancreatitis Ajaypal Singh and Andres Gelrud Endoscopic procedures of the biliary tree Jeffrey M. Marks and Ping Pan Endoscopy assistance in laparoscopic technique Morris E. Franklin Jr. and Miguel A. Hernandez

103 110 118 125 129

Section III NATURAL ORIFICE SURGERY 23 24 25 26 27 28

Transvaginal access for natural orifice transluminal endoscopic surgery Kurt Eric Roberts and Stephanie G. Wood Percutaneous endoscopic gastrostomy Jeffrey L. Ponsky and Avery C. Capone Peroral endoscopic myotomy (POEM) for achalasia Paul Colavita and Lee L. Swanstrom Transvaginal cholecystectomy Bill Ran Luo and Eric S. Hungness Transvaginal appendectomy Kurt Eric Roberts and Stephanie G. Wood Natural orifice surgery: Colectomy Christy E. Cauley and Patricia Sylla

134 140 148 154 157 162

Section IV  PREPARATION FOR MINIMALLY INVASIVE SURGERY 29 30 31 32 33 34 35 36 37 38 39 40

Telementoring in minimally invasive surgery Ian Choy and Allan Okrainec Objective metrics in the simulation of minimally invasive surgery Yusuke Watanabe, Elif Bilgic, Amin Madani, and Melina C. Vassiliou Virtual reality simulation in minimally invasive surgery Suvranu De Training and credentialing in laparoscopy, including the Fundamental Use of Surgical Energy Michael A. Russo, Shawn T. Tsuda, and Daniel J. Scott Measuring quality in minimally invasive surgery Elan R. Witkowski and Matthew M. Hutter How the commitment to patient safety impacts operative practice in minimally invasive surgery Eric Luedke, Dan Azagury, and John Morton Three-dimensional transesophageal echocardiography in minimally invasive cardiac surgery Mario Montealegre-Gallegos and Feroze Mahmood The impact of skills warm-up in minimally invasive surgery James C. Rosser, Jr., Scott Furer, and Neesha Patel The role of mental training in minimally invasive surgery Armando Rosales and Raul J. Rosenthal The ergonomic minimally invasive surgical/endoscopy suite H. Reza Zahiri and Adrian E. Park Energy sources in minimally invasive surgery Amin Madani and Sharon L. Bachman Anesthesia for laparoscopy: What does a surgeon need to know? Cindy M. Ku and Stephanie B. Jones

180 184 188 192 198 203 207 212 216 222 228 233


Access in minimally invasive surgery Margaret E. Clark and Robert B. Lim


Contents vii 42 43 44 45

Single port and reduced port access Benjamin Sadowitz, Alexander Rosemurgy, and Sharona Ross Diagnostic laparoscopy for benign and malignant disease Rita A. Brintzenhoff, William S. Richardson, and Dimitrios Stefanidis Laparoscopic ultrasound in surgery Maurice E. Arregui and Piyush Aggarwal Three-dimensional printing development and medical applications Feroze Mahmood and Daniel B. Jones

244 249 253 258

Section VI  MINIMALLY INVASIVE TREATMENT OF ESOPHAGEAL DISEASE 46 47 48 49 50 51 52 53 54 55 56 57

Anatomic and physiologic tests of esophageal function Joel M. Sternbach and Eric S. Hungness 360° Fundo Patrick Reardon Laparoscopic partial fundoplication Alex P. Nagle and Kenric M. Murayama Laparoscopic placement of external magnetic a­ ntireflux ring Yulia Zak and Ozanan Meireles Laparoscopic antireflux esophageal lengthening procedure Leena Khaitan and Abel Bello Laparoscopic repair of paraesophageal hernia C. Daniel Smith Reoperative surgery after fundoplication Carmen L. Mueller, Lorenzo E. Ferri, and Gerald M. Fried Laparoscopic treatment of achalasia Brian M. Nguyen and Jonathan F. Critchlow Robotic approach to achalasia Alberto S. Gallo and Santiago Horgan Laparoscopic treatment of esophageal diverticula Sarah E. Billmeier and Thadeus L. Trus Laparoscopic transhiatal esophagectomy for curative intent Moshim Kukar and Steven N. Hochwald Minimally invasive Ivor Lewis method for resection of esophageal cancer John-Paul Bellistri and W. Scott Melvin

267 274 281 286 289 292 298 305 310 316 321 326


Peptic ulcer disease Henry Lin Resection of nonadenomatous gastric tumors Jason K. Sicklick, Michele L. Babicky, and Ronald P. DeMatteo Laparoscopic resection for treatment of gastric cancer Tsuyoshi Etoh, Hajime Fujishima, and Seigo Kitano The laparoscopic placement of feeding tubes Jaisa Olasky

333 339 349 353


The impact of obesity epidemic: Relationship between body mass index and 30-day mortality risk Sara A. Hennessy and Bruce D. Schirmer Laparoscopic adjustable gastric banding Bradley F. Schwack and Jaime Ponce Laparoscopic Roux-en-Y gastric bypass David Spector and Scott Shikora Laparoscopic sleeve gastrectomy Jihui Li, Emanuele Lo Menzo, Samuel Szomstein, and Raul J. Rosenthal

358 363 372 378

viii Contents 66 67 68 69

Laparoscopic management of bariatric surgery complications Sungsoo Park, Hana Alhomoud, Emanuele Lo Menzo, and Raul J. Rosenthal Laparoscopic reoperative bariatric surgery Natan Zundel, Santiago Rodriguez, and Juan D. Hernandez Video-assisted thoracoscopic vagotomy for marginal ulcers Caroline Park and Sidhu Gangadharan Intragastric balloon Alfredo Genco and Ilaria Ernesti

381 386 396 400

Section IX  MINIMALLY INVASIVE TREATMENT OF H ­ EPATOBILIARY DISEASE 70 71 72 73 74 75 76 77 78 79 80 81

Laparoscopic cholecystectomy and intraoperative biliary imaging Robert D. Fanelli, Thomas J. VanderMeer, and Brandon D. Andrew Laparoscopic common bile duct exploration Ezra N. Teitelbaum and Nathaniel J. Soper Laparoscopic left hepatectomy Yasushi Hasegawa and Go Wakabayashi Totally laparoscopic right hepatectomy David Fuks and Brice Gayet Laparoscopic hepatectomy: The Glissonian approach Marcel Autran Cesar Machado Ablative treatment of liver tumors Pascal R. Fuchshuber, John B. Martinie, and David A. Iannitti Robotic approach to hepatic resections Susanne Warner and Yuman Fong Laparoscopic staging for pancreatic malignancy Ammara A. Watkins and Mark P. Callery Robot-assisted minimally invasive pancreaticoduodenectomy Alessandra Storino, Tara S. Kent, and A. James Moser Laparoscopic pancreaticoduodenectomy (Whipple) Ruchir Puri, John A. Stauffer, and Horacio J. Asbun Laparoscopic distal pancreatectomy Omar Yusef Kudsi, Lerna Ozcan, and Michel Gagner Laparoscopic surgery of the spleen Namir Katkhouda, Vivian Pham, and Kulmeet Sandhu

408 424 432 435 440 444 459 464 467 474 480 485


Laparoscopic adrenalectomy Jesse D. Pasternak and Quan-Yang Duh Endoscopic approaches to the thyroid and ­parathyroid glands Hyunsuk Suh and William B. Inabnet III Laparoscopic resection of endocrine pancreatic neoplasms Cherif Boutros and John A. Olson Jr.

493 497 504


Laparoscopic treatment of diseases of the small bowel Jeffrey N. Harr and Fred Brody Laparoscopic surgery of the appendix Eric Balent and Robert B. Lim Laparoscopic surgery for benign disease of the colon: Diverticulitis Ali Linsk Butash and Ketan Sheth Laparoscopic resection for carcinoma of the colon Jared Wong and James Fleshman

512 516 521 524

Contents ix 89 90 91 92 93

Laparoscopic total mesorectal excision Yuliya Yurko and Tonia M. Young-Fadok Laparoscopic treatment of inflammatory bowel disease Daniel Shouhed, Gustavo Fernandez-Ranvier, and Barry Salky Robotics in colon and rectal surgery Deborah M. Nagle Hand-assisted colectomy techniques Peter W. Marcello Minimally invasive therapies for fecal incontinence Isacco Montroni, Claire E. Peeples, and Steven D. Wexner

529 533 538 548 557


Laparoscopic totally extraperitoneal hernia repair Edward L. Felix Technique of transanal-assisted colon resection and rectopexy Karl-Hermann Fuchs, Wolfram Breithaupt, Gabor Varga, Kai Neki, Rebeca Dominguez Profeta, and Santiago Horgan Laparoscopic transabdominal preperitoneal inguinal hernia repair Brian Jacob and Alexandra Argiroff Laparoscopic component separation Russell C. Kirks, Jr. and David A. Iannitti Biomaterial considerations in laparoscopic hernia repair Brent D. Matthews Laparoscopic incisional and ventral hernia repair Bruce J. Ramshaw, Lisa A. Cunningham, and H. Charles Peters Robotic transabdominal preperitoneal inguinal hernia repair Fahri Gokcal and Omar Yusef Kudsi Robotic ventral hernia repair Fahri Gokcal and Omar Yusef Kudsi Laparoscopic repair of recurrent inguinal hernia Brandice Durkan and Edward H. Phillips Laparoscopic repair of sports hernia L. Michael Brunt Laparoscopic robotics Omar Yusef Kudsi, Anthony Gonzalez, Zachary McCabe, and Ernesto Dominguez

569 573 577 582 591 596 602 608 617 620 627

Section XIII THORACOSCOPY 104 Thoracoscopic surgery of the mediastinum and esophagus Nassrene Y. Elmadhun and Michael Kent 105 Video-assisted thoracic surgery lobectomy Alessandro Brunelli and Tim Batchelor

634 639

Section XIV OTHER MINIMALLY INVASIVE ABDOMINAL/­RETROPERITONEAL PROCEDURES 106 The role of robotics in minimally invasive urologic surgery Ostap Dovirak and Andrew A. Wagner 107 Laparoscopic nephrectomy for malignancy Aaron Lay and Jeffrey A. Cadeddu 108 Laparoscopic donor nephrectomy Daniel M. Herron 109 Laparoscopic approaches to aortic vascular disease Konstantinos S. Mylonas and Konstantinos P. Economopoulos 110 Laparoscopic median arcuate ligament release William S. Richardson and James Wooldridge

646 651 655 659 666

x Contents 111

Minimally invasive approach to retroperitoneal c­ ollections in necrotizing pancreatitis Pieter Timmerman, Marc G.H. Besselink, and Karen D. Horvath



Pediatric laparoscopy: General considerations Sebastian K. King and Jacob C. Langer Laparoscopic hernia repair in children David H. Rothstein and Carroll M. Harmon Laparoscopic treatment of reflux in children Steven Rothenberg Laparoscopic treatment of benign gastrointestinal disease in children Brian T. Bucher and Gretchen P. Jackson

677 682 687 691


Surgical procedures performed in radiology suites Kinga A. Powers and Kelley Whitmer Augmented reality Michele Diana, Luc Soler, Stéphane Nicolau, and Jacques Marescaux

698 703


The challenges and solutions of performing minimally invasive surgery in underdeveloped environments Raymond R. Price and Adewale O. Adisa 119 Essay: The future of robotics in minimally invasive surgery Crystal Krause, Songita Choudhury, and Dmitry Oleynikov 120 Essays on the future of endoscopic surgery: Redefining, future training, and credentialing pathways Aurora D. Pryor




716 721


Logic will get you from A to B. Imagination will take you everywhere. Albert Einstein

When Dan and Steve asked me to write the Foreword for this book, I looked at the book’s outline and had three observations: ●●



It is an enormous honor to add a Foreword to this monumental work, Operative Endoscopic and Minimally Invasive Surgery, with its 120 chapters covering the miniinvasive and endoscopic procedures with contributions from 241 authors. The chapter authors represent the brightest stars in the fi ­ rmament for every segment of minimally invasive o ­ perative procedures. I know almost every one and would trust them to make surgical decisions for me if needed. Many of them are close personal friends. Wrangling that many surgical superstars will be an ­interesting process. I hope the section on hernia repair is the best one, because carrying this book will improve business.

In my experience, this is the first textbook that seriously addresses COST (which conversion factors are

used?), a factor that has become part of the surgical decision-making process. I congratulate the authors for this dive into reality. It is amazing for me, having participated in the (r)evolution of endoscopic surgery for more than 60 years, performing some of the procedures for decades, how much our thinking has evolved. One can only imagine the names of the chapters in the second edition of the text in 10 years. When, after 3 years of hard work, I was able to publish a compendium of Endoscopy (Appleton Century Croft, New York) in 1976 with 60 chapters, and it was considered a “complete guide.” It covered the basic principles of the physics, optics, electronics, video, communications, as well as every procedure known at that time. We had 52 authors whose writings were interpreted as “modern data” or regarded by many as a utopian view of surgery. There is no utopia. We keep changing the definition for the better. We should be grateful that Daniel Jones and Steve Schwaitzberg’s imagination and integrity are unlimited, and these 241 authors will set the bar even higher. Good! George Berci, MD, FRCS, Ed (Hon) Cedars-Sinai Medical Center Los Angeles, California


Celioscopy, peritoneoscopy, or laparoscopy as it has been termed has been around in its earliest inceptions for at least 100 years. The era minimally invasive surgery exploded after the first videoscopic laparoscopic cholecystectomies were presented at Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American College of Surgeons (ACS). It became obvious pretty quickly that patients benefited of smaller scars, less pain, less intrusion, and faster recovery. Almost overnight, surgeons began to apply minimally invasive approaches to more and more operations. Today, laparoscopy is the standard approach for most diseases of the colon, hernia, spleen, and stomach. For more complex procedures, robotic-assisted surgery has made operations, such as the reconstruction after pancreatic head resection, more precise than perhaps even open surgery. The flexible endoscope, once the domain of the surgeons, is returning home in part as advances in therapeutic endoscopy change the face of GI tract surgery. No longer can a GI surgeon afford not to be proficient with this tool. Surgeons are preforming Natural Orifice Endoscopic Surgery (NOTES), transanal procedures including Transanal Minimally invasive Surgery (TAMIS, TEMS), and are performing endoscopic mucosal/submucosal dissection and resection (ESD, EMR). The flexible endoscope is a tool of the modern general surgeon well beyond simple screening applications.

Operative Endoscopic and Minimally Invasive Surgery is the first major textbook to describe new and potentially better approaches to old operations by experts. The chapters are concise and emphasize technique. The color artwork rivals other leading atlases. One feature that makes this book particularly valuable is the expert commentary that critiques the authors’ preoperative assessment, operative approach, and outcomes. The reader can quickly understand the operative pearls and potential challenges to a given operative procedure. We think another appeal of this book is the beautiful classic and contemporary art. Medicine and Surgery evolved as surgeons learned anatomy. Historical paintings have captured the first used operative tools, ether anesthesia, and apprentice model of teaching in operative theaters. Many thanks to Cara Jordan, who curated this collection. In Operative Endoscopic and Minimally Invasive Surgery, we have sought to bring the replicas of the art of surgery over time to the reader. We hope to capture the imagination and creativity of all our readers. Daniel B. Jones, MD, MS Steven D. Schwaitzberg, MD, FACS


Daniel B. Jones, MD, MS, is a professor of Surgery at Harvard Medical School, vice chair of Surgery at the Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Steven D. Schwaitzberg, MD, FACS, is professor of Surgery  SUNY Buffalo, chair of surgery SUNY Buffalo Medical Center, Buffalo, New York, USA.


Adewale O. Adisa, fwacs, fcms Department of Surgery Obafemi Awolowo University Ile-Ife, Nigeria Piyush Aggarwal, md Advanced Laparoscopy, Endoscopy and Ultrasound St. Vincent Hospital Indianapolis, Indiana Matthew R. Albert, md, fascrs Center for Colon and Rectal Surgery Florida Hospital Orlando, Florida Hana Alhomoud, md Department of Surgery Al Sabah Hospital Kuwait City, Kuwait

and Mayo College of Medicine and Sciences Uttar Pradesh, India Dan Azagury, md Section of Bariatric and Minimally Invasive Surgery Stanford University School of Medicine Stanford, California Michele L. Babicky, md Hepatobiliary and Surgical Oncology Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic Portland, Oregon Sharon L. Bachman, md Department of Surgery Inova Medical Group Falls Church, Virginia

Aman Ali, md Department of Medicine Wilkes Barre General Hospital The Commonwealth University Medical College Edwardsville, Pennsylvania

Eric Balent, md Department of Surgery Tripler Army Medical Center Honolulu, Hawaii

Brandon D. Andrew, md Medical and Surgical Weight Loss Clinic HSHS Sacred Heart and Evergreen Surgical Eau Claire, Wisconsin

Sheila Ryan Barnett, md Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts

Alexandra Argiroff, md Mount Sinai Medical Center New York City, New York

Tim Batchelor, bsc, mbchb, msc, frcs(cth) Department of Thoracic Surgery Bristol Royal Infirmary Bristol, United Kingdom

Maurice E. Arregui, md Advanced Laparoscopy, Endoscopy and Ultrasound St. Vincent Hospital Indianapolis, Indiana Horacio J. Asbun, md Hepatobiliary and Pancreas Surgery Miami Cancer Institute Miami, Florida

David E. Beck, md, fascrs Department of Colon and Rectal Surgery Ochsner Clinic Foundation New Orleans, Louisiana John-Paul Bellistri, md Columbia University Medical Center New York Presbyterian Lawrence Hospital Bronxville, New York

xviii Contributors Abel Bello, md, fasmbs MIB Surgery Plantation, Florida

and St. Louis Blues Hockey Club St. Louis, Missouri

Tyler Berzin, md, ms, fasge GI Endoscopy Advanced Therapeutic Endoscopy Fellowship Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts

Brian T. Bucher, md Department of Surgery Primary Children’s Hospital University of Utah School of Medicine Salt Lake City, Utah

Marc G.H. Besselink, md, msc, phd Department of Surgery Academic Medical Center Amsterdam, the Netherlands Elif Bilgic, phd Steinberg Centre for Simulation and Interactive Learning McGill University and Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada Sarah E. Billmeier, md, mph Section of General Surgery Division of Minimally Invasive Surgery Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire Cherif Boutros, md, msc Department of Surgery Division of General and Oncologic Surgery University of Maryland School of Medicine Baltimore, Maryland Wolfram Breithaupt, md AGAPLESION Markus Krankenhaus Department of Surgery Frankfurt, Germany Rita A. Brintzenhoff, md Department of General Surgery Carolinas Medical Center Charlotte, North Carolina Fred Brody, md, mba Department of Surgery The George Washington University Medical Center Washington, DC Alessandro Brunelli, md Department of Thoracic Surgery St. James’s University Hospital Leeds, United Kingdom L. Michael Brunt, md Section of Minimally Invasive Surgery Washington University School of Medicine

John P. Burke, phd, frcsi Center for Colon and Rectal Surgery Florida Hospital Orlando, Florida Ali Linsk Butash, md Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Jeffrey A. Cadeddu, md Department of Urology University of Texas Southwestern Medical Center Dallas, Texas Mark P. Callery, md Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Avery C. Capone, md Harvard Plastic Surgery Brigham and Women’s Hospital Boston, Massachusetts Christy E. Cauley, md, mph Cleveland Clinic Cleveland, Ohio I. Bulent Cetindag, md Department of Surgery Mercy Medical Center University of Iowa Cedar Rapids, Iowa Austin L. Chiang, md, mph Division of Gastroenterology, Hepatology, and Endoscopy Brigham and Women’s Hospital Boston, Massachusetts Songita Choudhury, bs College of Medicine Center for Advanced Surgical Technology University of Nebraska Medical Center Omaha, Nebraska Ian Choy Division of General Surgery Oakville Trafalgar Memorial Hospital Halton Healthcare McMaster University Oakville, Canada

Contributors xix Margaret E. Clark, md Department of Surgery Tripler Army Medical Center Honolulu, Hawaii

Brandice Durkan, md General and Breast Surgery Tuality Digestive Health and General Surgery Clinic Hillsboro, Oregon

Paul Colavita, md Division GI and Minimally Invasive Surgery Carolinas Medical Center Charlotte, North Carolina

Konstantinos P. Economopoulos, md, phd General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina

Jonathan F. Critchlow, md Division of General Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Lisa A. Cunningham, md The Ohio State University Wexner Medical Center Columbus, Ohio Suvranu De, scd Center for Modeling, Simulation and Imaging in Medicine Rensselaer Polytechnic Institute Troy, New York Ronald P. DeMatteo, md Department of Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Michele Diana, md IRCAD, Research Institute Against Cancer of the Digestive System and IHU-Strasbourg, Institute for Image-Guided Surgery Strasbourg, France Ernesto Dominguez, md Baptist Health South Florida Miami, Florida Ostap Dovirak, md Department of Surgery Division of Urology Beth Israel Deaconess Medical Center Boston, Massachusetts Quan-Yang Duh, md Endocrine Surgery and Oncology Department of Surgery Mount Zion Hospital University of California—San Francisco San Francisco, California Brian J. Dunkin, md Methodist Institute for Technology, Innovation, and Education (MITIE) Houston Methodist Hospital Houston, Texas

and Surgery Working Group Society of Junior Doctors Athens, Greece James Ellsmere, md, ms, frcsc Department of General Surgery Dalhousie University Halifax, Canada Nassrene Y. Elmadhun, md Minimally Invasive Thoracic Surgery Division of Thoracic Surgery and Interventional Pulmonology Beth Israel Deaconess Medical Center Boston, Massachusetts Ilaria Ernesti, md Department of Experimental Medicine-Medical Physiopathology Food Science and Endocrinology Section “Sapienza” University of Rome Rome, Italy Tsuyoshi Etoh, md, phd Department of Gastroenterological and Pediatric Surgery Oita University Faculty of Medicine Oita, Japan Robert D. Fanelli, md, mha, fasge Geisinger Commonwealth School of Medicine Minimally Invasive Surgery Surgical Endoscopy Department of Surgery The Guthrie Clinic Sayre, Pennsylvania Liane S. Feldman, md, cm Steinberg-Bernstein Chair in Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada Edward L. Felix, md Marian Regional Medical Center Santa Maria, California

xx Contributors Gustavo Fernandez-Ranvier, md, phd Department of Surgery Division of Metabolic, Endocrine and Minimally Invasive Surgery Mount Sinai Medical Center New York City, New York

Eleanor C. Fung, md Department of Surgery Jacobs School of Medicine and Biomedical Sciences University at Buffalo The State University of New York Buffalo, New York

Lorenzo E. Ferri, md, phd Division of Thoracic Surgery McGill University Montreal, Canada

Scott Furer, md Department of Pediatrics Johns Hopkins All Children’s Hospital St. Petersburg, Florida

James Fleshman, md, fascrs Department of Surgery Baylor University Medical Center Dallas, Texas Yuman Fong, md Sangiacomo Chair in Surgical Oncology Department of Surgery International Medicine City of Hope Comprehensive Cancer Center Duarte, California

Michel Gagner, md Clinique Michel Gagner Montreal, Canada Alberto S. Gallo, md Baptist Surgical Associates Baptist Health Hospital Louisville, Kentucky Sidhu Gangadharan, md Department of Thoracic Surgery Beth Israel Deaconess Medical Center Boston, Massachusetts

Morris E. Franklin Jr., md Department of Minimally Invasive Surgery Texas Endosurgery Institute San Antonio, Texas

Brice Gayet, md, phd Department of Digestive, Oncological and Metabolic Surgery Institut Mutualiste Montsouris Paris, France

Gerald M. Fried, msc, mD, Frcsc, fcahs Department of Surgery McGill University Montreal, Canada

Andres Gelrud, md, mmsc Pancreatic Disease Center Gastro Health and Miami Cancer Institute Baptist Hospital South Florida Miami, Florida

Hans F. Fuchs, md Department of General, Visceral and Cancer Surgery University of Cologne Cologne, Germany Karl-Hermann Fuchs, md University of California San Diego Center for the Future of Surgery La Jolla, California

Alfredo Genco Department of Surgical Sciences Policlinico Umberto I “Sapienza” University of Rome Rome, Italy Robert Gianotti, md Albany Gastroenterology Consultants Albany, New York

Pascal R. Fuchshuber, md, phd General and Oncologic Surgery UCSF-East Bay The Permanente Medical Group, Inc. Walnut Creek, California

Fahri Gokcal, md Department of General Surgery University of Health Sciences Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital Istanbul, Turkey

Hajime Fujishima, md Department of Gastroenterological and Pediatric Surgery Oita University Faculty of Medicine Oita, Japan


David Fuks, md, phd Department of Digestive, Oncological and Metabolic Surgery Institut Mutualiste Montsouris Paris, France

Good Samaritan Medical Center Brockton, Massachusetts Anthony Gonzalez, md, fasmbs Baptist Hospital of Miami FIU College of Medicine Bariatric Surgery Baptist Health South Florida Miami, Florida

Contributors xxi Carroll M. Harmon, md, phd Department of Surgery Jacobs School of Medicine and Biomedical Sciences University at Buffalo Buffalo, New York Cristina R. Harnsberger, md Department of Surgery University of California, San Diego San Diego, California Jeffrey N. Harr, md, mph Department of Surgery The George Washington University Medical Center Washington, DC Yasushi Hasegawa, md, phd Department of Surgery Iwate Medical University School of Medicine Iwate, Japan

Karen D. Horvath, md Department of Surgery University of Washington Seattle, Washington Eric S. Hungness, md Department of Surgery Northwestern University Chicago, Illinois Matthew M. Hutter, md, mph Department of Surgery Harvard Medical School Massachusetts General Hospital Boston, Massachusetts David A. Iannitti, md Department of Surgery Carolinas Medical Center Division of Hepato-Pancreatico-Biliary Surgery Charlotte, North Carolina

Jeffrey W. Hazey, md Memorial Hospital Marysville, Ohio

William B. Inabnet III, md Department of Surgery Icahn School of Medicine at Mount Sinai New York City, New York

Sara A. Hennessy, md Department of Surgery UT Southwestern Medical Center Dallas, Texas

Gretchen P. Jackson, md, phd Department of Pediatric Surgery Vanderbilt University School of Medicine Nashville, Tennessee

Juan D. Hernandez, md Hospital Universitario Fundacion Santa Fe de Bogota Universidad de los Andes Faculty of Medicine Bogota, Colombia

Brian Jacob, md Mount Sinai Medical Center New York City, New York

Miguel A. Hernandez, md Department of Minimally Invasive Surgery Texas Endosurgery Institute San Antonio, Texas Daniel M. Herron, md Department of Surgery Icahn School of Medicine at Mount Sinai New York City, New York Steven N. Hochwald, md Department of Surgical Oncology Roswell Park Cancer Institute Buffalo, New York Santiago Horgan, md Department of Surgery Center for the Future of Surgery University of California, San Diego Douglas Horst, md Department of Medicine Division of Gastroenterology Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts

Garth R. Jacobsen, md Department of Surgery University of California, San Diego San Diego, California Daniel B. Jones, md, ms Harvard Medical School and Beth Israel Deaconess Medical Center Boston, Massachusetts Edward L. Jones, md, ms Department of Surgery Rocky Mountain Regional VA Medical Center The University of Colorado Anschutz Medical Campus Aurora, Colorado Stephanie B. Jones, md Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Cara M. Jordan, phd Center for the Humanities Graduate Center, City University of New York New York City, New York

xxii Contributors Namir Katkhouda, md Department of Surgery University of Southern California Los Angeles, California Justin J. Kelly, md, frcsi Center for Colon and Rectal Surgery Florida Hospital Orlando, Florida Michael Kent, md Minimally Invasive Thoracic Surgery Division of Thoracic Surgery and Interventional Pulmonology Beth Israel Deaconess Medical Center Boston, Massachusetts Tara S. Kent, md Department of Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Leena Khaitan, md, mph Esophageal and Swallowing Center University Hospitals Digestive Health Institute Cleveland Medical Center Cleveland, Ohio Sebastian K. King, mbbs, phd, fracs Department of Paediatric Surgery The Royal Children’s Hospital Melbourne, Australia Boris Kiriazov, md Division of General Surgery University of South Florida Tampa, Florida Russell C. Kirks, Jr., md Department of Surgery Division of Hepato-Pancreatico-Biliary Surgery Carolinas Medical Center Charlotte, North Carolina Seigo Kitano, md, phd Oita University Oita, Japan Crystal Krause, phd Department of Surgery Center for Advanced Surgical Technology University of Nebraska Medical Center Omaha, Nebraska Cindy M. Ku, md Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts

Omar Yusef Kudsi, md, mba Robotic Surgery Fellowship Good Samaritan Medical Center Tufts University School of Medicine Boston, Massachusetts Moshim Kukar, md Department of Surgical Oncology Roswell Park Cancer Institute Buffalo, New York Jacob C. Langer, md Division of General and Thoracic Surgery Hospital for Sick Children and Department of Surgery University of Toronto Toronto, Canada Aaron Lay, md Department of Urology Emory University Atlanta, Georgia Jihui Li, md Horizon Health Paris Clinic Paris, Illinois Robert B. Lim, md Department of Surgery Tripler Army Medical Center Uniformed Services University of Health Sciences Honolulu, Hawaii Henry Lin, md Department of General Surgery Naval Hospital Camp Lejeune Uniformed Services University Camp Lejeune, North Carolina Emanuele Lo Menzo, md, phd, fasmbs Cleveland Clinic Florida Weston, Florida Eric Luedke, md Section of Bariatric and Minimally Invasive Surgery Stanford University School of Medicine Stanford, California Bill Ran Luo, md Department of Surgery Northwestern Medicine Chicago, Illinois Marcel Autran Cesar Machado, md Sírio Libanês Hospital University of São Paulo São Paulo, Brazil

Contributors xxiii Amin Madani, md, phd, frcsc Department of Surgery McGill University and Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada Feroze Mahmood, md Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Peter W. Marcello, md, fascrs Division of Colon and Rectal Surgery Lahey Hospital and Medical Center Burlington, Massachusetts Jacques Marescaux, md, frcs (hon), fjses (hon), apsa (hon) IRCAD, Research Institute Against Cancer of the Digestive System and IHU-Strasbourg, Institute for Image-Guided Surgery Strasbourg, France Jeffrey M. Marks, md, fasge Department of Surgery Case Western/University Hospitals Cleveland Medical Center Cleveland, Ohio John H. Marks, md, fascrs Division of Colorectal Surgery Lankenau Hospital Wynnewood, Pennsylvania Janet Martin, pharmd, msc (hta&m) Centre for Medical Evidence, Decision Integrity and Clinical Impact and Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics Schulich School of Medicine and Dentistry Western University London, Canada John B. Martinie, md HPB Surgery Carolinas Medical Center Charlotte, North Carolina

Brent D. Matthews, md Department of Surgery Carolinas HealthCare System University of North Carolina Charlotte, North Carolina Zachary McCabe, md student St. George University School of Medicine Grenada, West Indies Ozanan Meireles, md Massachusetts General Hospital Boston, Massachusetts John D. Mellinger, md Department of Surgery Southern Illinois University School of Medicine Springfield, Illinois W. Scott Melvin, md Montefiore Medical Center The University Hospital for Albert Einstein College of Medicine New York City, New York Dean J. Mikami, md Department of Surgery John A. Burn School of Medicine University of Hawaii Honolulu, Hawaii Mario Montealegre-Gallegos, md Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Isacco Montroni, md, phd Department of Colorectal Surgery Cleveland Clinic Florida Weston, Florida John Morton, md, mph Section of Bariatric and Minimally Invasive Surgery Stanford University School of Medicine Stanford, California A. James Moser, md Pancreas and Liver Institute Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Carmen L. Mueller, md, med Division of General Surgery McGill University Montreal, Canada

xxiv Contributors Kenric M. Murayama, md Department of Surgery John A. Burns School of Medicine University of Hawaii Honolulu, Hawaii

Dmitry Oleynikov, md Department of Surgery Center for Advanced Surgical Technology University of Nebraska Medical Center Omaha, Nebraska

Konstantinos S. Mylonas, md School of Medicine Faculty of Health Sciences Aristotle University of Thessaloniki Thessaloniki, Greece

John A. Olson, Jr., md, phd Department of Surgery Division of General and Oncologic Surgery University of Maryland School of Medicine Baltimore, Maryland


Lerna Ozcan, md Saint Elizabeth Medical Center Boston, Massachusetts

Surgery Working Group Society of Junior Doctors Athens, Greece Alex P. Nagle, md Department of Surgery Feinberg School of Medicine Northwestern University Evanston, Illinois Deborah M. Nagle, md Integrated Lead for Digital Surgery Preclinical, Clinical and Medical Medical Lead for the Colorectal Specialty Ethicon, Inc. Cincinnati, Ohio Kai Neki, md University of California San Diego Center for the Future of Surgery La Jolla, California Brian M. Nguyen, md Southern California Permanente Medical Group Department of Surgery Kaiser Permanente San Diego, California Stéphane Nicolau, phd IRCAD, Research Institute Against Cancer of the Digestive System Strasbourg, France Allan Okrainec, md, mhpe Temerty-Chang Telesimulation Centre Division of General Surgery University Health Network University of Toronto Toronto, Canada Jaisa Olasky, md Mount Auburn Hospital Cambridge, Massachusetts and Harvard Medical School Boston, Massachusetts

Ping Pan, md Department of Surgery University Hospitals Cleveland Medical Center Cleveland, Ohio Adrian E. Park, md Department of Surgery Anne Arundel Medical Center Annapolis, Maryland Caroline Park, md, mph Beth Israel Deaconess Medical Center Boston, Massachusetts Sungsoo Park, md, phd Department of Surgery Korea University College of Medicine and Center for Obesity and Metabolic Diseases Korea University Anam Hospital Seoul, South Korea Jesse D. Pasternak, md, mph Endocrine Surgery and Oncology Division of General Surgery Toronto General Hospital – University Health Network University of Toronto Toronto, Canada Neesha Patel, md Department of Pediatrics Michigan Medicine Ann Arbor, Michigan Nicolò Pecorelli, md Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada Claire E. Peeples, md Department of Colon and Rectal Surgery Beaumont Health Royal Oak, Michigan

Contributors xxv Kyle A. Perry, md Division of General and Gastrointestinal Surgery Center for Minimally Invasive Surgery The Ohio State University Wexner Medical Center Columbus, Ohio

and Department of Surgery Intermountain Medical Center Intermountain Healthcare Salt Lake City, Utah

H. Charles Peters, md VCU Health Richmond, Virginia

Rebeca Dominguez Profeta, md University of California San Diego Center for the Future of Surgery La Jolla, California

Vivian Pham, md Department of Anesthesia University of California, San Francisco San Francisco, California Edward H. Phillips, md Department of Surgery Division of General Surgery Cedars Sinai Medical Center Los Angeles, California Matthew R. Pittman, md Metabolic Health and Surgical Weight Loss Center Northwestern Medicine Delnor Hospital Geneva, Illinois Douglas Pleskow, md Division of Gastroenterology Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Jaime Ponce, md, fasmbs Bariatric Surgery Program CHI Memorial Hospital Chattanooga, Tennessee Jeffrey L. Ponsky, md Department of Surgery Cleveland Clinic Lerner College of Medicine Lynda and Marlin Younker Chair in Developmental Endoscopy Case Western Reserve University Cleveland, Ohio Kinga A. Powers, md, phd, frcsc Department of Surgery Salem Veteran Affairs Medical Center University of Virginia School of Medicine and Virginia Tech Carilion School of Medicine Salem, Virginia Raymond R. Price, md Department of Surgery Center for Global Surgery University of Utah

Aurora D. Pryor, md Department of Surgery Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery Health Sciences Center Stony Brook Medicine Stony Brook, New York Ruchir Puri, md, ms Department of General Surgery University of Florida Jacksonville, Florida Bruce J. Ramshaw, md Department of Surgery University of Tennessee Medical Center Knoxville, Tennessee Patrick Reardon, md Department of Surgery Houston Methodist Hospital Underwood Center for Digestive Disorders Houston, Texas Adam Reid, md Department of Surgery Southern Illinois University School of Medicine Springfield, Illinois William S. Richardson, md General Surgery Ochsner Clinic Chalmette, Louisiana Kurt Eric Roberts, md Gastrointestinal Surgery Yale School of Medicine New Haven, Connecticut Santiago Rodriguez, md University of Colorado School of Medicine Aurora, Colorado Armando Rosales, md Cleveland Clinic Florida Weston, Florida

xxvi Contributors Alexander Rosemurgy, md Florida Hospital Tampa, Florida

Kulmeet Sandhu, md Department of Surgery University of Southern California Los Angeles, California

Raul J. Rosenthal, md Department of General Surgery and the Bariatric and Metabolic Institute Cleveland Clinic Florida Weston, Florida

Bruce D. Schirmer, md Department of Surgery University of Virginia Charlottesville, Virginia

Sharona Ross, md Florida Hospital Tampa, Florida

Christopher M. Schlachta, bsc, mdcm, frcsc Canadian Surgical Technologies and Advanced Robotics (CSTAR) London Health Sciences Centre London, Canada

James C. Rosser, Jr., md University of Central Florida School of Medicine Orlando, Florida and University at Buffalo School of Medicine Buffalo, New York Steven Rothenberg, md Columbia University College of Physicians and Surgeons New York City, New York and The Rocky Mountain Hospital For Children Denver, Colorado David H. Rothstein, md, ms Department of Pediatric Surgery John R. Oishei Children’s Hospital Buffalo, New York Michael A. Russo, md Orange Coast Medical Center Fountain Valley, California Marvin Ryou, md Division of Gastroenterology, Hepatology, and Endoscopy Brigham and Women’s Hospital Boston, Massachusetts Benjamin Sadowitz, md Crouse Health Syracuse, New York Jean F. Salem, md Division of Colorectal Surgery Lankenau Hospital Wynnewood, Pennsylvania Barry Salky, md Department of Surgery Division of Metabolic, Endocrine and Minimally Invasive Surgery Mount Sinai Medical Center New York City, New York

Bradley F. Schwack, md NYU Langone Medical Center NYU Langone Weight Management Program New York City, New York Daniel J. Scott, md Department of Surgery UT Southwestern Medical Center Dallas, Texas Ketan Sheth, md Cambridge Health Alliance Harvard Medical School Boston, Massachusetts Scott Shikora, md Center for Metabolic Health and Bariatric Surgery and Department of Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts Daniel Shouhed, md Department of Surgery Division of Bariatric and Minimally Invasive Surgery Cedars Sinai Medical Center Los Angeles, California Jason K. Sicklick, md Department of Surgery Division of Surgical Oncology Moores Cancer Center University of California, San Diego La Jolla, California Ajaypal Singh, md Division of Digestive Diseases and Nutrition Rush Medical College Chicago, Illinois C. Daniel Smith, md Buckhead Surgical Associates Atlanta, Georgia

Contributors xxvii Luc Soler, phd IRCAD, Research Institute Against Cancer of the Digestive System Strasbourg, France Nathaniel J. Soper, md Department of Surgery Northwestern University Chicago, Illinois David Spector, md Center for Metabolic Health and Bariatric Surgery and Department of Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts John A. Stauffer, md Department of General Surgery Mayo Clinic Florida Jacksonville, Florida

Samuel Szomstein, md, fasmbs Cleveland Clinic Florida Weston, Florida Ezra N. Teitelbaum, md Department of Surgery Northwestern University Chicago, Illinois Pieter Timmerman, md Department of Surgery Academic Medical Center Amsterdam, the Netherlands Thadeus L. Trus, md Section of General Surgery Division of Minimally Invasive Surgery Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire Shawn T. Tsuda, md Department of Surgery University of Nevada School of Medicine Las Vegas, Nevada

Dimitrios Stefanidis, md, phd, fasmbs, fssh MIS/Bariatric Surgery Department of Surgery Indiana University School of Medicine Indianapolis, Indiana

Thomas J. VanderMeer, md Geisinger Commonwealth School of Medicine Department of Surgery The Guthrie Clinic Sayre, Pennsylvania

Joel M. Sternbach, md, mba Department of Surgery Northwestern University Chicago, Illinois

Gabor Varga, md AGAPLESION Markus Krankenhaus Department of Surgery Frankfurt, Germany

Alessandra Storino, md General Surgery Resident Beth Israel Deaconess Medical Center Boston, Massachusetts

Melina C. Vassiliou, md, med Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada

Hyunsuk Suh, md Department of Surgery Icahn School of Medicine at Mount Sinai New York City, New York Lee L. Swanstrom, md Division of Minimally Invasive and GI Surgery The Oregon Clinic Portland, Oregon and Institute for Image Guided Surgery IHU-Strasbourg Strasbourg, France Patricia Sylla, md Department of Surgery Division of Colon and Rectal Surgery Icahn School of Medicine at Mount Sinai Hospital New York City, New York

Vic Velanovich, md Division of General Surgery University of South Florida Tampa, Florida Vaibhav Wadhwa, md Gastroenterology and Hepatology Cleveland Clinic Florida Weston, Florida Andrew A. Wagner, md Department of Surgery Division of Urology Beth Israel Deaconess Medical Center Boston, Massachusetts Go Wakabayashi, md, phd Department of Surgery Ageo Central General Hospital Ageo, Japan

xxviii Contributors Judy Wang, md General Surgery Los Angeles County Harbor UCLA Medical Center Surgery Torrance, California Susanne Warner, md City of Hope Department of Surgery Duarte, California Yusuke Watanabe, md Department of Gastroenterological Surgery II Hokkaido University Graduate School of Medicine Sapporo, Hokkaido, Japan and Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation McGill University Health Centre Montreal, Canada Ammara A. Watkins, md, mph Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Jaclyn Weirzbicki, md Department of Surgery Northwestern Medicine Delnor Hospital Geneva, Illinois Steven D. Wexner, md, phd (hon), frcs, frcs (ed), frcsi (hon) Department of Colorectal Surgery Cleveland Clinic Florida Weston, Florida and College of Medicine Florida Atlantic University Boca Raton, Florida and

Gary Wind, md Uniformed Services University Walter Reed National Military Medical Center Washington, DC Elan R. Witkowski, md, ms Department of Surgery Harvard Medical School Massachusetts General Hospital Boston, Massachusetts Jared Wong, md Sharp Rees-Stealy San Diego, California Stephanie G. Wood, mb, bch GI and General Surgery Oregon Health and Science University Portland, Oregon James Wooldridge, md General Surgery Ochsner Clinic New Orleans, Louisiana D. Tami Yamashita, md Department of General Surgery Dalhousie University Halifax, Canada and Department of General Surgery Abbotsford Regional Hospital and Cancer Centre Abbotsford, Canada Tonia M. Young-Fadok, md, ms, fascrs Division of Colon and Rectal Surgery Mayo Clinic College of Medicine Mayo Clinic Phoenix, Arizona Yuliya Yurko, md Division of Colon and Rectal Surgery Mayo Clinic Phoenix, Arizona

College of Medicine Florida International University Miami, Florida

H. Reza Zahiri, do Division of Gastrointestinal and Bariatric Surgery Anne Arundel Medical Center Annapolis, Maryland

Kelley Whitmer, md Department of Radiology Virginia Tech Carilion School of Medicine and Department of Imaging Services Carilion Clinic Roanoke, Virginia

Yulia Zak, md Massachusetts General Hospital Boston, Massachusetts Natan Zundel, md, fasmbs Florida International University College of Medicine Miami, Florida

SECTION     Minimally invasive surgery in the m ­ odern health care environment

Joe Wilder, Operating Team, 1987. Giclée print, 24 × 20 inches. (Photo courtesy the Joe Wilder Collection.)


2  Minimally invasive surgery in the ­modern health care environment

There are few images that visualize the inner workings of the operating room with its technological advances and yet profoundly intimate and explicit views into the human body. Retired surgeon Dr. Joe Wilder provides a unique glimpse into the process through his paintings, which depict surgeries from the point of view of one of the actors. Peering over the shoulders of the surgeons in this image, we become a part of the operating team. We are given a momentary slice of what that responsibility might look like, even if we cannot experience it ourselves. While still a practicing surgeon—the chief of surgery at New York’s Hospital for Joint Diseases and a professor of surgery at Mount Sinai Medical School—Dr. Wilder reorganized his schedule to have time every day to devote to art. He became an acclaimed painter alongside his surgical practice, earning accolades from the New York Times and prominent critics for his exhibitions and books. In his words, “In my paintings I encapsulated a

half a century as a committed doctor, highlighting the powerful forces and actions which take place daily in a major hospital setting.” Dr. Wilder’s motivation comes from his belief that surgeons have a responsibility to those who seek their help. He tries to reflect his commitment to patient care in each of his paintings. He says, “Although hospitals have a macabre quality, they remain beacons of hope for the afflicted and suffering. But I see another side, and this is what my paintings depict. I have envisioned such richness and giving where paragons of kindness and love heal. A hospital after all has no equal as a center to alleviate suffering. The countless patients from all walks of life taught me about the beauty of the human spirit.” Quotes from “Statement by Joe Wilder,” Joe Wilder Medical Art, published 2011, https://joewilder.webs.com/statementbyjoewilder.htm.

1 Cost implications in minimally invasive surgery CHRISTOPHER M. SCHLACHTA AND JANET MARTIN

INTRODUCTION It is generally accepted that the technology required to perform advanced laparoscopy is more costly than the standard instruments employed for open surgery. However, these added operating room costs are rationalized on the presumption that we will realize downstream mitigation through faster recovery. Even though total hospital costs may remain elevated, we justify this on the basis of an acceptable level of increased costs required to achieve the improved outcomes provided by laparoscopy. We may be willing to pay more for better outcomes, but there is a limit to the amount of extra resources we are willing to commit, especially for relatively small benefits. In this chapter we explore the cost-effectiveness and provide some practical insight into the cost implications of introducing expensive new equipment into the value equation for minimally invasive surgery.

BACKGROUND AND RATIONALE FOR ECONOMIC ANALYSIS FOR MINIMALLY INVASIVE SURGERY Physicians and surgeons have a moral and ethical responsibility to provide their patients with the best possible care. If one is not concerned with resources, then the choice of which of two possible therapies to offer a patient becomes an exercise in assessing the evidence of effectiveness. For example, if Therapy A is more effective than Therapy B, then we prescribe Therapy A (Figure 1.1). We now live in an era of constrained health-care resources, and it is considered irresponsible to ignore cost implications when deliberating the therapeutic options for our patients. Choices must be made about how to provide the best possible care to as many patients as possible, but within a finite set of reserves. The Accreditation Council

Therapy B

Therapy A




Clinical outcome


Figure 1.1  Selection of therapy on the basis of effectiveness alone.

for Graduate Medical Education (ACGME) requires that accredited postgraduate programs must incorporate into their curriculum six core competencies. One of these ­competencies is Systems Based Practice, which includes “considerations of cost awareness and risk-benefit ­a nalysis in patient and/or population-based care as appropriate.”1 Of the seven CanMEDS competencies described by the Royal College of Physicians and Surgeons of Canada, the Manager competency includes a physician who is able to “allocate finite healthcare resources appropriately” and “apply evidence and management processes for cost-appropriate care.”2

4  Cost implications in minimally invasive surgery Greater

Therapy B

Therapy C



Therapy D

Therapy A






Clinical outcome


Figure 1.2  Health technology assessment considering trade-off between therapeutic effectiveness and cost.

Once we insert cost considerations into the decisionmaking process, we subdivide our chart into four conditions across the two dimensions of cost and effectiveness (Figure  1.2). Therapy A is generally accepted because it is better for patients and costs less. This is known as a dominating strategy in health economics, since trade-offs between costs and benefits are not necessary. Therapy B is less effective and costs more, which represents a dominating decision to reject. We are then left with two quadrants of the chart where the decision-making is not so clear, where competing objectives exist, and trade-offs between costs and effects must be made. Therapy C, which is more effective but costs more, requires an evaluation of cost-effectiveness and judgment of how much the funder is willing to pay for that additional benefit. In addition, we have Therapy D, which, although clinically inferior, does cost less and warrants evaluation when health-care resources are scarce. Most economic reports in the surgical literature focus primarily on hospital costs. While these analyses are relevant to the hospital, they are less useful for determining the balance of costs to the health system throughout a patient’s lifetime. Increasingly, surgical economic analyses are expanding the perspective of the economic analyses to include not only the hospital costs, but also the total cost of care including follow-up visits in the community (health system perspective or insurer perspective), and in some cases, costs related to loss of time at work or loss of productivity (societal perspective). Depending on the social context, the costs to the patient will also be relevant (patient perspective). Most will be familiar with the generic value equation for health care, which can be expressed simply as follows: Value =

Quality Cost

This can be applied to a new therapy or innovation by considering that the value of that therapy is directly proportional to the quality of care it provides and inversely proportional to the cost of that therapy.3 In order to provide meaningful comparison between two therapies, health economists and by extension health policy makers, in conjunction with political considerations, usually rely on the incremental cost-effectiveness ratio (ICER), typically defined by: ICER =

Net Cost Cost A − Cost B = Net Health Benefit QALYA − QALYB

where costs are expressed as the total monetary value of the inputs required, and health benefits are expressed in quality-adjusted life-years (QALYs). QALYs is a metric that is calculated by the extra length of life gained multiplied by the quality of life experienced during the remaining years of life.4

MINIMALLY INVASIVE COLORECTAL SURGERY: CASE STUDY One area in which there is a wealth of data available for analysis occurs in laparoscopic colon surgery. Since the introduction of laparoscopic colon surgery in 1991,5,6 early controversy surrounding oncologic safety has made this arguably one of the most scrutinized surgical procedures in history. As a result, a large quantity of high-level evidence is available for analysis of the differences between open and laparoscopic surgery. While we use laparoscopic colon surgery as a focus for the remainder of the chapter, many of the issues raised here will be equally applicable to other minimally invasive procedures and technologies.

Costs of laparoscopic versus open colorectal surgery A detailed economic evaluation of laparoscopic versus open surgery for colorectal cancer from the UK perspective was reported in two papers by de Verteuil7 and Murray.8 This analysis modeled cost-effectiveness of laparoscopic versus open surgery over 25 years using the best available evidence at the time. The authors found that laparoscopic colon surgery was dominated by open surgery because it had similar estimated clinical effectiveness but was more costly. They concluded that laparoscopic surgery likely provides short-term quality of life benefits and similar long-term outcomes compared with open surgery but costs an additional £300 (~$390 USD) per patient. In a threshold analysis, the authors suggested that at £30,000 (~$39,000 USD) per quality life-year in the United Kingdom, laparoscopic surgery could become cost effective if it provided a benefit of at least 0.01 QALY (essentially the equivalent of 3.5 days of full health over open surgery).

Minimally invasive colorectal surgery: Case study  5

In 2012, Aly and Quayyum published a systematic review of observational studies and clinical trials that reported the costs of laparoscopic and open colon surgery.9 Their systematic review of the evidence suggested a gradual decline in the cost gap of laparoscopic surgery over open surgery with time. This decline was partially attributed to the learning curve associated with the introduction of the technology, resulting in higher costs in the near term. This eventually lessened as efficiencies in skills and technology allowed the costs of laparoscopic surgery to approach those of open colon surgery. In a recent systematic review of the existing randomized and observational studies through 2015, we performed a meta-regression of the cost differential for laparoscopic versus open colorectal surgery and found a significant downward trend over time, which has continued to the present.10 When we limited our meta-regression to randomized clinical trials, the reduction in cost difference between laparoscopic and open surgery was similar to that found with observational studies (Table 1.1). In another assessment, we performed a retrospective cost minimization analysis of laparoscopic colon surgery versus open surgery at our institution.19 Considering hospital costs only, we found the laparoscopic approach was associated with a net cost savings compared to open surgery. Laparoscopic right colectomy costs approximately $350 less than open surgery ($10,097.93 CAD versus $10,444.69 CAD), while laparoscopic sigmoid colectomy cost just $70 less than open surgery ($11,076.72 CAD versus $11,146.56 CAD) for the total hospital stay. This cost saving was achieved in similar fashion to other reports, by offsetting the added cost of operating room technology with downstream inpatient cost savings. Given this hospital cost savings, and associated short-term patient benefits (assuming long-term equivalence in oncologic outcomes), the laparoscopic approach dominates open surgery. However, this analysis also revealed two important considerations: This cost savings was highly sensitive to changes in equipment costs and conversions to open surgery. As a result, the cost savings measured in our institution will not necessarily automatically translate to all settings. Rather, these savings

at our institution were achieved through good judgment and sensible frugality. If a case is converted to open surgery, then one incurs all of the operating room costs of a laparoscopic procedure in addition to open surgery, while realizing none of the downstream benefit. Furthermore, the use of a single disposable trocar (sigmoid colectomy) or an additional stapler or energy device (right colectomy) will flip the hospital cost in favor of open surgery. Good judgment on case selection is warranted, and a concerted effort to minimize operative technology cost is necessary. In our institution, and therefore represented in this analysis, is the policy that we use only reusable trocars and instruments. No energy devices or staplers are opened until we are certain that the laparoscopic approach will proceed. What then can we say about more advanced technology such as single-port surgery or robotic-assisted surgery?

Costs of robotic-assisted versus laparoscopic versus open colorectal surgery One randomized controlled trial (RCT) (n = 70 patients) compared robotic-assisted with laparoscopic right colectomy and found no proven difference in clinical outcomes or oncologic adequacy; however, operating time was increased on average by 65 minutes, and total costs were significantly increased for the hospital, the national insurance payer, and the patients. The extra costs were attributed primarily to the costs of surgery and consumables.18 A number of systematic reviews and meta-analyses have compared clinical outcomes and costs of robotic colorectal surgery versus laparoscopic or open surgery, including observational studies and the single existing RCT described above. Three separate systematic reviews found robotic colorectal surgery to be associated with longer operation times and increased costs with minimal clinical benefit.20–22 Overall, the evidence to date suggests that the additional costs associated with robotic colorectal surgery, when compared to laparoscopic or open surgery, have not been justified by offsets in downstream costs or by improved clinical outcomes for patients. As a result, many have proposed that

Table 1.1  RCTs of laparoscopic versus open colon surgery providing cost data Cost Trial


Braga et al.11 Franks et al.12 Janson et al.13 King et al.14 Leung et al.15 Norwood et al.16 Zheng et al.17

Hospital Societal Hospital Societal Hospital Operating room Hospital

Park et al.18




Open €4826a £6631 €7235 £6787 $9850 $9948 AUS 10,228 CNY Robotic $12,235 USD

Laparoscopic €4951a £6899 €9479 £6433 $9729 $10,111 AUS 11,499 CNY Laparoscopic $10,320 USD


Percentage (%)

€125 £268 €2244 (£353) ($121) $163 AUS 1271 CNY

2.6% 4.0% 31.0% (5.2%) (1.2%) 1.6% 12.4%



6  Cost implications in minimally invasive surgery

the uptake of robotic surgery should be done only within the context of formal clinical trials to guide future areas for uptake, and to assess whether mitigation of the learning curve, or whether competency-based expertise will allow for achieving acceptable cost-effectiveness.

Costs of single-incision laparoscopic surgery, laparo-endoscopic single-site surgery, natural orifice transluminal endoscopic surgery Single-incision laparoscopic surgery (SILS), laparo-endoscopic single-site (LESS) surgery, and natural orifice transluminal endoscopic surgery (NOTES) can be considered the extreme of minimally invasive therapy. A number of observational studies have evaluated whether tangible clinical and economic benefits of SILS or NOTES over conventional laparoscopic surgery are found for colorectal surgery. However, the bias inherent in these existing observational studies and meta-analyses of these observational studies preclude definitive conclusions. 23 RCTs with adequate power and follow-up will be required before the incremental cost-effectiveness ratio can be defined. As with most new technologies in the early stages, newly released sophisticated trocars and other dedicated instruments added significant costs to the operating procedure. With increased experience, industry competition, and use of conventional instruments, the costs of technologies for SILS have decreased.24 In a retrospective cost analysis of 260 patients, Stewart et al. reported similar total patient charges ($34,847 versus $38,306; p > 0.05) or hospital costs ($13,051 versus $12,703; p > 0.05) for single-site versus conventional laparoscopy, respectively.25 Only a demonstration of improved clinical outcomes in randomized studies and/ or reduced costs will ultimately render SILS cost effective compared with conventional approaches.

SPECIAL CONSIDERATIONS FOR COST ANALYSES AND COST-EFFECTIVENESS ESTIMATES IN LAPAROSCOPIC AND ROBOTIC SURGERY There is great heterogeneity in estimates of the costs for laparoscopic, robotic, and open surgery. This is not unique to colon and rectal surgery. Reasons for this heterogeneity are related to differences in the types of costs incorporated in the estimates provided within these studies, differences in time horizons of the evaluation, and the perspective of the analysis. In general, the studies are in agreement that laparoscopic techniques incur additional technologic costs compared with open surgery. As we continue to push the frontier of what can be accomplished in a minimally invasive fashion, it is important to consider that technology

costs will continue to be the most significant driver when clinical benefits are small. With the exception of de Verteuil and Murray et al.,7,8 all of the costing studies referred to in this chapter were cost analyses only without attempting to calculate the ICER. These provide partial estimates of the comparative cost side of the ICER only, without providing estimates of the incremental benefit, such as QALYs. This is likely due to the paucity of proof of large differences in clinical benefit. As a result, most ICERs, if calculated, would be extremely high, due to the very small size of the denominator. Future economic analyses should focus on providing a full economic perspective, with incremental costs (comprehensively defined) and incremental benefits defined. This will significantly advance our ability to make better decisions about committing resources and improve understanding of the trade-offs and opportunity costs among minimally invasive options for surgery.

REFERENCES 1. Common Program Requirements. ACGME approved focused revision, June 9, 2013. Accreditation Council of Graduate Medical Education. Chicago, Illinois. http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ProgramRequirements/ CPRs2013.pdf. Last accessed April 21, 2015. 2. Frank JR et al. Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada; March 2005. 3. Porter ME. N Engl J Med 2010 363:2477–81. 4. Knibb WJ. Surgery 2009;27(9):389–92. 5. Fowler DL et al. Surg Laparosc Endosc 1991;1(3):183–8. 6. Jacobs M et al. Surg Laparosc Endosc 1991;1(3):144–50. 7. de Verteuil RM et al. Int J Technol Assess Healthcare 2007;23(4):464–72. 8. Murray A et al. Health Technol Assess 2006;10(45):1–141, iii–iv. 9. Aly OE et al. Int J Colorectal Dis 2012;27:855–60. 10. Martin J et al. Submitted 2015. 11. Braga M et al. Ann Surg 2004;242:980–6. 12. Franks PJ et al. Br J Cancer 2006;95:6–12. 13. Janson M et al. Br J Surg 2004;91:409–17. 14. King PM et al. Br J Surg 2006;93:300–8. 15. Leung KL et al. Lancet 2004;363:1187–92. 16. Norwood MG et al. Colorectal Dis 2011;13(11):1303–7. 17. Zheng MH et al. World J Gastroenterol 2005;11:23–6. 18. Park JS et al. Br J Surg 2012;99:1219–26. 19. Alkhamesi NA et al. Surg Endosc 2011;25:3597–604. 20. Kim CW et al. J Gastrointest Surg 2014;18:816–30. 21. Witkiewicz W et al. Videosurg Mini Inv Tech 2013;8(3):253–7. 22. Trinh BB et al. JSLS 2014;18(4):​e2014.00187. 23. Daher R et al. World J Gastroenterol 2014;20(48):18104–20. 24. Fujii S et al. Surg Endosc 2012;26:1403–11. 25. Stewart DB et al. J Gastrointest Surg 2014;18(4):774–81.

2 Enhanced recovery programs in minimally invasive surgery NICOLÒ PECORELLI AND LIANE S. FELDMAN

INTRODUCTION Improving recovery for patients through reducing surgical trauma is a key goal of minimally invasive surgery. It is well understood that the negative consequences of surgery, including pain, organ dysfunction, catabolism, fluid/ salt retention, and sleep disturbances are proportional to the degree of tissue injury and the resulting surgical stress response.1 The mechanisms of surgical stress are very complex including a systemic inflammatory response mediated by pro-inflammatory cytokines and metabolic changes mediated by endogenous catecholamine and steroid release leading to increased insulin resistance and protein catabolism.2 Digestive surgery involves two separate wounds: one in the abdominal wall and one to the peritoneum and viscera, each triggering a systemic neurohumoral response.3 When the major trigger of the stress response is the abdominal wall incision, the benefits of laparoscopy are obvious. When the laparoscopic revolution began in the early 1990s, surgeons were immediately struck by how much better their patients looked after laparoscopic compared to open cholecystectomy. Patients undergoing cholecystectomy, fundoplication, and colonic and bariatric procedures now require hospital stays shorter than 24 hours. These results would be difficult to imagine after open surgery. But even when the length of stay is short, full functional recovery takes weeks or months.4 With colon surgery, full physical recovery is not complete even 2 months postoperatively. 5 Complications of abdominal surgery remain relatively high,6 and complications further delay patient recovery.7 Perioperative care is a complex intervention made up of multiple smaller interventions, each of which has the potential to improve or delay patient recovery and influence outcomes. In addition to minimally invasive surgery

(MIS), multiple other interventions are available that reduce metabolic stress through a variety of mechanisms.8,9 Some in clinical use include pharmacologic (afferent neural blockade using local anesthetics, glucocorticoids, intravenous local anesthetics, and nonsteroidal anti-inflammatory drugs [NSAIDs]), nutritional (preoperative carbohydrate and immediate postoperative feeding), physical (maintaining normothermia, euvolemia, and physical exercise), and hormonal (glycemic control). Guidelines for optimal perioperative care in colon, rectal, gastric, and pancreatic surgery10–13 include up to 25 evidence-based recommendations from all phases of perioperative care, involving multiple stakeholders (surgery, anesthesia, nursing, and patients). It is clear that as surgeons, if we only focus on the operation without being concerned with all of the other interventions our patients receive along the perioperative trajectory, our patients will not derive the maximal potential benefit of the minimally invasive approach. Even if the perfect laparoscopic bowel resection is performed, the impact will be much less if the patient comes out of the operating room hypothermic, fluid overloaded, and in pain. That patient is subsequently unlikely to be ready to eat or ambulate quickly, leading to more deconditioning and delaying full functional recovery. In 1995 a Danish group led by Henrik Kehlet published a report on nine patients undergoing laparoscopic colonic resection who were treated with a multimodal intervention program including epidural analgesia, early oral nutrition, and mobilization.14 This was the first step for the development of fast-track programs, which later evolved into what are currently known as enhanced recovery pathways (ERPs). ERPs are evidence-based, multimodal, standardized care plans that integrate the multiple steps and interventions in the perioperative period. They aim to reduce the metabolic

8  Enhanced recovery programs in minimally invasive surgery

response to surgery in multiple ways,9 but also to better organize care for patients undergoing a particular procedure, and thereby contribute to reducing unwanted variability in care processes and outcomes. A meta-analysis of 38 trials across multiple specialties concluded that ERPs reduced the risk of complications by about 30% and were associated with reduced hospital stays by about 1 day overall.15 The impact was consistent across specialties, which included colorectal, upper gastrointestinal, genitourinary, thoracic, and joint surgery. The approach also decreases costs, especially for the entire trajectory of perioperative care including posthospital costs.16–17 Including MIS as the foundation of an ERP and considering the entire care trajectory, from the preoperative phase through to full patient functional recovery, maximizes the value of the laparoscopic approach and its higher operating room equipment costs. In this chapter, we first describe elements included in ERPs. We then review the evidence regarding the relative benefit of MIS and enhanced recovery on postoperative recovery. Finally, we provide an example of an ERP for bowel surgery to help others adopt this approach.

COMPONENTS OF ENHANCED RECOVERY PROGRAMS ERPs represent a paradigm shift, from traditional care where the patient moves from one clinician-based expertise silo to the next, to a patient-centered pathway, where the steps of perioperative care are integrated. Interdisciplinary collaboration involving credible champions from surgery, anesthesiology, and nursing who will promote implementation with their constituencies is required. Creation of a new ERP begins by the team mapping out the trajectory of perioperative care at their institution and reviewing existing guidelines for each element of perioperative care, such as those from the Enhanced Recovery After Surgery (ERAS) Society.10–13 There are some elements that are common across a variety of procedures and some that are procedure specific, but the approach can be applied to any procedure (Table 2.1). The number of elements in a program per se does not seem to be critical, and success measured by a shorter hospital stay and complications has been seen with both complex and simpler programs.15,18 While the specific ways in which these elements are approached may vary from center to center, what seems most important is to come together as a team to create a multidisciplinary consensus for each element and from each phase of perioperative care about “how we’re going to do it at our hospital” for the average patient. Daily care maps help with adherence as they provide consistency between the information received by patients and the health-care team. Beginning in the surgeon’s clinic and continuing with the preoperative clinic education, the patient and the patient’s family are provided with the daily plan for each day of hospitalization. This includes specific daily goals for nutrition, mobilization, drain management,

Table 2.1  Key elements to include in ERPs for gastrointestinal surgery Preoperative



Optimization of organ dysfunction Patient education and engagement Prehabilitation/exercise Smoking abstinence Nutrition assessment/supplement Selective bowel preparation Limit preoperative fasting Carbohydrate drink No long-acting sedative Postoperative nausea and vomiting (PONV) prophylaxis Fluid therapy to achieve fluid balance Nerve block (when evidence based) Minimally invasive surgery Short-acting opioids Normothermia Multimodal opioid-sparing analgesia (evidence based, procedure specific) Anti-ileus prophylaxis PONV prophylaxis Question use of drains, catheters, and monitoring (evidence based) Immediate or early oral nutrition Immediate ambulation Daily care maps, well-defined discharge criteria Postdischarge rehabilitation plan (evidence based)

Source: Kehlet H. Langenbecks Arch Surg 2011;396(5):585–90.62 Note: This approach is applicable across procedures, but how each element is operationalized may differ depending on the available evidence for that procedure as well as available local expertise.

and pain control, as well as milestones to reach to enable discharge (Figure 2.1). When all of the recovery milestones are met, patients generally feel very comfortable leaving the hospital, even if this is earlier than with traditional care. Patients are encouraged to bring the information with them to the hospital, and the care maps are also posted on the ward. Patients are encouraged to speak up and ask questions about their own recovery trajectory and play an active role. As with any quality improvement initiative, having data about both processes and outcomes is critical. Data collection should ideally begin when the ERP team is assembled, to show the team where they are starting. Length of stay (LOS) is an easy way to monitor outcomes within an institution as it relates to recovery, organization, complications, and cost. Readmissions and emergency department visits should also be monitored. However, it is also important to collect information about adherence to the different care processes that will be included in the ERP in order to understand those outcomes and how to improve care. When creating a pathway for bowel surgery, key elements to address include preoperative patient education/

Components of enhanced recovery programs  9

Breathing Exercises

DAY of SURGERY 10 X every hour




10 X every hour




10 X every hour




10 X every hour



Pain Control















1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10

pain should be kept below 4

Gum, liquids, protein drinks










pain should be kept below 4

Gum, protein drinks, food as tolerated. GUM GUM



1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10

pain should be kept below 4

pain should be kept below 4

Gum, protein drinks, food as tolerated.

Gum, protein drinks, food as tolerated.




Tubes & Drains


Figure 2.1  Example of daily care plan provided to the patient in an ERP for bowel surgery. (Used with permission of the MUHC patient information office.)

engagement, nutrition, fluid balance, opioid-sparing analgesia, exercise/mobilization, and use of drains. However, most of the evidence in the guidelines was from studies of open surgery. The significant role of MIS in reducing pain, ileus, and the inflammatory response means that some of the ERP objectives will be achieved differently for open and laparoscopic surgery. For example, thoracic epidural


analgesia is strongly recommended for open surgery11 but may delay recovery after laparoscopic surgery,19 and simpler approaches, such as transversus abdominis plane (TAP) blocks, have been used successfully.20 Similarly, for higherrisk patients undergoing major surgery, goal-directed fluid therapy using cardiac output monitoring is recommended, but in the context of laparoscopic surgery within an ERP,

10  Enhanced recovery programs in minimally invasive surgery

Path to Home Guide: Bowel Surgery Breathing Exercises


Day of surgery

1 Day after Surgery

2 Days after Surgery

3 Days after Surgery

Do breathing exercises

Do breathing exercises

Do breathing exercises

Do breathing exercises

Do leg exercises

Sit in a chair for meals

Sit in a chair for meals

Sit in a chair for meals

Sit in a chair with help

Walk in the hallway 3 times, with help

Walk in the hallway 3 times

Be out of bed for a total of 6 hours

Be out of bed for a total of 6 hours

Go home today

Start taking pills for pain

Have epidural catheter removed if my pain is controlled

Tell my nurse if pain reaches 4/10 on the pain scale

Tell my nurse if pain reaches 4/10 on the pain scale

Pain Control


Be out of bed for a total of 6 hours

May have an epidural infusion for pain

May have an epidural infusion for pain

Tell my nurse if pain reaches 4/10 on the pain scale

Drink liquids and protein drinks as tolerated

Drink liquids, including protein drinks

Drink liquids, including protein drinks

Drink liquids, including protein drinks

Chew gum for 30 minutes

Eat regular food as tolerated

Eat regular food as tolerated

Eat regular food as tolerated

Chew gum for 30 minutes, 3 times/day

Chew gum for 30 minutes, 3 times/day

Chew gum for 30 minutes, 3 times/day

My urinary catheter may be removed today

My intravenous line will be removed when I am drinking well

My urinary catheter will be removed today, if it wasn’t removed yesterday

My intravenous line will be removed when I am drinking well

My epidural catheter will be removed and my pain will be managed with pills

I may have:

Tubes & Lines

Tell my nurse if pain reaches 4/10 on the pain scale

Oxygen mask or prongs (removed today)

Intravenous line

Epidural catheter

Urinary catheter


Figure 2.1 (Continued)  Example of daily care plan provided to the patient in an ERP for bowel surgery. (Used with ­permission of the MUHC patient information office.)

similar results may be obtained using a simpler restrictive fluid approach.21

COMBINING LAPAROSCOPIC SURGERY WITH AN ERP Both laparoscopic surgery and ERPs result in improved outcomes when used in isolation. Some elements of the ERP approach are already used more readily after laparoscopic surgery, such as early feeding. Are there advantages, beyond the theoretical, in adding a multidisciplinary ERP to a laparoscopic operation? In the following sections evidence regarding the relative benefit of MIS and enhanced recovery on postoperative recovery in different general surgery subspecialties is reviewed. This is in the form of a narrative review synthesizing studies found through literature searches performed in early 2015 using various combinations of “laparoscopic” or “minimally invasive” with “Enhanced recovery” or “Fast track” surgery.

Colorectal surgery Two types of study designs have been used to evaluate the relative impact of MIS and ERP on recovery in the setting of colorectal surgery: (1) studies comparing open and laparoscopic surgery for patients treated within an ERP

and (2) studies comparing conventional perioperative care to enhanced recovery in patients undergoing laparoscopic resection. Five randomized clinical trials (RCTs)22–26 compared laparoscopic versus open surgery when an ERP is in use (Table 2.2). Two early studies were single-center trials with a relatively small sample of patients and yielded contrasting results. Kehlet’s group found no difference in length of hospital stay, postoperative complications, gastrointestinal function, or patient-reported outcomes after open or laparoscopic colectomy when treated with enhanced recovery,22 suggesting that when an ERP is used, the benefits ascribed to laparoscopy could be achieved with open surgery. In contrast, Kennedy’s group reported improved LOS, lower pain scores, and greater physical performance 2 weeks after laparoscopic compared to open surgery.23 Two large multicenter RCTs were subsequently published: the LAFA study in the Netherlands,24 and the EnRol trial in the United Kingdom.26 The LAFA study allocated 400 patients undergoing colonic segmental resection for cancer to one of four groups combining surgical approach (laparoscopic or open) and perioperative care (enhanced recovery or standard). The combination of laparoscopy and enhanced recovery resulted in shorter length of hospital stay compared to the other groups, with laparoscopy the only independent predictor of reduced length of hospital stay. No differences were found for secondary outcomes including morbidity and quality of life. In a subset of patients, gastrointestinal recovery as measured by scintigraphy was faster in patients









Wang et al.25 EnRol26 Colorectal





Type of surgery


Immune function

Length of stay

Length of stay

Length of stay

Primary outcome

32 (31%)

  3 (8%)

34 (34%)

  6 (15%)

  8 (27%)


36 (36%)

  7 (17%)

43 (46%)

  5 (26%)

  6 (20%)


Postoperative morbidity

Note: CI, confidence interval; IQR, interquartile range; Lap, laparoscopy; SD, standard deviation.




Basse et al.22 King et al.23




Sample size






P-value Mean 3.8 Mean (95%CI) 5.5 (4–7) Median (IQR) 5 (4–7) Mean (SD) 5.2 (3.9) Median (IQR) 5 (4–6)


Mean 3.9 Mean (95%CI) 8.3 (6–11) Median (IQR) 6 (4.5–10) Mean (SD) 6.5 (4.1) Median (IQR) 6 (4–9)


Total hospital stay




14 (14%)

  1 (3%)

  6 (6%)

  2 (5%)

  6 (20%)


10 (10%)

  3 (7%)

  7 (8%)

  5 (26%)

  8 (27%)



Table 2.2  Characteristics and outcomes of randomized controlled trials evaluating laparoscopic versus open colorectal surgery within an enhanced recovery pathway







Combining laparoscopic surgery with an ERP  11

12  Enhanced recovery programs in minimally invasive surgery

treated with laparoscopic surgery and enhanced recovery compared to the other groups. Both laparoscopy and enhanced recovery were independent predictors of faster colonic transit, earlier time to tolerance of solid food, and defecation.27 Immune status and stress response after surgery were evaluated in another subset of patients from the LAFA trial.28 Laparoscopy and not the type of perioperative care was an independent factor of better-preserved immune competence and reduced inflammation. In a randomized study with a design similar to the LAFA trial, Wang et al.25 confirmed that the inflammatory response was attenuated in patients treated with MIS compared to open surgery, while enhanced recovery similarly protected immune function in both laparoscopic and open surgery patients. Finally, in the EnRol trial, 26 204 patients planned for colorectal resection were randomized to open or laparoscopic surgery in 12 UK centers applying an extensive ERP with 30 care elements and blinding of patients and assessors. LOS was shorter with laparoscopy, but no other differences were seen for physical fatigue, body image, and quality of life 1 month after surgery. The authors concluded that laparoscopic surgery within an ERP is recommended because of the shorter hospital stay. Zhuang et al.29 recently published a meta-analysis including the aforementioned studies. Pooled data revealed that total hospital stay including postdischarge readmissions was significantly shorter in patients who underwent a laparoscopic procedure. The total number of complications was also reduced for laparoscopy, while no difference was found between open and laparoscopic surgery for the number of patients developing at least one complication. Several randomized trials 30–35 and a larger number of case control studies36–43 have estimated the effect of enhanced recovery compared to conventional care when minimally invasive colorectal resection is performed. All but one study30 reported that the implementation of an ERP in the context of MIS reduces LOS and accelerates recovery of gastrointestinal function. These findings are confirmed by larger case control studies from high volume institutions and a few available case match studies. A report from the Mayo Clinic37 showed that 45% of patients treated within an ERP were discharged within 2 days after minimally invasive colorectal cancer surgery. Postoperative complications were similar between ERP patients and conventional care in most of the RCTs and nonrandomized studies. Focusing on economic analysis, in a prospective comparative trial where most patients had laparoscopic resections,16 the addition of an ERP resulted in lower societal costs compared to a conventional care strategy. After discharge, patients managed in the ERP institution incurred less productivity loss, had less caregiver burden, and made fewer visits to outpatient health centers. A recent Cochrane review of three RCTs and six case-controlled studies found that for patients having laparoscopic colectomy, the addition of an ERP reduced LOS without affecting morbidity.44 In a large multicenter registry, increasing adherence with pathway elements and the use of laparoscopic surgery were both

independently associated with shorter hospitalization and complications.45 Although the quality of the evidence is not uniformly high, the data suggest that for colorectal resection, combining minimally invasive surgery with an ERP offers the greatest benefit, both for patients and for the health-care system. To date, most of the studies have only focused on short-term in-hospital recovery outcomes such as LOS and morbidity,46 and future studies should also include postdischarge functional recovery measures to better capture all dimensions of recovery both in the short and longer term.47

Bariatric and foregut surgery There are very few reports investigating the effectiveness of a formal multidisciplinary ERP in bariatric surgery. However, there are numerous reports about ambulatory bariatric surgery. McCarty et al.48 reported 23-hour discharge in 84% of 2,000 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), with few complications and readmissions. In this very high volume group with low leak rates, this was accomplished by simple optimization of perioperative analgesia and early return to oral feeding; the most significant factor in predicting successful 23-hour patient discharge was surgeon experience. Similar results were reported in a systematic review including six series of RYGB patients and eight series of laparoscopic gastric banding patients with planned outpatient surgery.49 However, a recent population-based study including more than 50,000 laparoscopic RYGB patients from the Bariatric Surgery Centers of Excellence database has raised concerns about increased risk of 30-day mortality and a trend toward increased risk of 30-day serious complications in patients with a LOS of 1 day or less.50 Only a few studies have reported on the use of multidisciplinary ERPs for bariatric surgery. These suggest that for laparoscopic RYGB and sleeve gastrectomy, ERPs facilitate early discharge without increasing complication and readmission rates.51,52 The use of enhanced recovery strategies in the context of minimally invasive gastric surgery is limited to a few studies. Grantcharov and Kehlet53 found that an ERP was feasible and safe resulting in short hospital stays (median LOS was 4 days) in a consecutive series of patients undergoing laparoscopic gastric resection for cancer. Two small RCTs comparing ERP to conventional care in laparoscopic distal gastrectomy patients have been published.54,55 Although underpowered to detect differences in postoperative morbidity, both studies showed reduced hospital stays in the ERP group compared to conventional care, and one also found that enhanced recovery was associated with improved quality of life at 2 weeks after surgery.54

Hepato-Pancreato-Biliary (HPB) Surgery Few studies have focused on the role of enhanced recovery in laparoscopic liver surgery. In a case-control series, patients

Combining laparoscopic surgery with an ERP  13

Table 2.3  Example of a multimodal ERP for elective colorectal surgery Preoperative Assessment and Optimization • Evaluation of medication compliance and control of risk factors: hypertension, diabetes, chronic obstructive pulmonary disease (COPD), smoking, alcohol, asthma, coronary artery disease (CAD), malnutrition, anemia • Psychological preparation for surgery and postoperative recovery: provide written information and e-module link including daily milestones in perioperative pathway (diet and ambulation plan, management of drains) and expectation about duration of hospital stay (3 days for colon, 4 days for rectal) • Physical preparation with exercises at home: aerobic 30 minutes/day, three times per week at moderate intensity; resistance exercises; breathing exercises • Full oral mechanical bowel preparation with oral antibiotics for rectal resections; no prep for laparoscopic colectomy; stoma teaching as needed • Nutritional preparation: oral nutritional supplements for patients with diminished oral intake or mild malnutrition Day of surgery • Drink clear fluids with carbohydrates up to 2 hours prior to operation unless risk factors are present (e.g., gastroparesis, obstruction, dysphagia, previous difficult intubation, pregnancy) Intraoperative Management Anesthetic management • Epidural catheter for open cases inserted at appropriate intervertebral level. Use local anesthetics and test epidural blockade for bilateral spread. Infusion of local anesthetics during surgery. Minimal amount of IV opioids throughout surgery. Intrathecal morphine as alternative for laparoscopic surgery • Bilateral transversus abdominis plane (TAP) block with ketorolac IV for laparoscopic surgery • Prophylactic antiemetics: one or more antiemetics based on baseline risk score • Antibiotics and deep vein thrombosis (DVT) prophylaxis • Avoid overhydration. IV Ringer lactate at 3 mL/kg/h for laparoscopic surgery; 5 mL/kg/h for open cases. Colloid 1:1 (Voluven) to replace blood loss • Anesthesia protocol: total IV anesthesia (tiva)/desflurane/sevoflurane. Lidocaine 1.5 mg/kg bolus then 2 mg/kg/h for duration of case (in patients without epidural) • Maintenance of normothermia (core temperature >36°) • Neuromuscular blockade to facilitate laparoscopic exposure at lower pressure pneumoperitoneum (12 mmHg) • Maintain glucose below 10 mmol/L (180 mg/dL) • Titrate anesthesia according to bispectral index Surgical care • Minimize incision size, minimally invasive approach if possible • Accurate hemostasis and removal of debris • Check integrity of anastomosis • No routine nasogastric and abdominal drains • Remove urinary catheter for right hemicolectomy Postoperative Strategy Postanesthesia care unit • Discharge criteria to ward: patient alert, cooperative, pain-free, warm, normotensive, able to lift legs, adequate urine output Day of surgery (postoperative day 0) • Out of bed when transferred to ward • Drinking fluids including nutritional supplements. Hold oral intake if abdomen distended or nausea/vomiting • Confirm working epidural with visual analog scale (VAS) for pain at rest, cough, and mobilization. Check skin site (repeated in subsequent days) • Oral acetaminophen 650 mg every 4 hours and Celecoxib 200 mg PO BID × 72 hours then reassess • Normal saline to keep vein open (30 mL/h) if has patient controlled analgesia (PCA) • Gum chewing for 30 minutes TID (continue daily) Postoperative day 1 • HepLock IV in morning of POD 1 • Urinary catheter removed in the morning • Mobilized 4–6 hours • Full oral diet including nutritional supplements • Hold oral intake if abdomen distended. Nasogastric tube for persistent nausea and vomiting (repeated in subsequent days) (Continued)

14  Enhanced recovery programs in minimally invasive surgery

Table 2.3 (Continued )  Example of a multimodal ERP for elective colorectal surgery Postoperative day 2 and later (>48 hours) • Full mobilization • Full oral diet including nutritional supplements • Transition from epidural to oral medication (OxyContin + oxycodone + acetaminophen + NSAIDs) if epidural stop test successful (repeated in subsequent days if epidural stop test not successful) • Discharge criteria: passing gas or stool, no fever, minimal pain (400). In addition, numbers recommended for more complex procedures, like endoscopic mucosal resection (n = 20) or endoscopic submucosal dissection (n = 30), are small compared to numbers listed for EGD (n = 130) and colonoscopy. Based on this information, multiple societies have recommended that the numbers proposed in the ASGE document not be used for granting privileges for GI endoscopy.

CONCLUSIONS Both surgeons and gastroenterologists play an important role in providing endoscopic services to patients. Both specialties have created credible training pathways that lead to competence in performing flexible endoscopy. Privileging for these procedures should recognize these pathways and be based on uniform standards that do not rely on procedure numbers alone, but include valid assessments of knowledge and skill. After the granting of initial privileges, maintenance and renewal of privileges should be based on assessments of quality and participation in quality improvement measures.

REFERENCES 1. Fenwick EH. The Electric Illumination of the Bladder and ­Urethra as a Means of Diagnosis of Obscure Vesico-Urethral Diseases, 2nd ed. London, UK: J&A Churchill; 1889. 2. Modlin IM. A Brief History of Endoscopy. Milan, Italy: Multimed; 2000. 3. Reuter MA et al. History of Endoscopy. Vol V–VII. Stuttgart, Germany: Kohlhammer Book; 2003.

4. Schindler R. Lehrbuch und Atlas der Gasteroskopie. Munich, Germany: Lehmann; 1923. 5. McCune WS et al. Ann Surg 1968;167:753. 6. Sivak Jr MV. Gastrointest Endosc 2004;60:977–82. 7. Gauderer MWL et al. J Pediatr Surg 1980;15:872–5. 8. Stiegmann GV et al. Gastrointest Endosc 1989;35(5):431–4. 9. Shaheen NJ et al. N Engl J Med 2009;360:2277–88. 10. Inoue H et al. Endoscopy 2010;42(4):265–71. 11. http://www.abim.org/∼/media/ABIM%20Public/Files/pdf/ publications/certification-guides/policies-and-procedures.pdf 12. https://www.acgme.org/Portals/0/PFAssets/Program­ Requirements/144_gastroenterology_2017-07-01. pdf?ver=2017-04-​27-145620-577 13. https://www.asge.org/docs/default-source/education/training/ gicorecurriculum.pdf?sfvrsn=4 14. https://www.asge.org/docs/default-source/education/training/​ 022e0ff663bd455bb5a0476272aa871c.pdf?sfvrsn=4 15. Sedlack RE et al. Gastrointest Endosc 2012;76(3):482–90. 16. Sedlack RE et al. Gastrointest Endosc 2014;79(1):1–7. 17. https://www.acgme.org/Portals/0/UPDATED_DEFINED_ CATEGORY_MINIMUM_NUMBERS_EFFECTIVE_ACADEMIC_YEAR_2017-2018_GENERAL_SURGERY.pdf 18. Zuckerman R et al. Am Surg 2007;73(9):903–5. 19. Harris JD et al. Am J Surg 2010;200(6):820–5. 20. Hilsden RJ et al. Can J Gastroenterol 2007;21(12):843–6. 21. http://www.absurgery.org/default.jsp?certgsqe_fec 22. http://www.surgicalcore.org/public/about 23. http://www.fesprogram.org/about/ 24. Vassiliou MC et al. Surg Endosc 2010;24:1834. 25. Poulose BK et al. Surg Endosc 2014;28(2):631–8. 26. Vassiliou MC et al. Surg Endosc 2014;28(3):704–11. 27. https://www.acgme.org/Portals/0/PFAssets/Program­ Resources/060_CRS_Minimum_Case_Numbers.pdf? ver=2017-09-08-124842-213 28. http://www.acgme.org/Portals/0/PFAssets/Program Resources/060_CRS_Minimum_Case_Numbers.pdf 29. http://www.abcrs.org/wp-content/themes/cromasolutions/ pdf/min_op_standards.pdf 30. https://fellowshipcouncil.org/about/ 31. https://fellowshipcouncil.org/wp-content/uploads/2012/02/ Flexible-Endoscopy.pdf 32. http://www.esge.com/fellowship-grants.html 33. https://www.sages.org/publications/guidelines/guidelinesprivileging-credentialing-physicians-gastrointestinal-endoscopy/ 34. Faulx AL et al. Gastrointest Endosc 2017;85(2):273–81. 35. Grantcharov TP et al. Am J Surg 2009;197:447–9. 36. Stefanidis D. Surg Clin North Am 2010;90(3):475–89. 37. Fried GM. Gastrointest Endosc Clin N Am 2006;16(3):​425–34. 38. Gallagher AG et al. Ann Surg 2005;241(2):364–72.

4 Anesthetic challenges in the gastrointestinal suites SHEILA RYAN BARNETT

INTRODUCTION The number and types of cases performed in the gastrointestinal suites settings are exploding. With advances in therapeutic technology, common gastrointestinal conditions that in the past may have required an open surgery are now often amenable to noninvasive procedures.1,2 At the same time, the demand for noninvasive diagnostic studies using an endoscopic ultrasound and other modalities has led to a significant increase in the volume of cases. These complex procedures frequently require a deep level of sedation or anesthesia.3,4 To accommodate the increased demand, many suites are now frequently equipped to allow the delivery of deep sedation and even general anesthesia in addition to traditional nurse-administered moderate sedation.4 An understanding of the different sedation and anesthesia options available is important when choosing the type of sedation or anesthesia for these cases. Appropriate choices can improve patient and provider outcomes, including satisfaction.5 This chapter highlights the differences between anesthesia options, common medications administered, and potential hazards of sedation during some of the more common procedures encountered.

WHAT TYPES OF SEDATION AND ANESTHESIA ARE AVAILABLE? The American Society of Anesthesiologists describes four levels of sedation—minimal, moderate, deep, and general anesthesia (Table 4.1). 6 Most simple endoscopy cases are performed with either nurse-administered moderate sedation or using deep sedation with propofol with an anesthesia provider, referred to as Monitored Anesthesia Care (MAC). Less commonly, a patient may require a general anesthesia and endotracheal intubation, usually in cases that are painful, are prolonged, or carry a significant risk of aspiration, hypoventilation, or general hemodynamic instability. The type of sedation and anesthesia required for an endoscopy case depends on the patient, both expectations and comorbid conditions, and the invasiveness of the procedure.7 Certain patient conditions increase the difficulty of administering sedation; for example, a history of opioid tolerance, alcohol, and regular illicit drug use can increase the patient’s tolerance to common sedatives such as benzodiazepines and opioids (Table 4.2). These patients will be challenging to sedate without very large doses of medications and

Table 4.1  American Society of Anesthesiologists level of sedation Minimal sedation

Moderate sedation

Deep sedation

General anesthesia


Normal response to verbal stimulation Unaffected

Spontaneous ventilation Cardiovascular function

Unaffected Unaffected

Adequate Usually maintained

Purposeful response following repeated or painful stimulation Intervention may be required May be inadequate Usually maintained

Unarousable, even with painful stimulus


Purposeful response to verbal and tactile stimulation No intervention required

Intervention often required Frequently inadequate May be impaired

Source: American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002;96(4):1004–17.

Medications 27

Table 4.2  Predictors of difficult sedation


Heavy alcohol or substance abuse Chronic pain medications and tolerance History of difficult sedation in the past Obstructive sleep apnea Obesity Unstable or severe medical condition Significant dementia or developmental cognitive conditions Symptomatic psychiatric conditions

In the United States, an increasing percentage of colonoscopies is being performed with deep sedation with propofol under the direction of an anesthesiologist, and an estimated increase from approximately 20% to 50% of upper endoscopic and colonoscopy procedures in 2015 is expected.1,10 For cases done under moderate sedation, over 75% of providers use a combination of midazolam and fentanyl.10 A brief description of the common medications used is included in the next section (Table 4.3).

are likely to need deep sedation with MAC even for a simple procedure. A major challenge when administering ­s edation is keeping patients in the correct “zone,” and understanding the pharmacological profiles of the medications administered is important.7

Benzodiazepines Midazolam is a short-acting benzodiazepine, with a rapid onset. Midazolam is extremely lipophilic and is metabolized by the liver, and the dose should be reduced in elderly patients and in those with renal insufficiency. In obese patients, large doses may lead to extended action. Midazolam is a sedative that has anxiolytic and amnestic properties making it an excellent medication for procedural sedation. It has no analgesic properties and is generally combined with a shortacting opioid such as fentanyl. Although it has limited cardiovascular effects, hypotension can occur when combined with an opioid, especially in hypovolemic patients. In adults the usual dose is 2–6 mg intravenously in divided doses.

MONITORING All patients receiving moderate, deep, or general anesthesia must be monitored. Standard basic monitoring includes continuous electrocardiogram, pulse oximetry with audible tones, and noninvasive blood pressure monitoring at a minimum of 5-minute intervals. Continuous capnography (end tidal CO2 monitoring) is required for MAC patients undergoing deep sedation or patients receiving general anesthesia. In 2011 the American Society of Anesthesiologists standard (www.asahq.org) also recommended capnography for patients undergoing moderate sedation, but this is not universally accepted. Capnography, or noninvasive, real-time measurement of carbon dioxide (CO2) measures ventilation through detection of maximum partial pressure of CO2 at the end of an exhaled breath, or end-tidal CO2 (EtCO2), to form a graphic waveform describing the distinct phases of the respiratory cycle. Using capnography, it is possible to detect alveolar hypoventilation prior to the development of hypoxemia, providing an early warning of impending hypoxemia and providing time for appropriate intervention.8,9

Opioids Fentanyl is a short-acting synthetic opioid that is most commonly used in combination with midazolam for moderate sedation. It is lipophilic, rapidly crosses the blood-brain barrier, and has a rapid onset. Dosing should be done incrementally and titrated to effect, and reduced in the elderly and patients with sleep apnea, either diagnosed or suspected. Respiratory depression occurs through a central ventilatory suppression of brainstem neurons and also through a muscle relaxant effect that can lead to airway obstruction, particularly in frail, obese, or elderly patients. Other side effects common to opioids include nausea and vomiting,

Table 4.3  Suggested moderate sedation drug dosage information Initial IV dose (titrate)

Maximum cumulative

0.5–2 mg IV 0.5–1.5 mg

6 mg 4 mg

Hepatic insufficiency, reduce if concomitant opioids given Fifty percent reduction other opioids; increased susceptibility to respiratory depression and apnea

Initial dose 25–50 mcg IV, titrate 25 mcg at intervals

2 mcg/kg to total of 200 mcg

Hepatic insufficiency, decrease dose; reduce doses with concomitant benzodiazepines; reduce by 50% for elderly patients


Benzodiazepines Healthy adults 70 years, or debilitated chronically ill patients Opioids Fentanyl

28  Anesthetic challenges in the gastrointestinal suites

itching, and muscle rigidity, although the latter is unlikely to occur with small doses used for sedation. The usual dose range for procedures is 25–150 mcg intravenously.

HYPNOTIC AGENTS Propofol Propofol is a hypnotic anesthetic agent. The central nervous system effects are dose dependent, ranging from light sedation at lower doses to deep sedation and ultimately hypnosis or unconsciousness (general anesthesia) at larger doses. Following injection, Propofol undergoes rapid distribution and subsequent redistribution from central to peripheral compartments and elimination; these properties make continuous infusion a popular option. In addition to the impact on consciousness, propofol has significant respiratory and cardiovascular effects. With a large bolus dose, apnea will frequently ensue for 30–40 seconds, and during infusion a decrease in tidal volume and increase in rate are commonly observed. There is a significant risk of apnea or hypoventilation with propofol as it also blunts the normal response to hypercapnia and hypoxia. Propofol can also cause myocardial depression as well as peripheral and arterial vasodilation leading to significant hypotension; this is most common after a bolus dose and exacerbated by hypovolemia. In older patients, the dose should be reduced, and the effect can be delayed due to age-related changes in the initial volume of distribution and intercompartmental clearance. Pain on injection is common with propofol, but this can be minimized by the addition of 20–40 mg lidocaine with the injection and by using bigger veins. Usual bolus doses range from 10 to 30 mg, and infusion rates range from 40 mcg/kg/h to over 150 mcg/kg/h depending on the type of procedure and the patient’s age and comorbidities. Unlike the opioids and benzodiazepines, there is no reversal agent for propofol, and because of the rapid transition that may occur from light sedation to unconsciousness general anesthesia with potential apnea, providers administering propofol should be prepared to provide respiratory support via bag mask ventilation or endotracheal intubation.

Ketamine Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist, and acts by suppressing thalamocortical systems and stimulating the limbic pathways, producing dissociative anesthesia. This is characterized by profound analgesia and amnesia, with little or no impact on respiration or protective reflexes. For procedural sedation, ketamine is most commonly given with propofol for its analgesic and respiratory-sparing properties. Small doses of midazolam are also commonly employed, and in these conditions the

hallucinatory side effects are uncommon. Ketamine has strong cardiovascular stimulating impacts and can produce significant hypertension and tachycardia. It can also lead to an increase in oral secretions that can be reduced by giving a small dose of an antisialagogue drug such as glycopyrrolate as a premedication. Usual ketamine doses for procedural sedation are 10–40 mg intravenous bolus in divided doses, used as an adjuvant with other agents.

REVERSAL AGENTS Flumazenil is a competitive antagonist specific to benzodiazepines; during procedural sedation, it is most commonly used to partially reverse or reduce the respiratory effects of midazolam. The usual dose is between 0.5 and 3 mg intravenously. It is short acting and can be expected to provide antagonism of 45–90 minutes. Reversal with flumazenil is not associated with cardiovascular or stress effects. Naloxone is a µ-opioid receptor competitive antagonist used to reverse the respiratory depression associated with fentanyl. It is a short duration drug lasting only 15–45 minutes, and when longer-acting opioids have been administered, a continuous infusion or re-dosing may be necessary. In general, naloxone should be titrated slowly starting with 40–80 mcg intravenous boluses. It reverses the respiratory effects and also the analgesic effects of opioids and can produce symptoms of acute narcotic withdrawal. Reversal agents are convenient for procedural sedation areas but should not replace judgment in appropriate patient selection for sedation.

SEDATION-RELATED ADVERSE EVENTS Overall, significant sedation-related adverse events are rare, estimated at less than 1% in most studies,3,11 and many can be avoided with careful patient selection. The lower rate of complications from the gastrointestinal literature compared to the Anesthesia Closed Claims Project5 data may reflect the changes in practice in many remote procedural locations—most advanced endoscopy suites now utilize anesthesia services to provide a full range of anesthesia from sedation and MAC to general anesthesia. Respiratory depression, hypoxemia, and hypotension are the most common sedation-related adverse events during endoscopic procedures.1,7,11 Airway obstruction and hypoxemia are the most concerning adverse events during sedation and anesthesia, but fortunately, serious events are relatively uncommon. Airway obstruction can occur when a patient becomes relaxed and the musculature relaxes, leading to a constricted upper airway. Obstruction frequently responds to lightening the anesthesia if possible and providing a jaw thrust, tilting the chin or moving the head. Capnography can be particularly useful in detecting airway obstruction or apnea prior to the development of hypoxemia—especially in obese or difficult patients.

References 29

In routine screening colonoscopy, aspiration and microaspiration, identified as coughing, are uncommon, occurring in 0.1%–0.16% of colonoscopy cases, although this percentage appears to be higher in patients receiving propofol sedation versus traditional moderate sedation. This probably reflects the different sedative profiles: propofol has a narrow therapeutic window, and it is easy for a patient to rapidly become more sedated than planned, leading to increased relaxation of musculature and diminished cough reflex. The risk of aspiration during upper endoscopy is more significant, especially in patients with bowel obstruction, or those already vomiting. In these types of patients, a general anesthesia and endotracheal intubation are recommended. Hypotension is frequently related to drug administration, and it is most pronounced during propofol sedation. Light sedation may conversely lead to hypertension and tachycardia. Hypotension during sedation frequently responds to administration of intravenous fluids, although occasionally a short-acting vasopressor might be needed. Bradycardia occasionally occurs as a result of a vagal reaction to the intraluminal stretching of the intestines during a colonoscopy. In most instances, just releasing some of the air is enough, if not atropine, an anticholinergic can be administered.

anesthesia may be required, especially in obese, ASA physical classification 4, and patients with pulmonary disease.12,13 Radiofrequency ablation or cryotherapy of the esophagus are examples of other therapeutic procedures performed in the advanced endoscopy suites that may require deep sedation. Colonoscopy is the most common of all gastrointestinal procedures and can frequently be performed with moderate sedation, although deep sedation with propofol is becoming increasingly popular.1,3 Advantages of propofol over moderate sedation include greater relaxation, more rapid awakening after the procedure, and recall in the recovery areas. However, propofol sedation for colonoscopy can add to cost, and there is significant controversy surrounding the “right” choice of anesthesia for screening procedures. In conclusion, appropriate sedation for endoscopic procedures will depend on both patient features and the characteristics of procedures. In general, most advanced endoscopic procedures should be done with an anesthesia provider to ensure that an appropriate level of anesthesia is achieved without additional patient risk.


As mentioned, it is becoming more common for advanced endoscopic procedures to be performed with an anesthesia provider under deep sedation. A procedure such as endoscopic ultrasound evaluation of the esophagus and stomach and pancreas can be long, and patient cooperation is important especially if ultrasound-guided biopsies are anticipated. Endoscopic retrograde cholangiopancreatography can also be challenging and is generally performed in a semiprone or swimmer’s position, making the airway more challenging. For these cases, bolsters placed under the chest can make the airway more accessible if a jaw thrust or suction is required. MAC anesthesia is frequently adequate, although occasionally, general anesthesia with general endotracheal

REFERENCES 1. Childers RE et al. Gastrointest Endosc 2015;82: 503–11. 2. Pino RM et al. Curr Opin Anaesthesiol 2007;20(4):347–51. 3. Guimaraes ES et al. Anesth Anal 2014;119(2):349–56. 4. Inadomi JM et al. Gastrointest Endosc 2010;72(3):580–6. 5. Metzner J et al. Curr Opin Anaesthesiol 2009;22(4):502–8. 6. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002;96(4):1004–17. 7. Lee TH et al. Clin Endosc 2014;47(2):141. 8. Waugh JB et al. J Clin Anesth 2011;23(3):189–96. 9. Kodali BS et al. Anesthesiology 2012;118:192–201. 10. Cohen LB et al. Am J Gastroenterol. 2006;101(5):967–74. 11. Berzin TM et al. Gastrointest Endosc 2011;73(4):710–7. 12. Barnett SR et al. Dig Dis Sci 2013;58(11):3287–92. 13. Cooper GS et al. JAMA Intern Med 2013;173(7):551–6.


INTRODUCTION Endoscopic evaluation of the upper gastrointestinal tract has evolved significantly over the last 50 years. The flexible endoscope first utilized in the 1960s required the endoscopist to peer through one end of the instrument, while relying on coherent fiber-optic cables to convey an image of the gastrointestinal tract at the opposite end. This provided the first minimally invasive approach to diagnostic evaluation of the foregut. Since then the development of high-resolution video endoscopy has allowed superior images to be projected for all participants in the procedure to see. Continued improvements in the endoscope have broadened the use of this instrument from a simple window into the gastrointestinal tract to a routinely used diagnostic, screening, and surveillance tool, which proffers a continually expanding platform for therapeutic intervention. With an already wide array of techniques available and newer procedures such as natural orifice surgery being employed, familiarity with the endoscope is a fundamental requisite skill for contemporary surgeons who wish to diagnose and treat foregut pathology in a minimally invasive fashion.8

INDICATIONS/CONTRAINDICATIONS Upper gastrointestinal endoscopy is indicated for evaluation in patients with a variety of symptoms as well as known medical conditions. Dyspepsia, dysphagia, odynophagia, gastroesophageal reflux disease, as well as persistent nausea and vomiting are all reasons to consider diagnostic evaluation using endoscopy. Early endoscopy should be prioritized in some of these settings when associated with “alarm” symptoms, for example, those more likely to be associated with malignant processes. Included in this category would be patients with dysphagia, weight loss, or persistent vomiting in the absence of evident pathology beyond the foregut.

Other conditions associated with malignancy require careful surveillance. These include Barrett esophagus, familial adenomatous polyposis, and prior history of gastric ulcers or polyps. Situations such as gastrointestinal bleeding and ingestion of corrosives also warrant endoscopy to stratify risk, guide management decisions, and allow minimally invasive therapeutic intervention. This procedure is similarly useful for evaluation and treatment of varices in the portal hypertensive patient, and can provide access for small bowel biopsy in patients with malabsorptive disorders. Endoscopic evaluation of the foregut is also a useful adjunct in the operating room to guide intraoperative decision-making in difficult cases, or in function-restoring cases such as procedures for achalasia or gastroesophageal reflux disease3 (Table 5.1). Both absolute and relative contraindications to upper gastrointestinal endoscopy exist. One absolute contraindication is the inability to tolerate the procedure or attendant sedation due to severe medical comorbidities. A suspected perforation may be worsened by insufflation and should also deter endoscopic evaluation, unless endoscopy will be critical to therapeutic decision-making or delivery. Other conditions such as Zenker diverticulum, uncorrected coagulopathy, and less severe comorbidities such as respiratory insufficiency or recent myocardial infarction may be relative contraindications, depending on the indications and clinical setting.3

TECHNIQUE Preoperative preparation When first evaluating a patient for upper endoscopy, several issues must be addressed. The indications and potential benefit of endoscopic evaluation should be reviewed for each individual patient, as comorbidities determine the associated

Technique 31

Table 5.1  Indications and contraindications to diagnostic upper endoscopy

Indications—Diagnostic Dyspepsia Dysphagia Odynophagia Gastroesophageal reflux disease Nausea and vomiting Indications—Surveillance Barrett esophagus Familial adenomatous polyposis History of gastric ulcers or polyps Indications—Miscellaneous Bleeding Corrosive ingestion Varices Malabsorption disorder Intraoperative evaluation Contraindications—Absolute Inability to tolerate the procedure Inability to tolerate sedation Contraindications—Relative Suspected perforation Zenker diverticulum Uncorrected coagulopathy Less severe comorbidities

risk of complications and may dictate additional planning and preparation. While small-caliber nasal endoscopes may be used with local anesthesia alone in some diagnostic settings, most diagnostic and essentially all therapeutic esophagogastroduodenoscopy (EGD) is accomplished with conscious sedation or higher-level anesthesia. The need for sedation during the procedure dictates assessment of the patient’s airway, American Society of Anesthesiologists (ASA) class, and comorbidities so that appropriate monitoring and anesthesia assistance are provided if higherlevel sedation or airway management is required, so as to ensure patient safety. Continuous electrocardiographic and pulse oximetry as well as intermittent blood pressure monitoring are routinely employed, as the most common complications are cardiopulmonary and sedation related in nature. Capnography may also be very useful as a more sensitive indicator of respiratory depression related to sedation than pulse oximetry. The presence of significant airway impairment as judged by Mallampati classification (reference or picture) or other assessments, or attendant cardiac or pulmonary disease may dictate anesthesia involvement for closer peri-procedural monitoring and management. Coagulation disorders should also be identified and planned for accordingly. Management of anticoagulation issues periprocedurally involves a risk-benefit analysis depending on the reasons for anticoagulation and expected procedural

risks and interventions.15 If a patient is taking anticoagulant medications, these should be held in the days prior to the procedure when such risk-benefit analysis justifies.5 On the day of the procedure, the patient should be instructed to take nothing by mouth for a period of 6–8 hours. Clear liquid intake closer to the procedural time in patients with normal foregut motility is likely permissible in line with ASA guidelines, if necessary.16 Patients with motility issues or gastric outlet obstruction may require a longer period without oral intake or lavage to achieve emptying of the stomach and decrease the need for repeat evaluations due to inadequate visualization. Preprocedural motility agents such as erythromycin may be helpful in such settings and have been shown to improve visualization in the setting of upper gastrointestinal bleeding.17 Additionally, if a patient wears dentures they should be removed at the time of the procedure. Mellinger–Sages antibiotics are currently recommended only in the setting of percutaneous gastrostomy tube placement, or intervention for bleeding in cirrhotic patients (starting at time of admission), as the risk of infection including endocarditis with diagnostic upper endoscopy is quite low.1,4 As with any other invasive procedures, informed consent is an important step in preparing the patient for his or her endoscopic evaluation. The potential risks range from bleeding or infection to less likely but more devastating complications like perforation and must be disclosed in the preoperative setting. Because of their relative frequency compared to other complications, cardiopulmonary complications related to sedation should also be reviewed. Discussion of any therapeutic interventions being contemplated should be held beforehand as well, and the patient should have a chance to ask any questions. A more detailed discussion of procedure-related complications occurs later in this chapter.5

Equipment The standard features of an upper endoscope include a control head, bending tip, and the intervening shaft, which is approximately 1 m in length. The control head is generally held in the left hand of the endoscopist. Buttons on the front are manipulated using the index and middle fingers and function as valves, which provide suction and air/water control. The two knobs on the side are turned using the thumb and allow angulation of the scope tip in four directions. The axis of the larger knob is referred to as “up and down” by convention, and the smaller knob moves “left and right.” The bending section is the distal 10 cm of the endoscope and deflects the tip 180° or more. The shaft of the endoscope houses channels for air or carbon dioxide insufflation, water, suctioning, and passage of instruments for biopsy or other therapeutic devices.2,12 The endoscopic tower includes a light source, imaging processor, and irrigation bottle, and often includes a video screen. Other devices may also be housed on the tower, including units for thermal energy intervention and carbon dioxide insufflators.

32  Diagnostic upper gastrointestinal endoscopy

Patient positioning The patient is placed in the left lateral decubitus position facing the endoscopist for standard EGD. Supine position may be used in certain settings such as planned gastrostomy placement or intraoperative endoscopy. The head should be supported on a small pillow. Intravenous access is preferably obtained in the right upper extremity to allow easy access to the access site. A bite block is placed between the teeth to facilitate scope passage and prevent damage to the instrument during the procedure. Supplemental oxygen is provided via nasal cannula, and monitoring devices are attached to the patient. Elevating the head of the bed slightly and angling the neck so the mouth faces downward are maneuvers to minimize aspiration risk during the procedure. Sedating medications can be administered once the patient is appropriately positioned.6,7,9

Passing the endoscope Prior to insertion of the scope, the air, irrigation, suction, and image projection should all be tested so troubleshooting the equipment can occur prior to the start of the procedure. As the endoscopist awaits an appropriate level of sedation, he or she should position the scope in front of the patient and rehearse the tip angulation. The natural curvature of the scope and the position of the patient should be noted and can help in facilitating easy passage and manipulation of the scope. The tip should be well lubricated with water-soluble lubricant. The end of the scope should be held in the right hand approximately 30 cm from the tip. This position allows passage of the scope without need for regrasping before the cricopharyngeus muscle is negotiated, but avoids too much length, which can cause buckling and hinder attempts to intubate the upper esophagus. The axis of the bending portion should be positioned to move in the superior and inferior directions of the patient’s midline. The tip is inserted while straight through the bite block over the tongue and then slowly angled inferiorly with the larger knob once the posterior pharynx is reached. Rehearsal of this movement prior to starting the procedure is useful and ensures proper alignment of the scope in the direction of the esophagus. Once passage is initiated, the endoscopist should focus on the video screen projecting the endoscopic view. Gentle movements of the scope limit gagging and avoid tissue trauma. The larger knob should now manipulate movement of the tip in the anterior and posterior midline plane. By torquing the scope with the right hand, right and left movements can be easily performed. As the scope enters, orientation can be achieved by keeping the midline centered. The pale surface of the tongue will be anterior and the darker red palate will be seen posterior. The laryngeal cartilages and vocal cords should be identified anteriorly once past the epiglottis. Posteriorly, a small slit behind the arytenoid cartilages is seen and marks the esophageal opening. The piriform sinuses are also seen flanking each side of this opening.

Advancement of the scope posteriorly toward the esophageal opening is done gently. Asking the patient to swallow can help facilitate relaxation of the cricopharyngeal sphincter. The view through the scope may be obscured when this sphincter is closed against the scope tip. With gentle pressure while the patient swallows, the scope can be guided into the esophagus as the sphincter relaxes. This maneuver requires smooth, gentle movements, and the scope should only be advanced when minimal resistance is encountered and visualization remains adequate.6,9,12 There are several other approaches that may be utilized to initially pass the endoscope. The commonly used technique under direct visualization described previously is typically adequate and optimal. Blind insertion can also be performed but is more commonly used with a side-viewing scope such as that used for endoscopic retrograde cholangiopancreatography (ERCP). This technique requires knowledge of anatomical landmarks and coordinates scope movements depending on the length of scope that has passed. Depending on the size of the patient, the cricopharyngeus is usually encountered around 15–18 cm from the incisors, and the patient is asked to swallow to facilitate scope passage. The endoscopist uses tactile feel to guide the tip in, and if resistance is encountered, must stop to avoid injury. Some physicians use their fingers to assist in blind insertion. The second and third fingers are placed over the tongue to guide the scope over them into the posterior pharynx. The bite block is placed on the scope initially and then slid in place between the teeth once the scope has passed. Disadvantages of blind techniques include higher risk of iatrogenic injury and difficulty encouraging sedated patients to follow commands that aid in scope passage. Furthermore, if insertion is performed without the bite block in place, the patient may bite the scope or the physician’s fingers.6,12

STEPS OF DIAGNOSTIC EVALUATION Once intubation of the esophagus is achieved, an evaluation of the upper gastrointestinal tract should be performed in a methodical approach to ensure thorough evaluation. The esophagus, stomach, and proximal duodenum are all inspected regardless of the inciting indication. As with initial intubation of the esophagus, manipulation of the scope should be gentle to avoid scope trauma to the mucosa, which may confound diagnosis or cause injury to the patient. Specific findings of common pathologies that may be seen on evaluation are described in the section “Common Pathology.”

Esophagus The esophagus is first evaluated as the endoscope is advanced downward and again at the end of the procedure while withdrawing the scope. The appearance of the mucosa of the esophagus should be noted. Peristalsis may occur, and insufflation of gas can be used to maintain an open lumen

Specimen collection  33

to adequately visualize the entire esophagus. When the scope tip is at the level of a structure within the esophagus, its position can be measured by noting the length of scope passed in relation to the incisors. The gastroesophageal (GE) junction is generally encountered approximately 38–40 cm from the incisors. The site at which the pale mucosa of the esophagus meets the darker red mucosa of the stomach is the squamocolumnar junction and is referred to as the “Z line.” The hiatus of the diaphragm can be observed as a constriction of the esophagus during inspiration and normally is within 2 cm of this line. By asking the patient to sniff, this constriction appears more prominent.6,12

Stomach The stomach is evaluated once the scope is advanced past the GE junction. To facilitate relaxation of any torque on the scope, the right hand should let go of the endoscope, and the endoscopist should step back from the table, allowing the endoscope to straighten. With the patient in left lateral position, the scope should then orient so that the lesser curvature is at the 12 o’clock position and the greater curvature is at the 6 o’clock position in the visual field. The anterior stomach wall will be on the left and the posterior wall on the right. The cardia, fundus, body, and antrum are all inspected sequentially while insufflating to maintain an adequate view. Any pooled gastric contents should be suctioned so no lesions are missed, and the risk of reflux or aspiration is decreased. The mucosa, blood vessels, and gastric folds should be evaluated, and distensibility and peristalsis should be assessed. With the previously described orientation, the rugal folds should run parallel toward the pylorus. Once the pylorus is encountered, it can be intubated for further exploration of the duodenum. As the scope is backed away from the pylorus and antrum, the final step in evaluating the stomach is to retroflex and examine the hiatus. To obtain this view, the endoscope should be positioned in the antrum. The tip is then deflected upward using the thumb on the large knob, and the left hand is rotated 90° counterclockwise. With the scope in this position, the cardia is visualized, and the scope shaft can be withdrawn to achieve a closer view of the hiatus. Torque applied with the right hand allows circumferential visualization of all areas in the proximal stomach from this retroflexed position. Occasional fine adjustments of the smaller right/left knob may help with optimal visualization. The incisura is similarly best inspected from this position before allowing the endoscope to return to its fully straightened position.9,10

Duodenum Intubation of the pylorus allows inspection of the duodenum. The opening should be centered in the endoscopic view. It is easiest to manipulate the left and right movements with torque and up and down deflections with the

larger knob. In most patients, the scope can be easily passed through the pylorus. The surgeon may need to wait for a spasm to pass and advance only when the sphincter relaxes. If undue resistance is encountered, this may signify stenosis. It is helpful to avoid overdistention of the stomach when preparing to negotiate the pylorus, which may facilitate pyloric spasm. Occasionally a small burst of suction applied when the endoscope is peering through the pyloric opening may engender entry. It should also be remembered that some of the best viewing of the duodenal bulb may be accomplished through the pylorus, rather than after it has been passed. When the scope is advanced into the duodenal bulb, the momentum usually propels it into the distal bulb. To evaluate this area, the scope must be backed out slowly with slight deflections of the tip to ensure all mucosa is inspected. Lesions in this area can be easily missed due to the propensity of the scope to slip back into the stomach, and particular care should be taken to visualize all aspects of the bulb. Passage of the scope into the distal duodenum is the next step and can be challenging due to the superior duodenal angle, depending on patient anatomy. This sharp turn connects the duodenal bulb to the descending duodenum and must be navigated to gain access to the remainder of the duodenum. As the duodenum sweeps posteriorly, the luminal view often disappears. To advance past this turn, the right hand should release the scope while the left hand manipulates the larger knob so the tip deflects slightly upward. Rotation of the left hand 90° clockwise facilitates negotiation of the angle into the descending duodenum. This is followed by pulling back on the scope, allowing paradoxical advancement into the more distal duodenum as the instrument moves from a looped, greater curve position in the stomach to a lesser curve and straightened position. Continued evaluation of the distal duodenum can be accomplished as desired by advancing the scope under direct luminal inspection. If recurrent looping in the stomach occurs and limits more distal duodenal intubation, gentle pressure on the epigastrium may help overcome this.9

WITHDRAWAL OF THE ENDOSCOPE At the conclusion of the procedure, the endoscope should be straightened out and any air in the stomach should be suctioned. Desufflation decreases postprocedure discomfort related to gastric distension. It is important to reinspect all surfaces during scope withdrawal to ensure pathology is not missed. As the tip is backed out of the cardia into the esophagus, small amounts of gas may need to be instilled to maintain an open lumen for a final look at the esophageal mucosa. The right hand should slowly withdraw the scope. Fine movements with the larger knob and torque of the right hand should be used to keep the lumen centered as the scope is removed.12

SPECIMEN COLLECTION During endoscopic evaluation, lesions may be identified that warrant biopsy of tissue for microscopic examination.

34  Diagnostic upper gastrointestinal endoscopy

Specimens should be obtained using cupped forceps passed through the instrument insertion channel. Lesions should be centered in front of the endoscope. It is easiest to keep the forceps relatively close to the scope tip and approach the lesion by moving the scope instead of the forceps themselves, as fine control becomes more difficult when the forceps extend far beyond the tip of the endoscope. It is helpful to know that the suction and biopsy channel is at 6 o’clock on the endoscopic visual field, so positioning pathology or material to be suctioned in that location will facilitate the task. With the forceps in the open position, the jaws of the same should be pressed against the lesion, closed, and the forceps pulled back quickly to obtain the specimen. Some forceps are spiked, which allows multiple specimens to be taken and secured on the spike before withdrawing the biopsy forceps. A few additional tissue sampling principles are useful to help ensure an appropriate piece of tissue is obtained to ­maximize the diagnostic yield. Ulcers should be biopsied at the rim in four quadrants. Biopsy of the center is usually only helpful if the sample will be used to identify a viral process. Neoplastic lesions may have necrotic portions, so if possible, avoid taking the biopsy from these areas as they lack the architecture to make an accurate histologic diagnosis. Esophageal lesions should be approached with the scope pressed against the wall and the forceps kept close to the tip of the scope. Submucosal lesions are difficult to sample with standard forceps. In such settings, biopsy-on-biopsy techniques may be utilized, or more advanced therapeutic tools such as endoscopic ultrasound-guided tissue acquisition, large particle biopsy, endoscopic mucosal resection, and endoscopic submucosal dissection may be considered. Advanced skills and equipment are required for these interventions.6

Normal findings on upper gastrointestinal endoscopy

Figure 5.1  Esophagus—midportion of esophagus.

NORMAL FINDINGS Mastery of the technique of upper gastrointestinal endoscopy along with knowledge of the expected normal appearance of foregut anatomy are necessary for successful diagnostic evaluation. Pictures of normal findings in the esophagus, stomach, and duodenum are provided in the following section (Figures 5.1 through 5.6). The normal mucosa of the esophagus appears pink and smooth, and small vessels may be seen running longitudinally within the wall. The Z-line is a slightly irregular line where the pale esophageal mucosa meets the darker red stomach mucosa. The indentation of a normal hiatus with no hernia can be seen near the level of the Z-line.7 Normal stomach mucosal appearance varies considerably, and the color can range from pink to red to orange. Differences may result from the presence of bile or other gastric contents, which can alter the absorption of light, as can other physiologic conditions such as anemia. The endoscopist should be more cognizant of areas that are markedly different in appearance rather than the color itself. Gastric folds are more prominent in the greater curvature and should become less prominent with adequate insufflation.10

Figure 5.2  Esophagus—normal Z-line.

Figure 5.3  Stomach—retroflexed view demonstrating normal mucosa at the angularis or incisura.

Common pathology  35

Normal findings on upper gastrointestinal endoscopy (Continued )

The duodenal mucosa appears pale and granular. Small white nodules in the duodenal bulb typically signify ectopic gastric mucosa and/or Brunner glands, and are a normal finding. There are no folds in the bulb, and the first fold indicates the transition into the second portion of the duodenum. Fold architecture should be mildly prominent and smooth in the absence of underlying disease.7

COMMON PATHOLOGY When performing diagnostic endoscopies, the physician will undoubtedly encounter a variety of abnormal findings. Recognition of common pathology is necessary. An endoscopist in training should profitably spend time with atlases of common and uncommon pathologies so that they may be recognized when encountered. Pictures and descriptions of common pathologic findings that should be recognized are depicted in Figures 5.7 through 5.17.

Figure 5.4  Stomach—normal gastroesophageal junction on retroflexion with no hiatal hernia.

Figure 5.5  Stomach—antrum with view of pylorus.

Figure 5.6  Duodenum—normal mucosa in the second portion of the duodenum.

Common pathology on upper gastrointestinal endoscopy

Figure 5.7  Esophagus—Barrett esophagus (intestinal

metaplasia): lesion extends proximal to the Z-line as “tongues” of salmon-colored mucosa. Lesions may be circumferential or occur as “islands” above the squamocolumnar junction.

Figure 5.8  Esophagus—esophagitis: circumferential mucosal ulceration with peptic stricture.

36  Diagnostic upper gastrointestinal endoscopy

Common pathology on upper gastrointestinal endoscopy (Continued )

Figure 5.9  Esophagus—esophageal neoplasm:

exophytic mass projecting into the lumen of the esophagus, may appear nodular or have ulcerated areas.

Figure 5.10  Esophagus—ring: thin and symmetric

circumferential projections that partially occlude the esophageal lumen.

Figure 5.11  Stomach—gastric antral vascular ectasia.

Figure 5.12  Stomach—neoplasm: carcinoma or

lymphoma range from polypoid masses to exophytic, ulcerated lesions.

Figure 5.13  Stomach—hiatal hernia: retroflexed

view shows patulous gastroesophageal junction with a pouch of stomach above a ridge at the level of the diaphragmatic hiatus.

Figure 5.14  Stomach—gastrointestinal stromal tumor: mass emanating from beneath mucosal plane.

Education 37

Common pathology on upper gastrointestinal endoscopy (Continued )

Figure 5.15  Stomach—gastric varices related to underlying portal hypertension.

Figure 5.16  Duodenum—ampullary mass: adenoma or cancer.

Figure 5.17  Duodenum—ulcer with arrow pointing to visible vessel.

COMPLICATIONS Upper endoscopy is a relatively safe procedure. though it is not without risk. A variety of complications can result and range from mild to life-threatening.11 The most feared adverse event is perforation. This occurs most frequently at the level of the cricopharyngeus and is associated with anatomic abnormalities including Zenker diverticulum, and difficult esophageal intubation. Perforation beyond the proximal esophagus is quite rare. This risk can increase, however, if therapeutic interventions are performed. Pulmonary aspiration may occur in patients with retained gastric contents either due to gastroparesis, gastric outlet obstruction, or active upper gastrointestinal bleeding. Though a transient postprocedure bacteremia can occur, infection is rare, and unless percutaneous gastrostomy tube placement is planned or the patient is a known cirrhotic with bleeding, antibiotics are not routinely administered preoperatively. The incidence of endocarditis from diagnostic upper endoscopy is extremely rare. There is also potential for infectious entities including Helicobacter pylori or hepatitis to be spread from a contaminated endoscope or accessory, necessitating meticulous disinfection of all instruments. While not germane to typical diagnostic EGD, the potential for side-viewing duodenoscopes such as are commonly used for ERCP to harbor resistant organisms in the elevator assembly of the biopsy channel has been a recent area of significant public health concern.18 Bleeding, as with any procedure, is always a potential risk, particularly when tissue sampling or intervention is required, and especially so in patients with coagulopathy. Other issues that may arise include hypoxia and cardiac dysrhythmia, which make careful monitoring throughout the procedure imperative.5,13

EDUCATION Upper gastrointestinal endoscopy is an essential diagnostic tool for evaluating the foregut. Contemporary surgical and nonsurgical interventionalists are increasingly employing less-invasive methods of treating surgical diseases. Endoscopic skill not only provides the foregut surgeon with a necessary tool for diagnosis, including tissue acquisition, but has become a truly requisite interven­ tional  skill  as  intraluminal approaches replace standard operative options for treatment of many conditions that commonly present in their practices. Examples of such transitions included dysplastic Barrett epithelium, achalasia, bleeding peptic and portal hypertensive diatheses, esophageal perforation, and some forms of reflux disease. Intraoperative endoscopy has also become critical in performing even standard foregut surgery, including fundoplication and esophageal myotomy. Recognizing the utility of proficiency in this arena, educators through the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have developed a curriculum and examination

38  Diagnostic upper gastrointestinal endoscopy

process to ensure surgical trainees demonstrate basic competency with this technology. The Fundamentals of Endoscopic Surgery (FES) program was put forth as a way to confirm new surgeons entering the workforce possess basic knowledge and technical skills needed to provide safe and appropriate gastrointestinal patient care. The American Board of Surgery (ABS) now requires current trainees (beginning with 2018 general surgery residency graduates) to have FES certification for board eligibility, attesting to the fundamental nature of endoscopy training for the field of gastrointestinal surgery.14

CONCLUSION Upper endoscopy is a commonly performed procedure utilized for a broad range of indications. A methodical approach preparatory and technical approach, along with knowledge of both normal and common pathologic findings, is necessary for accurate diagnosis and management of foregut disease. EGD is a relatively safe procedure, which provides valuable information including the opportunity for tissue diagnosis. Its use for therapeutic intervention continues to expand, and mastery of this skill is necessary for the gastrointestinal interventionalist of the present and the future.

REFERENCES 1. Khashab MA et al. Gastrointest Endosc 2015;81:​81–9. 2. Carey WD. Chapter 12, Indications, contraindications, and complications of upper gastrointestinal endoscopy. In: ­G astroenterologic Endoscopy. Philadelphia, PA: W.B. ­Saunders; 1987:296–306. 3. Cooper GS. Gastrointest Endosc Clin N Am: Upper Gastrointes Endosc 1994;4(3):439–54. 4. Haycock A et al. Chapter 2, Endoscopic equipment. In: Cotton and Williams’ Practical Gastrointestinal Endoscopy: The Fundamentals, 7th ed. Oxford, UK: Blackwell; 2014:6–18.

5. Haycock A et al. Chapter 3, Patient care, risks, and safety. In: Cotton and W ­ illiams’ Practical Gastrointestinal Endoscopy: The Fundamentals, 7th ed. Oxford, UK: Blackwell; 2014:19– 32. 6. Haycock A et al. Chapter 4, Upper endoscopy: Diagnostic techniques. In: C ­ otton and Williams’ Practical Gastrointestinal Endoscopy: The Fundamentals, 7th ed. Oxford, UK: Blackwell; 2014:33–53. 7. Jaffe PE. Gastrointest Endosc Clin N Am: Upper Gastrointest Endosc 1994;4(3):501–22. 8. Larsen MC. Chapter 3, New technology in flexible endoscopy. In: Swanstrom LL, Soper NJ. (eds.) Thompson, Mastery of Endoscopic and Laparoscopic Surgery, 4th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2014. 9. Mellinger JD. Chapter 50, Diagnostic upper gastrointestinal endoscopy. In: The SAGES Manual Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy, 2nd ed. New York, NY: Springer; 2006:547–61. 10. Morales TG. Gastrointest Endosc Clin N Am: The Stomach 1996;6(3):477–88. 11. Newcomer MK et al. Gastrointest Endosc Clin N Am: Upper Gastrointest Endosc 1994;4(3):​551–70. 12. Sivak MV. Chapter 11, Technique of upper gastrointestinal endoscopy. In: Gastroenterologic Endoscopy. Philadelphia, PA: W.B. Saunders; 1987:272–95. 13. Sivak MV. Chapter 12, Indications, contraindications, and complications of upper gastrointestinal endoscopy. In: ­Gastroenterologic Endoscopy. Philadelphia, PA: W.B. ­Saunders; 1987:296–306. 14. Vassiliou MC et al. Surg Clin N Am 2010;90:535–58. 15. Acosta RD et al. Gastrointest Endosc 2016;83:3–16. 16. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology 2017;126(3):376–393. 17. Carbonell N et al. Am J Gastroenterol 2006;101(6): 1211–15. 18. Epstein L et al. JAMA 2014;312(14):1447–55.

6 Diagnostic upper endoscopy II: Endoscopic ultrasound VAIBHAV WADHWA AND DOUGLAS PLESKOW

INTRODUCTION Esophageal ultrasound (EUS) was introduced into clinical medicine in the late 1980s. At that time it was primarily a diagnostic procedure. Over the last several decades, it has evolved into an important tool in the armamentarium of gastroenterologists, surgeons, and oncologists. The original echoendoscopes incorporated radial mechanical transducers. These instruments were useful for examining lesions in the upper gastrointestinal (UGI) tract and had a limited role in the evaluation of the pancreas. Over time instrumentation has evolved into more sophisticated devices. The echoendoscopes are now composed of electronic transducers. There are three types of instruments available: radial echoendoscopes, linear echoendoscopes, and probe ultrasound (US) devices. The indications have developed over time from routine staging and evaluation of subepithelial lesions to therapeutic interventions. The accessories for EUS have evolved over time to allow for therapeutic interventions.

ROLE OF ENDOSCOPIC ULTRASOUND Evaluation of subepithelial lesions of the upper gastrointestinal tract Subepithelial lesions of the UGI tract are a common finding during routine esophagogastroduodenoscopy (EGD). The most common site of occurrence is within the stomach, but lesions are also seen in the colon, esophagus, and duodenum.1 A majority of subepithelial lesions are benign when diagnosed; however, several of these lesions have a potential for malignant transformation.2

Subepithelial lesions are often an incidental finding and are unrelated to the indication for which the patient is undergoing an endoscopic examination.3 Imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) are not sensitive enough to discover these lesions owing to their small size. EUS is the gold standard for evaluation of subepithelial lesions, as it affords the following benefits: ability to differentiate extramural compression from intramural growth, determine layer of origin, accurately size the lesion, evaluate for regional lymphadenopathy, obtain tissue for diagnosis, and help determine appropriate management and follow-up.4 EUS imaging of the gastrointestinal (GI) tract is characterized by five layers that approximate but do not directly correlate to the histological layers: layer (1) mucosal interface; layer (2) muscularis mucosae; layer (3) submucosa plus the acoustical interface between the submucosa and the muscularis propria; layer (4) muscularis propria minus the acoustical interface between the submucosa and the muscularis propria; and layer (5) serosa and subserosal fat.5–7 An algorithmic approach has been suggested to approach such lesions, and it is based on the size on the initial EGD. If a lesion is less than 1 cm, a biopsy should be taken and repeat EGD should be done in a year to reevaluate. If a lesion is greater than 1 cm, an EUS should be done initially to further characterize the lesion, look for any signs of malignancy, and also to acquire tissue for diagnosis.3,4

Staging cancer EUS has become an increasingly important diagnostic tool in the staging of carcinomas. The accuracy in staging cancers is a vital step for the guidance of treatment options.

40  Diagnostic upper endoscopy II: Endoscopic ultrasound


Esophageal cancer is the fifth most common GI cancer in the United States. EUS provides a detailed view of the esophageal wall. It helps determine the depth of the tumor. EUS assists in the differentiation of benign and malignant lymph nodes. EUS is the most accurate modality for regional staging of esophageal cancer. The role of EUS in the initial diagnosis of esophageal cancer is limited to cases in which the initial endoscopy fails to make a diagnosis.8 An example would be in a patient with pseudoachalasia, the lesion may be subepithelial. EUS with or without fine needle aspiration (FNA) is typically performed if the biopsies or brush cytology during the initial endoscopy are nondiagnostic and there is high clinical suspicion for malignancy.9 EUS plays only a limited role in the detection of metastatic disease and restaging after neoadjuvant therapy. GASTRIC CANCER

The gold standard for diagnosing gastric cancer is standard upper endoscopy with biopsy.10 The staging workup should begin with noninvasive imaging studies such as CT and possibly MRI. EUS is not recommended before these studies, unless it is available at the time of the initial endoscopy. Detection of any unresectable disease or metastasis eliminates the need for EUS evaluation. EUS evaluation of gastric cancer can be performed with EUS endoscopes or with a probe. The T staging increases in accuracy when high-frequency US probes (20 MHz) are used.11 The echoendoscopes are more useful in evaluation of lymph nodes and blood vessel involvement. Accuracy rates of as high as 92% have been reported when both endoscopic appearance and EUS findings are used together for tumor classification.12 A recently published Cochrane review of 66 studies concluded that EUS has high accuracy for the diagnosis of gastric cancer, although the authors advised caution while interpreting the results due to large heterogeneity observed in the review.13 PANCREATIC CANCER

Pancreatic cancer is the second most common GI cancer in the United States. It is the fourth leading cause of cancerrelated deaths in the United States.14 Over the last few decades, EUS has gradually become the method of choice for diagnosis and local treatment of pancreatic cancer. Radial and linear echoendoscopes are similar in efficacy for diagnosing and staging pancreatic cancer.15 When compared with CT or abdominal US-guided procedures, interventional EUS provides a more comprehensive real-time image and a shorter puncture pathway. The present literature demonstrates that EUS-guided fine needle injection (EUS-FNI) is a feasible and safe procedure for treating pancreatic cancer.

Interventional EUS includes antitumor agent delivery, radiofrequency ablation (RFA), photodynamic drugs, radioactive seeds, celiac neurolysis, and placement of fiducial markers for image-guided radiotherapy (CyberKnife). LUNG CANCER

The endoscopic approach to the diagnosis and staging of  lung  cancer has some advantages over conventional methods—­it is less invasive than the surgical staging techniques, and it can provide a pathological diagnosis when compared to imaging studies. Endobronchial US-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal US-guided fine needle aspiration (EUS-FNA) are complementary techniques. These procedures are being increasingly used as alternatives to surgical staging.16,17 The latest guidelines recommend that endosonography can be used as the first-line approach for diagnosis as well as staging of suspected and proven lung cancer owing to its high accuracy to detect lymph node metastases.18,19 Hence, surgical exploration can be avoided in a large number of patients who require staging. However, it is still recommended that negative findings by EUS-FNA or EBUSTBNA should be confirmed by surgical techniques.

Evaluation of pancreatic cysts Pancreatic cystic lesions are being identified more frequently with the liberal use of cross-sectional imaging studies. It is estimated that 5%–15% of imaging studies demonstrate pancreatic cysts. PCLs can be classified on the basis of imaging morphological features into the following: (1) unilocular (pseudocysts, intraductal papillary mucinous neoplasms [IPMNs], unilocular macrocystic serous cystadenoma, and lymphoepithelial cysts); (2) microcystic (serous cystic neoplasms); (3) macrocystic (mucinous cystic neoplasms [MCNs] and IPMNs); and (4) cysts with a solid component (MCNs, IPMNs, cystic neuroendocrine neoplasms, solidpseudopapillary neoplasms, ductal adenocarcinoma with cystic degeneration, and metastasis).20,21 The most commonly used diagnostic tool for detection of PCLs is CT, owing to its widespread availability and ability to detect cystic lesions.22 The use of MRI with magnetic resonance cholangiopancreatography (MRCP) is an important tool to demonstrate the relationship between a PCL and the pancreatic duct.20 The advantage of EUS stems from the fact that the morphology of the cyst can be clearly identified. In addition, a specimen of the fluid can be obtained for biochemical and cytologic analysis. These specimens assist in the diagnosis of PCL. EUS findings that are typical of serous cystic neoplasms include multiple small, anechoic areas and thin septations.23 MCNs are visualized as fluid-filled, thin-walled, septated cavities.24 IPMNs in EUS demonstrate the dilation of the main pancreatic duct or branch duct with or without mural nodules and intraluminal contents.25

Therapeutic endoscopic ultrasound  41

EQUIPMENT Echoendoscopes are composed of a US transducer that is embedded into the tip of an endoscope. The transducer is usually mounted in front of the optic lens. These echoendoscopes are similar to the standard endoscopes, but with a larger-sized tip and insertion tube to accommodate the US component. They are available in two different designs, radial and curvilinear, depending on the orientation of the transducer.26 On the basis of the ability to position the transducer in close proximity to the target tissue, US imaging is able to define five acoustic layers in the GI wall that correspond to histologic layers of the mucosa, deep mucosa, submucosa, muscularis propria, and serosa or surrounding adventitia. Extramural structures, such as lymph nodes, blood vessels, ganglia, and solid intra-abdominal organs, are seen. In addition, the endoscope can maneuver in unique imaging planes and remove intraluminal air, which often obscures imaging during transcutaneous US.27 Acoustic contact between the wall of the GI tract and the US probe are typically obtained through a water-filled balloon that surrounds the probe. Less frequently, this is accomplished by filling the GI lumen with water. Samples can be obtained effectively from small lesions irrespective of the organ affected. Tumors less than 5 mm in diameter can be detected and sampled by the use of high-resolution echoendoscopes with FNA or core biopsy needles.26,27

Radial echoendoscope A radial scanning echoendoscope produces a 360° real-time view perpendicular to the shaft of the echoendoscope.26

The probes can be used to evaluate benign and malignant processes. Submucosal lesions in the luminal GI tract are the most frequently evaluated structures. Evaluation of obstructing tumors can be evaluated with EUS probes when echoendoscopes cannot be inserted.29

THERAPEUTIC ENDOSCOPIC ULTRASOUND Fine needle aspiration EUS-FNA is a technique that permits the analysis of cells obtained through the puncture of various locations in the GI tract.30 It was introduced for the first time in 1992 by Vilmann et al., who used it for the diagnosis of pancreatic masses.31 The advances in EUS since then have expanded the use of EUS-FNA from diagnosis of various diseases to therapeutic drainage and injections. EUS-FNA has greatly increased the diagnostic yield in patients undergoing EUS, and there have been reports suggestive of treatment changes in as many as 25% of patients with malignancy.32 EUS-FNA has been reported to have a sensitivity of about 80%–90% and specificity of around 85%–100%.33 The most important principle for EUS-FNA use is to acquire the information that would potentially affect patient management, like differentiating between benign and malignant disease, staging of cancer, and histological evidence of malignancy.34 As per the recent guidelines, EUS-FNA is currently recommended for sampling of the pancreas, esophagus, lung, lymph nodes in the mediastinum and abdomen, submucosal tumors, liver masses, and some left-sided adrenal masses.33,34

Linear echoendoscope

Core biopsy

Linear echoendoscopes produce real-time US images parallel to the shaft of the insertion tube, which are usually in a sector between 100° and 180°.26 This orientation of the US image with the linear instrument facilitates visualization of the entire length of the needle during EUS-FNA. This is advantageous over the radial echoendoscope, which only shows a cross section of the needle, at the point where the needle crosses the imaging plane. Hence, all EUS-FNAs are done using the linear echoendoscope.28

EUS-guided core biopsy was introduced to overcome the limitations of EUS-FNA in terms of sensitivity for the diagnosis of GI subepithelial lesions. 35 There are two types of core biopsy needles that are currently available: a 19-gauge ProCore biopsy needle (Wilson-Cook Inc., Winston-Salem, North Carolina)36 and a 25- and 22-gaute SharkCore biopsy needle (Beacon Endoscopic, Newton, Massachusetts). The advantage of these needles is that they provide a core of the tissue from which individual cell morphology can be easily seen. It can also be examined histologically for any architectural changes. A recent retrospective study showed the clinical impact of the Tru-Cut needle by demonstrating that treatment plans for 27% of the patients were changed with its usage.37 The unique design of these needles helps to obtain both cytology and histology using reverse bevel technology, aiming for diagnosis on a decreased number of passes. A recent study showed that the diagnostic accuracy with the use of the ProCore needle was greater than 90%.38

Probe EUS probes are useful adjuncts to US of the GI tract. The probes are mechanical transducers and are placed via the accessory channel of an endoscope. These probes can be used to evaluate lesions in the esophagus, stomach, duodenum, colon, and pancreaticobiliary tree. The probes have a fixed frequency and are available in 12 and 20 mHz sizes.

42  Diagnostic upper endoscopy II: Endoscopic ultrasound

Pancreatic pseudocyst A pseudocyst is a circumscribed collection of pancreatic enzymes, blood, and necrotic tissues. It is distinguished from a true cyst by the fact that the cyst lacks an epithelial layer—it is lined by granulation tissue. Pseudocysts are typically complications of acute or chronic pancreatitis.39 EUS technique can be used to diagnose and manage pancreatic pseudocysts. There are several advantages of EUSguided drainage of the pseudocyst: (1) it is less invasive and (2) there is a lower complication rate when compared to percutaneous drainage. EUS provides real-time visualization of the pseudocyst. Interposed blood vessels can be identified by Doppler US, thereby decreasing bleeding rates.21,40 EUS-guided pseudocyst drainage has been shown to have a treatment success rate ranging from 82% to 100%.21,41,42 A recent randomized controlled trial showed no difference in treatment efficacy between surgical and endoscopic treatment of pseudocysts. Endoscopic treatment, however, was associated with shorter hospital stays, better physical and mental health of patients, and lower cost.43

Pancreatic necrosis Pancreatic necrosis is a complex problem that requires a multidisciplinary approach. The indications for drainage of pancreatic necrosis include intractable pain, obstruction of the stomach or bile duct, and infected walled-off necrosis.44,45 It was treated with open pancreatic necrosectomy until recently, but this approach is associated with significant morbidity, mortality, and prolonged hospitalization. EUS-guided treatment is advantageous as it helps in imaging the necrosis, confirms adherence of the cavity to the gastric wall, and demonstrates the absence of intervening vessels in the lumen prior to puncture. Success rates of up to 95% have been reported, demonstrating the safety and efficacy of this minimally invasive procedure as an alternative to surgery.46

Fiducial placement Radiotherapy is an important treatment modality for patients with several types of cancer in the pancreas. It is essential for the target organs to be visualized properly during radiotherapy treatment. Since most of the organs are made of soft tissue, bony landmarks are usually used as a surrogate marker to localize the organs. But organs move relative to the bony landmarks; therefore, static points are preferred to improve the delivery of radiotherapy to patients with cancer.47 A fiduciary marker or fiducial is an object used as a point of reference in external beam radiation therapy. Fiducials are cylindrical gold seeds measuring 3–5 mm in length and 0.8–1.2 mm in diameter.48

Several studies have reported technical success rates of as high as 88%–100% for EUS-guided fiducial placement.49–51 The technique of fiducial placement involves loading a gold seed into a 19-gauge needle. EUS is used to identify the lesion, and the needle punctures the tumor. This technique is repeated such that three or four markers are placed in a nonlinear sequence adjacent to the tumor.49,52,53

Celiac plexus neurolysis Patients with advanced pancreatic cancer may develop debilitating abdominal pain.54 It is due to the invasion of the celiac plexus, which receives nociceptive stimuli from the pancreas.55 Celiac plexus neurolysis (CPN) is a chemical ablation of the celiac plexus that can be used to treat this pain. It refers to the permanent destruction of nerve endings using phenol- and alcohol-based solutions, leading to the inhibition of the ascending pain information. Wiersema et al. described EUS-CPN for the first time in 1996, in which they used bupivacaine and 98% alcohol for ablation of the celiac plexus.56 They reported significant improvement in pain scores at 12 weeks postprocedure. A fairly recent randomized double-blinded controlled trial showed significant improvement in pain relief 3 months post-EUS-CPN.57 Since then, it has become a recommended treatment for cancer-related pain. National Comprehensive Cancer Network (NCCN) guidelines recommend EUS-CPN for the treatment of severe cancer-associated pain.58

Pancreatic cyst ablation Pancreatic cyst ablation is another therapeutic application of EUS. Under EUS guidance, a PCL is punctured, aspirated, and injected with an ablative agent. This agent is cytotoxic to the cyst epithelium causing its destruction.59 Ethanol was the first cytotoxic agent to be used for this purpose. An initial prospective pilot study used increasing concentrations of ethanol up to 80% for EUS-guided cyst ablation, and complete resolution was reported in only 35% of the cases.60 EUS-guided ethanol lavage with paclitaxel injection (EUSELPI) for pancreatic cysts has been recently introduced. The cyst is first aspirated under EUS guidance, 99% ethanol is then used to lavage, and finally paclitaxel is injected into the cyst.61 A larger prospective study for EUS-ELPI for PCLs was reported in 2011. There were 52 patients in the study, out of which 29 (62%) of them showed complete resolution of the cysts.62

Injection of chemotherapy Pancreatic cancer is characterized by an abundance of desmoplasia and exhibits a hypovascular nature leading to poor

References 43

drug delivery. EUS-FNIs of antitumor agents adequately address this issue. Presently, several novel therapeutic agents and techniques delivered through EUS-FNI are used in clinical trials to treat advanced pancreatic cancer. Gemcitabine shows improvement over 5-fluorouracil in patients with unresectable disease. In 2011, Levy et al. reported EUS-FNI of gemcitabine in patients with unresectable pancreatic cancer. The survival rates at 6 months and 1 year were 76% and 46%, respectively.63 OncoGel (ReGel/paclitaxel) is a new intralesional injectable formulation of the chemotherapeutic drug paclitaxel. The drug is mixed with a thermosensitive, biodegradable polymer, which allows for a slow, continuous release of the drug for up to 6 weeks. EUS-guided delivery of OncoGel into a porcine pancreas model has already been demonstrated.64

Future of endoscopic ultrasound BILIARY DRAINAGE

EUS-guided biliary drainage (EUS-BD) is an excellent alternative to percutaneous transhepatic biliary drainage or surgery for the management of biliary obstruction after unsuccessful endoscopic retrograde cholangiopancreatography.65 The generally accepted indications for EUS-BD include the following: (1) failure of conventional endoscopic retrograde cholangiopancreatography, (2) altered anatomy, (3) tumor preventing access into the biliary tree, and (4) contraindication to percutaneous access such as large ascites. 66 OBESITY TREATMENT

EUS has been shown to be useful in the treatment of obesity. A pilot study done in 2008 showed that EUS-guided injections of botulinum toxin can be safely achieved with minimal adverse effects. However, the study was small and included only 10 subjects.67 A recent meta-analysis of eight randomized and nonrandomized studies concluded that intragastric botulinum toxin injection is effective for the treatment of obesity; however, there was significant heterogeneity in the methodology of the included studies.68 CONTRAST-ENHANCED ENDOSCOPIC ULTRASOUND

Contrast agents are the newest adjuvant tools in the field of US. They are microbubbles consisting of gas encapsulated by a phospholipid or a lipid membrane.69 Administration of these contrast agents intravenously enhances the EUS images by depicting the vasculature of the abdominal organs. Therefore, clear differentiation of vascular-rich and hypovascular areas is possible by using contrast-enhanced diffusion-EUS.70,71 With the development of contrast-enhanced harmonic EUS, it is possible to better differentiate the tissue for more accurate classification.72,73

SUMMARY EUS was first introduced in the early 1990s as a diagnostic tool in the evaluation of subepithelial lesions, cancer staging, and evaluation of pancreatic cysts. In the ensuing 20 years, it has become a routine tool for gastroenterologists. Endoscopic diagnosis and therapy is routinely performed with EUS. The future of EUS is full of promise with new technologies on the horizon.


1. Hedenbro JL et al. Surg Endosc 1991;5:20–3. 2. Polkowski W et al. Surg Oncol 1995;4:163–71. 3. Humphris JL et al. J Gastroenterol Hepatol 2008;23:556–66. 4. Menon L et al. Therap Adv Gastroenterol 2014;7:123–30. 5. Janssen J et al. Eur Respir J 2006;27:238–9; author reply 239–40. 6. Kimmey MB et al. Gastroenterology 1989;96:433–41. 7. Pavic T et al. Coll Antropol 2010;34:757–62. 8. Jacobson BC et al. Gastrointest Endosc 2003;57:817–22. 9. Attila T et al. Dis Esophagus 2009;22:104–12. 10. Kurtz RC et al. Semin Oncol 1985;12:11–8. 11. Singh N et al. High-frequency ultrasound probes. In: Frank GG, Thomas JS (eds.) Endoscopic Ultrasonography. Hoboken, NJ: Wiley-Blackwell; 2009:63–9. 12. Yanai H et al. Gastrointest Endosc 1997;46:212–6. 13. Mocellin S et al. Cochrane Database Syst Rev 2015;2:CD009944. 14. Jemal A et al. CA Cancer J Clin 2008;58:71–96. 15. Gress F et al. Gastrointest Endosc 1997;45:138–42. 16. Vilmann P et al. Best Pract Res Clin Gastroenterol 2009;23:711–28. 17. Annema JT et al. JAMA 2010;304:2245–52. 18. De Leyn P et al. Eur J Cardiothorac Surg 2014;45:787–98. 19. Detterbeck FC et al. Chest 2013;143:e191S–210S. 20. Sahani DV et al. Radiographics 2005;25:1471–84. 21. Yoon WJ et al. Endosc Ultrasound 2012;1:75–9. 22. Curry CA et al. AJR Am J Roentgenol 2000;175:99–103. 23. Sakorafas GH et al. Surg Oncol 2011;20:e84–92. 24. Sakorafas GH et al. Surg Oncol 2011;20:e93–101. 25. Sakorafas GH et al. Surg Oncol 2011;20:e109–18. 26. Asge Technology C et al. Gastrointest Endosc 2007;66:435–42. 27. Mallery S. Endosonographic instrumentation. In: Shami VM, Kahaleh M. (eds.) Endoscopic Ultrasound. New York, NY:Humana Press; 2010:3–31. 28. Conway J et al. Linear endoscopic ultrasound. In: Shami VM, Kahaleh M. (eds.) Endoscopic Ultrasound. New York, NY:Humana Press; 2010:91–110. 29. Liu J et al. Gastrointest Endosc 2006;63:751–4. 30. Costache MI et al. Endosc Ultrasound 2013;2:77–85. 31. Vilmann P et al. Gastrointest Endosc 1992;38:172–3. 32. Chang KJ et al. Gastrointest Endosc 1994;40:​694–9. 33. Wani S et al. Gastrointest Endosc 2015;81:67–80. 34. Dumonceau JM et al. Endoscopy 2011;43:897–912. 35. Sepe PS et al. Gastrointest Endosc 2009;70:254–61.

44  Diagnostic upper endoscopy II: Endoscopic ultrasound 36. Polkowski M et al. Endoscopy 2012;44:190–206. 37. Lee JH et al. Gastrointest Endosc 2011;74:1010–8. 38. Varadarajulu S et al. Clin Gastroenterol Hepatol 2012;10:​ 697–703. 39. Bradley EL, 3rd. Arch Surg 1993;128:586–90. 40. Seewald S et al. Dig Endosc 2009;21(Suppl 1):S61–5. 41. Kahaleh M et al. Endoscopy 2006;38:355–9. 42. Giovannini M et al. Endoscopy 2001;33:473–7. 43. Varadarajulu S et al. Gastroenterology 2013;145:583–90 e1. 44. Freeman ML et al. Pancreas 2012;41:1176–94. 45. Wamsteker EJ. Curr Opin Gastroenterol 2014;30:524–30. 46. von Renteln D et al. Gastrointest Endosc 2008;67:738–44. 47. Fuccio L et al. Expert Rev Gastroenterol Hepatol 2014;8:​ 793–802. 48. Welsh JS et al. Technol Cancer Res Treat 2004;3:359–64. 49. Park WG et al. Gastrointest Endosc 2010;71:513–8. 50. Sanders MK et al. Gastrointest Endosc 2010;71:1178–84. 51. Majumder S et al. Pancreas 2013;42:692–5. 52. Khashab MA et al. Gastrointest Endosc 2012;76:962–71. 53. DiMaio CJ et al. Gastrointest Endosc 2010;71:1204–10. 54. Grahm AL et al. Digestion 1997;58:542–9. 55. Michaels AJ et al. World J Gastroenterol 2007;13:3575–80.

56. Wiersema MJ et al. Gastrointest Endosc 1996;44:656–62. 57. Wyse JM et al. J Clin Oncol 2011;29:3541–6. 58. Pancreatic Adenocarcinoma. NCCN Clinical Practice Guidelines in Oncology [cited 4/20/2015]; Version 2.2015. Available from: http://www.nccn.org/professionals/physician_gls/pdf/ pancreatic.pdf 59. Trevino JM et al. J Hepatobiliary Pancreat Sci 2011;18:304–10. 60. Gan SI et al. Gastrointest Endosc 2005;61:746–52. 61. Oh H-C et al. Gastrointest Endosc 67:636–42. 62. Oh HC et al. Gastroenterology 2011;140:172–9. 63. Levy MJ et al. Gastrointest Endosc 2012;75:200–6. 64. Matthes K et al. Gastrointest Endosc 2007;65:448–53. 65. Kahaleh M et al. World J Gastroenterol 2013;19:1372–9. 66. Kedia P et al. Clin Endosc 2013;46:543–51. 67. Topazian M et al. Obes Surg 2008;18:401–7. 68. Bang CS et al. Gastrointest Endosc 2015;81:1141–9 e7. 69. Saftoiu A et al. Endoscopy 2012;44:612–7. 70. Klibanov AL. J Nucl Cardiol 2007;14:876–84. 71. Reddy NK et al. World J Gastroenterol 2011;17:42–8. 72. Quaia E. Eur Radiol 2007;17:1995–2008. 73. Ishikawa T et al. Gastrointest Endosc 2010;71:951–9.

7 Dilatation and stenting MATTHEW R. PITTMAN AND DEAN J. MIKAMI

INTRODUCTION Esophageal stenosis can arise from a multitude of conditions from malignancies to more benign conditions like gastroesophageal reflux disease, caustic ingestion, and anastomotic complications. Endoscopy is the standard approach to the treatment of these strictures, with dilation and stenting being the most common tools employed. This chapter presents a discussion of evolution of dilation and stenting along with current recommendations and indications for use.

luminal expansion. This class of dilators is frequently generically referred to as bougie dilators. The original weighted dilators were mercury filled, but given the concern for the safety of mercury spillage and waste management, most of these dilators have been transitioned to tungsten filled. The tip of the dilator can be in a tapered (Maloney) or blunt (Hurst) style (Figure 7.1). Weighted dilators are frequently

DILATION The concept of esophageal dilation is not new, having its origins in the Middle Ages. The original dilators were used as a technique of disimpaction of food boluses that had become lodged in the esophagus by pushing them distally.1 The uses for dilators have expanded significantly, powered by the relatively low complication and high success rates. Dilation is first-line treatment for many benign conditions including peptic strictures from reflux disease, radiation- or caustic-induced strictures, anastomotic strictures, and dysmotility conditions like achalasia and esophageal spasm. The most common presenting symptom is dysphagia, and unlike malignant strictures, weight loss is not typical. Dilation has a high success rate with 80%–90% of patients reporting symptom relief.2 Unfortunately, up to a third of these patients will have recurrent symptoms within a year.2

TYPES OF DILATORS There are essentially two different conceptual approaches to dilation with multiple dilator styles available within these approaches. The first is push dilation, which utilizes both an axial sheer stress and a radial stress to obtain adequate

Figure 7.1  Maloney (red) and Hurst (blue) tipped push dilators.

46  Dilatation and stenting

Figure 7.2  Savary dilator. delivered blindly. The second type of push dilator is an overthe-wire dilator. The polyvinyl Savary-Gillard dilators are the most common of this style used in the United States (Figure 7.2). They are typically used in conjunction with an upper endoscopy where the wire is placed through the working port of the endoscope. Once its location beyond the distal stricture margin is confirmed, the endoscope is removed and the dilators are passed blindly over the wire. Since both types of push dilation are performed without direct visualization, pre-procedure sizing and feel for resistance are essential. Sizing can be accomplished with either pre-procedure imaging or endoscopy. The goal is to feel mild resistance when the dilator is passed, and a small amount of blood should be seen on postdilation endoscopy. The second major approach is balloon dilation, which uses either pneumatic or hydrostatic pressure to produce a radial force against the stricture. There is no longitudinal shear force employed with balloon dilation. Balloon dilators can be used in an over-the-wire or through-scope fashion. The balloon can also be filled with a mix of contrast material and the dilation monitored with the assistance of fluoroscopy (Figure 7.3).

TECHNIQUE For a dilation to be safely performed, appropriate pre-procedure assessment must be performed. First, esophageal

Figure 7.3  Balloon dilator with insufflator. dilations require a technician with advanced endoscopic skills. An English study showed that endoscopists with less than 500 cases have a four times higher perforation rate than more experienced technicians.1,3 The nature of the stricture must be investigated with a thorough history, endoscopy, and possibly a swallow study, especially if the stricture cannot be traversed with the endoscope.1 Any mucosal abnormalities should be biopsied to rule out underlying malignancy. Any concern for and underlying dysmotility syndrome should be appropriately evaluated with motility studies. It is advisable to have the patient discontinue all anticoagulation and antiplatelet therapy prior to dilation to minimize the risk of difficult to control bleeding. We recommend checking a prothrombin time/international normalized ratio prior to initiating the procedure. The role of antibiotics in an endoscopic dilation procedure has been discussed in the literature, given the theoretical risk of exposing micro tears to endogenous bacteria. There are no data to suggest any benefit for prophylactic antibiotic administration in upper endoscopy patients, and current American Society for Gastrointestinal Endoscopy (ASGE) recommendations are against pre-procedure prophylaxis, even for patients with prosthetic heart valves.4 The dilation technique depends on the type of dilator being used and the nature of the stricture, but all dilations require consideration of a few basic principles. First is determining the final endoluminal diameter that is desired. It is

Stenting 47

generally believed that a diameter of at least 13 mm should be achieved to ensure resolution of dysphagia in benign strictures.1 This rule does not apply to bariatric anastomosis strictures where a smaller-diameter lumen is desired for appropriate weight loss. In the case of malignant strictures, less aggressive dilation is typically employed given the greater risk of perforation. This is not to say that the goal diameter should be achieved with the first dilation. Often, serial dilations are required to obtain the desired final diameter. It is generally recommended that the initial dilation be roughly the same size as the stricture. Traditional dogma states that the endoscopist should follow the “rule of three,” in which no more than three progressively larger dilators should be used at a time.5 This belief was based on data from Savary dilatators and may not be as important for balloon dilators, though further studies are needed. The second decision to be made involves the type of dilator used. There has been substantial debate regarding the preferred dilator: push versus balloon. Though each camp has its supporters and small studies with differing evidence, no large study has shown a difference in regard to success or complication rates when comparing the types of dilators.6 It is our recommendation that the endoscopist use the device he or she is most comfortable with and clinical judgment for type of stricture being treated. A weighted dilator is used with a blind technique. Preoperative imaging and endoscopy are used to determine the size of the stricture (both diameter and length) as well as its location. The dilator is then passed beyond the level of the stricture, using tactile response to resistance as a guide. Endoscopy should be done immediately following the dilation confirming the presence of a small amount of blood as expected in an adequate dilation and no perforation. A balloon dilator, as discussed, uses only radial force to achieve stricture relief. An appropriate size balloon is determined, and the catheter is passed until the balloon is seated with the stricture at its center. The balloon is then inflated slowly with increasing atmospheres of pressure correlating to distinct diameters. A single balloon can be inflated to the three sequential diameters to fulfill the “rule of three” without having to exchange for larger balloons (Figure 7.4). A third principle involves whether or not to use a guidewire. Guidance wires assist in safely directing the dilator past the stricture, with the goal of minimizing complications, especially perforations. It also plays a significant role in the dilation of strictures where the endoscope cannot be advanced beyond the stricture. The wire is advanced a minimum of 20 cm past the stricture, and either the weighted or balloon dilator is passed over the wire. After a minimal dilation, the endoscope can traverse the stricture and evaluate the remaining esophagus and stomach. The final principle to be determined prior to intervention is the use of fluoroscopy. Radiographic imaging can be used in conjunction with both push and balloon dilators. Wire location can be confirmed before the dilator is passed and

Figure 7.4  Through the scope balloon dilator. the actual dilation observed in real time. With a Savary dilator, fluoroscopy can be used to observe the tapered portion of the dilator extending beyond the stricture so that the full diameter of the tool is utilized in the dilation. With a balloon dilator, a 50:50 mixture of radiopaque contrast and saline can be used to fill the balloon. The stricture is localized to the midpoint of the balloon. As the balloon is expanded, authors recommend seeing the “waist” of the stricture indented on the balloon. Elimination of this indentation is used as confirmation that adequate dilation has been achieved.

COMPLICATIONS Complications of esophageal perforation are rare, but their effects can be devastating. The most feared complication is perforation, with reported rates in the literature ranging from 0.5%–1% for benign stricture and as high as 6%–7% in malignant strictures.1,7 There is a reported increased risk of perforation when the procedure is performed by an inexperienced endoscopist and when dilators are passed blindly. Other major complications include bleeding and pulmonary aspiration.

STENTING When dilation of esophageal strictures fails, esophageal stenting is generally considered to be the second-line treatment. Esophageal stents were originally developed for treatment of dysphagia from malignant strictures. These stents were quite different from those used today. They were composed of rigid plastic with very high complication rates.8

48  Dilatation and stenting

Figure 7.5  Fully covered and partially covered stents. Use of self-expanding metal stents (SEMSs) began in the 1990s and initially consisted of bare metal stents. Still being used mainly for malignant pathology, these were uncovered metal stents with the intention of permanent palliation. Unfortunately, bare metal stents have a high rate of tissue/ tumor ingrowth and re-occlusion. This tissue ingrowth also makes stent retrieval extremely difficult. Given these drawbacks, covered stents were developed. Covered SEMSs come in two major varieties: fully covered and partially covered (Figure 7.5). They consist of a woven metal alloy frame, commonly Nitinol, and some sort of coating material, often polytetrafluorethylene.8 Fully covered SEMSs have no exposed metal, while partially covered SEMSs have a proximal and distal margin of uncovered metal with the goal of minimizing migration. More recently, we have seen the development of the self-expanding plastic stent (SEPS), in which no metal is used. While the initial self-expanding stents were used to manage malignant disease, their lower complication rates and better patient tolerability made them better equipped for use in benign conditions as well. Today’s SEMSs and SEPSs are used for benign esophageal strictures from gastroesophageal reflux disease and caustic ingestion, esophageal fistulas, perforations, and even surgical complications such as staple line leaks from sleeve gastrectomies.9

non-through the scope. In either delivery system, a guidewire is used to direct the stent into the proper location. Preoperative evaluation is much the same as that for dilation where a swallow study and upper endoscopy are used to evaluate and characterize the stricture. This includes measurement of stricture length and determination of proximal and distal margins. The procedure can be performed under sedation, though most endoscopists prefer general anesthesia with the goal of improved patient tolerance and decreased rate of peri-procedural aspiration. Fluoroscopy is used in both techniques. The wire is passed 20 cm beyond the stricture and the proximal and distal extent of the stricture marked. This can be done endoluminally with clips or externally with radiographic markers. Our institution finds externally placed paper clips to be cheap and effective markers. Once the stricture length is determined, the proper stent length is chosen. We generally aim to have the stent in the middle of the stricture or leak and to have least 5 cm extension proximal and distal to the stricture or leak margins. TTS stents are performed with the endoscope and fluoroscopy, giving the endoscopist both endoluminal and radiographic views of the stent deployment. In this case, a therapeutic scope is required to accommodate both the guidewire and the deployment device. Non-through scope devices are deployed with fluoroscopic viewing only. In this technique, the scope is withdrawn from the patient, and the deployment device with contained stent is passed over the guidewire under fluoroscopic observation. The deployment technique differs for each stent manufacturer, and the user should familiarize him- or herself with the package instruction prior to use. Most SEMS and SEPS placement can be adjusted if not fully deployed (Figure 7.6). Many fully covered stents can usually be pulled back once fully deployed by grasping the retrieval loop at the proximal ring of the stent. Advancement after full deployment is often not possible. Some authors recommend using an endoluminal injection of a contrast mix following deployment to confirm proximal sealing of

TECHNIQUE SEMSs and SEPSs can be deployed in two fashions depending on the stent type: Through the scope (TTS) and

Figure 7.6  Stent on deployment device.

References 49

Figure 7.7  Deployed stent. the stent, though this is not routinely performed at our institution (Figure 7.7).

Outcomes Outcomes from SEMSs and SEPSs depend on the underlying condition being treated. Esophageal and anastomotic leaks as well as perforations are discussed in more detail in Chapter 13. In regard to stenosis, the data on long-term resolutions are varied. Initial reports suggested success rates as high as 80%. More recent prospective studies have shown those numbers to be a bit exaggerated, with success rates in the 20%–40% range for SEMSs.8,10 Covered SEMSs and SEPSs have helped to correct many of the complications of uncovered stents, mainly stent erosion and tissue ingrowth. Unfortunately the coating of these stents has led to an increase in stent migration. Migration is the most common complication of SEMSs and SEPSs with reported rates around 30% but as high as 80% in some studies.9,11 Partially uncovered stents seem to improve these rates with better tissue adhesion from the uncovered portions.

Lower migration rates of uncovered and partially covered SEMSs comes at a price with significantly higher rates of tissue embedment and occlusion, erosion, fistulas, and severe bleeding. Furthermore, retrieving an uncovered stent can be extremely challenging and often requires a technique of deploying a covered stent within the first, leading to necrosis of the ingrowth. Bronchoesophageal and aortoesophageal fistula along with massive gastrointestinal bleeds, though rare, are potentially life-threatening complications. The future of esophageal stents may lie within the recent development of biodegradable stents.12 These stents would have an advantage over standard self-expanding stents with a prolonged time for dilation and absence of need for stent retrieval. Preliminary data are varied with reported success rate up to 50% and complication rates similar to SEMSs and SEPSs.12 Larger randomized controlled studies are needed to appropriately compare these newer-generation stents.

REFERENCES 1. Riley S et al. Gut 2004;53(Suppl 1):i1–6. 2. Van Boeckel PGA et al. Curr Treat Options Gastroenterol 2015;13(1):47–58. 3. Quine MA et al. Gut 1995;36(3):462–7. 4. ASGE Standards of Practice Committee, Khashab M et al. Gastrointest Endosc 2015;81(1):81–9. 5. Langdon DF. Gastrointest Endosc 1997;45(1):111. 6. Shemesh E et al. World J Surg 1994;518–21. 7. Pereiraa-Lima JC et al. Am J Gastroenterol 1999;94(6):​ 1497–501. 8. Hindy P et al. Gastroenterol Hepatol 2012;8(8):526–34. 9. Van Halsema EE et al. World J Gastrointes Endosc 2015;7(2):135–53. 10. Dua KS et al. Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: A prospective twocenter study. Am J Gastroenterol 2008;103(12):2988–94. 11. Holm AN et al. Am J Gastroenterol 2008;67(1):20–5. 12. Repici A et al. Gastrointest Endosc 2010;72(5):927–34.

8 Therapeutic upper endoscopy II: Treatment of Barrett esophagus BORIS KIRIAZOV AND VIC VELANOVICH

INTRODUCTION Barrett esophagus is defined as the conversion of normal esophageal squamous epithelium to specialized columnarline epithelium related to symptomatic or asymptomatic gastroesophageal reflux. Patients with Barrett esophagus are at increased risk of developing esophageal adenocarcinoma.1,2 This risk is directly related to the grade of dysplasia present: intestinal metaplasia: 4 per 1,000 patients per year; low-grade dysplasia: 7–8 per 1,000 patients per year; and high-grade dysplasia: 146 per 1,000 patients per year.1,2 Although controversies exist with regard to screening, surveillance, and surgical management of the disease, the focus of this chapter is endoscopic management.

DIAGNOSIS Barrett esophagus is diagnosed endoscopically. Although standard white light endoscopy has been the standard in visualizing the “salmon-colored” epithelium of Barrett esophagus, more recent recommendations include the use of high-definition endoscopy.1 This can readily identify the change in color of squamous epithelium to intestinal metaplasia (Figure 8.1). Not uncommonly, it may be difficult to distinguish between normal squamous epithelium and Barrett epithelium. In these cases, narrow-band imaging effectively enhances the distinction between Barrett epithelium and squamous epithelium (Figure 8.2). Visual identification alone is not adequate to diagnose Barrett esophagus—pathologic evaluation from tissue biopsies is necessary. Despite continued controversy regarding the definition of Barrett esophagus, several key components are necessary for pathologic diagnosis. In Europe, the pathologic diagnosis of Barrett esophagus necessitates the

Figure 8.1  High-definition white light image of Barrett esophagus.

presence of glandular mucosa and goblet cells. While in the United States, pathologic diagnosis that requires intestinal metaplasia with periodic acid-Schiff positive staining of goblet cells remains the most widely used method of diagnosis (Figure 8.3). It is important to adequately report the length of the Barrett esophagus segment. Some standardization has been achieved with the introduction of the Prague classification, employing the extent of circumferential length of Barrett metaplasia (C) and the total length of metaplasia  (M)

Endoscopic management  51

Figure 8.2  Narrow-band imaging of Barrett esophagus.

removal of the diseased mucosa, not the entire organ. This concept of removing cancer-prone tissue is not new to surgeons. There are numerous examples of premalignant diseases that are treated with “prophylactic” resection prior to the development of malignancy. With respect to Barrett metaplasia, the value of ablation is dependent on the incidence of progression to invasive carcinoma. Although prevention of esophageal adenocarcinoma is the primary reason to perform ablation, there are other reasons as well. First, ablation may be a cost-effective alternative to observation. Inadomi et al.5 have shown that for all grades of dysplasia, ablation is more cost-effective than surveillance. This is particularly true when one considers the costs of esophagectomy. 6 In a sense, ablation can be considered a method to prevent esophagectomy. Although esophagectomy has a high cure rate for adenocarcinoma in a screened Barrett population,7 it does come at a cost in quality of life. 8 In addition, the presence of Barrett esophagus does affect quality of life, and ablation seems to improve it.9 Although it now appears that ablation of Barrett esophagus with high-grade dysplasia is an accepted standard of care,10 data also support that its use in low-grade dysplasia reduces the progression to adenocarcinoma, and an argument can be made for ablation of nondysplastic Barrett metaplasia.11 This argument centers on the facts that the morphologic evaluation of dysplasia is fraught with error; some studies show a substantial progression rate of low-grade dysplasia to cancer; post-ablation neosquamous epithelium reveals no molecular abnormalities and is biologically stable; and no other method reliably reduces cancer risk, is durable, and eliminates the need for surveillance.

Endoscopic ablation techniques

Figure 8.3  Photomicrograph of Barrett metaplasia. Note

Once the decision is made to proceed with endoscopic ablation, several techniques are available.

the columnar-lined epithelium with goblet cells.

of the Barrett esophagus. 3 Once length is ­established, it is important to adequately sample the entire length of Barrett epithelium, otherwise the risk of sampling error increases. Currently, the Seattle protocol calls for obtaining four-quadrant biopsies every 2 cm.4 It is very important that “suspicious” areas, namely, nodules or ulcers within segment of Barrett metaplasia, be biopsied thoroughly, as these will have the highest yield of malignancy.

ENDOSCOPIC MANAGEMENT Rationale for treatment Until Barrett metaplasia progresses to carcinoma, it is a mucosal disease. Therefore, eradication only requires

Photodynamic therapy Photodynamic therapy (PDT) involves injecting light sensitizing drugs into the esophagus (such as porfimer sodium) and exposing the injected portion to a specific wavelength of light to promote cell death. However, the demonstrated effectiveness is not as high as initially hoped, and the complication rates after treatment may outweigh the benefits. Although PDT works to ablate the segment of Barrett esophagus, buried glands may be unaffected and the dysplasia may persist underneath a layer of normal-appearing squamous epithelium. A randomized trial comparing PDT and omeprazole to omeprazole only demonstrated 13% progression to adenocarcinoma in the PDT group compared to 28% progression with the proton pump inhibitor group, percentages that are still quite high.12 In patients with longsegment Barrett esophagus, stricture rates after ablative

52  Therapeutic upper endoscopy II: Treatment of Barrett esophagus

therapy may be as high as 40%,13 contributing to further loss of popularity of this modality.

Multipolar electrocoagulation Multipolar electrocoagulation (MPEC) uses an endoscopic multipolar electrical probe to treat the areas of metaplasia. Complete eradication of Barrett esophagus can be as high as 88% in 3 months post-ablation14; however, success rates are operator dependent, and all areas must be treated equally. Dysphagia was the most common side effect in another series of patients.15

Argon plasma coagulation Argon plasma coagulation (APC) produces a flow of ionized argon plasma, generating a high-frequency monopolar current. The 3-month eradication rates are in the high 80% range,14 with lower rates of stricture formation and bleeding compared to PDT. Odynophagia rates were more than 10% with this modality.15

Radiofrequency ablation Radiofrequency ablation (RFA) employs bipolar electrical energy to the mucosal surfaces at frequencies at the radio level. The most widely used and best studied of these devices is the BARRx system16,17 (Figure 8.4). The general steps of ablation is to first determine the size of the area of Barrett epithelium to be treated. If it is a large area, the Halo-360 device is used; if it is a small area, the Halo-90 device is chosen. When using the Halo-360 device, after the length of Barrett epithelium to be ablated is determined, a sizing catheter is passed into the esophagus to the

level to be ablated. The balloon is inflated and the size of the ablating catheter determined. The ablating catheter is passed to the level of ablation and the endoscope passed alongside for visualization. The ablating balloon is inflated to create contact with the esophageal mucosa and suction applied to the esophageal lumen. The applied energy is 10 joules per second. The balloon is deflated. The coagulum is removed from the ablated segment of the esophagus and the process repeated. This effectively ablates to the submucosal level, and within several weeks to months, a new squamous epithelium arises at the site (Figure 8.5).18 Alternatively, if only a relatively small segment of Barrett epithelium is to be treated, the Halo-90 device can be used. This device is attached to the end of a standard endoscope to which it is oriented at the 12 o’clock position of the scope and visualized at the top of the monitor. After identifying the segment to be treated, the scope is deflected up to the segment and energy applied. Using the device, the coagulum is removed and the energy applied once again. This process can be repeated until all of the area of planned treatment is completed. A one-time RFA is 70% effective in eliminating Barrett metaplasia. Thus, follow-up sessions are required, usually at 3- and 12-month intervals.19 There is superiority of endoscopic RFA in reduction of carcinoma progression in nondysplastic metaplasia, low-grade dysplasia, and high-grade dysplasia. Endoscopic RFA can eliminate Barrett esophagus with high-grade dysplasia and reduce the risk of esophageal adenocarcinoma.20 In a study following patients at 3 years, complete eradication of intestinal metaplasia was still present in 91% of patients, 96% of patients with high-grade dysplasia. However, patients with segments shorter than 3 cm in length of Barrett esophagus are the optimal population.21 However, even after complete eradication, up to 30% of patients will still have recurrence of Barrett metaplasia at some time post-treatment follow-up.

Cryoablation Cryoablation involves directed spray of liquid nitrogen at –196°C onto the affected segment.22,23 After the segment of Barrett epithelium to be treated is identified, a catheter is passed through the scope into the esophageal lumen. Under direct visualization, the liquid nitrogen is sprayed onto the epithelium. Complete eradication of intestinal metaplasia occurs in 68%–97% of patients,24,25 complete eradication of intestinal metaplasia occurs in 57% of patients,20 and eradication of intramucosal adenocarcinoma occurs in 80% of patients.23

Endoscopic mucosal resection

Figure 8.4  The BARRx generator with Halo-360 ablation catheter and Halo-90 endoscope ablation attachment.

Endoscopic mucosal resection (EMR) is most useful in nodular Barrett esophagus, as the risk of high-grade dysplasia or malignancy is greatest in these areas, 3 or when a short segment of dysplasia is present. EMR can be used for

References 53

Figure 8.5 

Clockwise from the upper left image: Sequence of identification of Barrett esophagus, ablation with the Halo-360 device, immediate post-ablation coagulum and ulceration, and final replacement of Barrett epithelium with normal squamous epithelium.

Tis and T1a esophageal adenocarcinoma as long as submucosa is not involved, as the risk of lymph node involvement is low. EMR can be used in combination with RFA to resect both nodular Barrett high-grade dysplasia and “flat” Barrett metaplasia.26 Techniques of EMR are covered in greater detail in Chapter 10.

CONCLUSION Endoscopy is essential in the diagnosis of Barrett esophagus. RFA has become the standard of care for Barrett esophagus with high-grade dysplasia and should be considered in patients with low-grade dysplasia or other high-risk features. EMR should be used in patients with nodules with or without additional ablation of the areas of “flat” Barrett metaplasia.

REFERENCES 1. AGA Institute Medical Position Panel. Gastroenterology 2011;140:1084–91. 2. Estores D et al. Curr Prob Surg 2013;50:192–226. 3. Spechlar SJ et al. Gastroenterology 2011;140:e18–52. 4. Kiesslich R. Eur Gastroenterol Hepatol Rev 2009;5:22–5. 5. Inadomi JM et al. Gastroenterology 2009;136:2101–14. 6. Velanovich V. How many esophageal cancers need to be prevented to make ablation of Barrett’s esophagus cost-effective? In: 2007 Annual Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons, Las Vegas, NV. April 18–22, 2007. 7. Ferguson MK et al. J Gastrointest Surg 2002;6:29–35. 8. Courrech Staal EFW et al. J Thorac Cardiovasc Surg 2010;140:777–83. 9. Shaheen NJ et al. Endoscopy 2010;42:790–9.

54  Therapeutic upper endoscopy II: Treatment of Barrett esophagus 10. Rees JR et al. Cochrane Database Syst Rev 2010;(1):CD 004060. 11. Fleischer DE et al. Dig Dis Sci 2010;55:1918–31. 12. Overholt BF et al. Gastrointest Endosc 2007;66:460–8. 13. Prasad GA et al. Gastrointest Endosc 2007;65:60–6. 14. Menon D et al. BMC Gastroenterol 2010;10:111. 15. Kovacs BJ et al. Gastrointest Endosc 1999;49:547–53. 16. Dunkin BJ et al. Surg Endosc 2006;20:125–30. 17. Smith CD et al. Surg Endosc 2007;21:560–9.

18. Velanovich V. Surg Endosc 2009;23:2175–80. 19. Shaheen NJ et al. N Engl J Med 2009;360:2277–88. 20. Vaccaro BJ et al. Dig Dis Sci 2011;56:1996–2000. 21. Shaheen NJ et al. Gastroenterology 2011;141:460–8. 22. Johnston MH et al. Gastrointest Endosc 2005;62:842–8. 23. Dumot JA et al. Gastrointest Endosc 2009;70:635–44. 24. Shaheen NJ et al. Gastrointest Endosc 2010;71:680–5. 25. McGill S et al. Can J Gastroenterol 2009;23:741–6. 26. Bisschops R. Expert Rev Gastroenterol Hepatol 2011;4:319–33.

9 Therapeutic upper endoscopy III: Treatment of gastroesophageal reflux EDWARD L. JONES, KYLE A. PERRY, AND JEFFREY W. HAZEY

INTRODUCTION Gastroesophageal reflux disease (GERD) is a complex disorder resulting from multiple factors including abnormal lower esophageal sphincter function, acid production, and/ or alteration of the diaphragmatic hiatus and angle of His.1 These abnormalities most commonly result in heartburn, dysphagia, and regurgitation. Atypical symptoms such as chronic cough, hoarseness, laryngitis, and noncardiac chest pain may also be encountered.2 Symptomatic GERD has been reported in 30%–40% of adults and negatively impacts sleep, productivity, and overall quality of life.3 Left untreated, it can progress to erosive esophagitis, stricture, Barrett esophagus, esophageal adenocarcinoma, as well as other pulmonary and laryngeal conditions.4 The initial diagnosis of GERD is made based on patient symptoms and response to lifestyle modifications and proton pump inhibitors (PPIs). A significant proportion of patients who cannot tolerate PPIs or remain symptomatic despite maximal medical therapy are confirmed to have gastroesophageal reflux via esophagogastroduodenoscopy (EGD) and pH testing. These patients should be considered for endoscopic or surgical treatment. Laparoscopic Nissen fundoplication remains the gold standard for the treatment of GERD with 80%–90% of patients no longer requiring PPIs 10 or more years after surgery.5,6 However, many suitable patients avoid or are not offered antireflux surgery due to concerns about the risk of perioperative complications and long-term side effects including dysphagia, bloating, and flatulence. This treatment gap between medical and surgical treatment has driven the evolution of endoscopic GERD therapies that may adequately control symptoms with fewer side effects. Endoluminal therapies for GERD have focused on improving the lower esophageal sphincter (LES) function

through the delivery of radiofrequency energy (Stretta) or endoscopic suturing/stapling devices (EsophyX, MUSE) that restore the structure of a competent LES.7 This chapter discusses the indications and outcomes of currently available endoscopic reflux therapies: 1. Radiofrequency ablation (Stretta, Mederi Therapeutics, Greenwich, Connecticut) 2. Transoral fundoplication (EsophyX, EndoGastric Solutions, Redmond, Washington) 3. Endoscopic stapling (Medigus Ultrasonic Surgical Endostapler, Medigus, Tel Aviv, Israel)

TECHNIQUES Radiofrequency ablation (Stretta) TECHNIQUE AND INDICATIONS

Stretta was initially approved by the U.S. Food and Drug Administration (FDA) in 2000 and received updated clearance for a new radiofrequency generator in 2011. This device delivers low-power (5 Watt) radiofrequency energy to the LES while protecting the esophageal mucosa with temperature-controlled irrigation. Stretta can be performed as an outpatient procedure with conscious sedation and begins with standard endoscopy and measurement of the gastroesophageal junction (GEJ). A guidewire is then placed through the endoscope and exchanged for the Stretta catheter. The catheter is positioned 2 cm proximal to the GEJ and four nickel-titanium electrodes are deployed (Figure 9.1). Radiofrequency energy is then delivered to the esophageal musculature via these needle electrodes with continuous power adjustment based on tissue impedance and mucosal

56  Therapeutic upper endoscopy III: Treatment of gastroesophageal reflux

intervention. Patients with severe esophagitis, long-segment Barrett esophagus, known collagen vascular disease, or a hiatal hernia larger than 2 cm should not undergo Stretta. EVIDENCE

Figure 9.1  Stretta radiofrequency ablation. The Stretta

The first randomized, sham-controlled trial was published in 2003 and demonstrated significantly improved symptom scores and quality of life at 12 months.10 However, there was no difference in PPI usage or esophageal acid exposure at followup. Coron et al. found similar results in a randomized doubleblind, sham-controlled multicenter study of 65 patients. At 6 months, the active treatment group had significantly improved symptoms and quality of life.11 Another prospective, randomized, double-blind, sham-controlled crossover study was published by Arts et al. and again demonstrated improved GERD symptoms thought to be a result of decreased GEJ compliance resulting in decreased acid exposure at 3 months.12 A meta-analysis of randomized controlled trials and cohort studies reported on 18 studies over a 10-year span including 1,441 patients.13 Heartburn scores significantly improved as did quality of life as measured by the GERD-Health Related Quality of Life (GERD-HRQL) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. DeMeester scores significantly decreased from 44.4 to 28.5. Complications such as gastroparesis and erosive esophagitis were rare. Major complications occurred in less than 0.24% of patients. Long-term follow-up has been published by Noar et al. following 217 patients who were treated with Stretta for medically refractory reflux.14 At 10 years, GERD-HRQL scores had normalized in 72% of patients. The majority (64%) reduced their PPI use by 50%, and 89 patients (41%) stopped their PPI use completely. Preexisting Barrett metaplasia regressed in 85% of patients, and there were no cases of esophageal cancer.

catheter, once positioned and inflated, deploys four nickel-titanium electrodes into the esophageal muscle. It is activated twice at eight different treatment levels to complete the procedure.

Transoral fundoplication (EsophyX)

temperature. The device is then rotated 45° and fired again to complete a treatment level consisting of eight treatment sites. This is then repeated after moving distally 0.5 cm and continued for a total of eight treatment levels (four above and four below the Z-line). Two additional gastric cardia treatment levels are created to complete the procedure. The exact mechanism of reflux control following radiofrequency ablation of the LES is unknown and likely multifactorial. Remodeling the musculature of the GEJ and gastric cardia as well as ablation of vagal nerve endings are thought to restore the natural barrier function of the LES.8 Symptom improvement may also result from decreased esophageal acid sensitivity and reduced frequency in transient LES relaxations.9 Currently, Stretta is indicated for use in adults with chronic gastroesophageal reflux for 6 months that is at least partially responsive to PPI therapy. Normal esophageal peristalsis and pathologic reflux should be confirmed with manometry and pH or impedance monitoring prior to any

Transoral fundoplication using the EsophyX device was introduced as method to create a gastroesophageal plication that would restore the valve function of the angle of His at the GEJ. Transoral fundoplication (TF) was approved by the FDA in 2007 to be performed under general anesthesia. The patient is placed in the left lateral position, and EGD is performed after which the EsophyX device is placed over the scope and manipulated by a second physician. Copious lubrication is required to safely pass the cricopharyngeal constriction, and dilation with a 56 French dilator prior to device insertion facilitates this process. Following device insertion, the GEJ is viewed in retroflexion, and the gastric fundus is drawn into the device tip (Figure 9.2). Between 12 and 20 “H”-shaped polypropylene fasteners are then deployed to create a 200°–310° plication.15 The first iteration of the procedure, Transoral Incisionless Fundoplication (TIF) 1.0, created a gastro-gastric plication at the level of the squamocolumnar junction. The


Techniques 57 (a)


Figure 9.2  Esophyx Transoral Fundoplication.

(a) Appropriate placement of TIF 2.0 device with fasteners firing 1–3 cm proximal to the gastroesophageal junction. (b) Completed fundoplication.

second-generation procedure, TIF 2.0, places fasteners 1–3 cm proximal to the GEJ creating a gastroesophageal plication that is thought to create a stronger valve resulting in durable increases in resting LES pressure.16 Currently, TIF 2.0 is indicated for use in adults with chronic gastroesophageal reflux and/or regurgitation for 6 months that is at least partially responsive to PPI therapy. Patients with severe esophagitis, long segment Barrett esophagus, motility disorders, prior esophageal myotomy, esophageal varices, esophageal stricture, and hiatal hernia greater than 2 cm or a connective tissue disorder should not undergo TF.


Cadière et al. published the first prospective clinical trial in 2008 with 1 year of follow-up on 19 patients. At 12 months, 63% had normal esophageal acid exposure and 82% did not require daily PPI therapy. Fifty-three percent of patients experienced at least 50% improvement in their GERDHRQL.17 The 2-year follow-up data were equally promising: 64% of patients had at least a 50% improvement in their GERD-HRQL scores, and 71% did not require PPI therapy.18 The first multicenter study of 84 patients with 12 months of follow-up demonstrated cessation of PPI use in 81% of patients, and 37% had normal esophageal acid exposure. Patients with pre-procedure Hill grade I GEJ valves had the best outcome with 86% discontinuing PPIs and 48% demonstrating normal esophageal acid exposure. Three major complications occurred including two esophageal perforations during device insertion and one case of bleeding requiring blood transfusion.19 None of the adverse effects of laparoscopic fundoplication (e.g., bloating, dysphagia, and flatulence) were reported. The first published case series in the United States consisted of a 10-month follow-up of 26 patients. Fifty-three percent of patients had either discontinued PPIs or reduced their dose by at least 50%, and a significant improvement in GERD-HRQL score was also seen (10 from 22, p = 0.0007).20 Two hemorrhages requiring intervention were reported. A meta-analysis of 15 cohort studies including over 550 procedures demonstrated improved GERD-HRQL scores after TF with 72% of patients being satisfied and 67% of patients ceasing PPI therapy at a mean follow-up interval of 8 months. The major complication rate was 3.2% with postoperative bleeding being the most common. Overall, 8.1% of patients experienced a relapse of reflux symptoms and underwent a laparoscopic fundoplication.21 Recently, two randomized controlled trials have been published. The first compared TF in 39 patients to maximal PPI dosing in 21 patients. After 6 months, TF patients experienced significantly better relief of extra-esophageal symptoms (62% versus 5%, p = 0.009) and resolution of bothersome regurgitation (97% versus 50%, p = 0.006). Esophageal acid exposure was similar in both groups (54% versus 52%, p = 0.91); however 90% of TF patients ceased PPI therapy and 90% resolved preoperative esophagitis compared to 38% of medically managed patients (p = 0.18).22 A second study randomized 87 patients to undergo TF plus 6 months of placebo compared to 42 patients who underwent a sham-procedure plus daily omeprazole. Both groups had improved GERD-HRQL scores at 6 months, but TF eliminated regurgitation in a larger proportion of patients (67%) than medical acid suppression (45%, p = 0.23). Esophageal acid exposure improved after TF (6.3% from 9.3%, p  35 kg/m2, severe esophagitis, complicated GERD, long-segment Barrett esophagus, or a hiatal hernia greater than 3 cm have not been included.27 EVIDENCE

The initial clinical trial compared 11 patients undergoing MUSE to 16 undergoing laparoscopic fundoplication. MUSE required 89 minutes to perform compared to 47 minutes for fundoplication (p  50 kg/m2 or in high-risk obese patients (regardless of BMI)

402  Intragastric balloon

Placement and removal technique Orbera IGB placement and removal can be performed in conscious sedation with diazepam or midazolam, in unconscious sedation with propofol, or with orotracheal intubation. Before placement, a diagnostic esophagogastroduodenoscopy is performed. Then the balloon is positioned with the valve under the cardia and is filled with 500–700 mL of saline solution under endoscopic vision. Moreover, methylene blue (10 mL) is used in European clinical experience in order to early identify the balloon rupture or valve leaks. This dye is contraindicated in patients with glucose-6-phosphate-dehydrogenase (G-6-PDH) deficit, due to the risk to hemolysis crisis in case of its release. Finally, the connection catheter is removed, and the valve is checked for possible leaks. The procedure lasts on average 15 minutes. The Orbera removal is carried out after 6 months. Recently, is available the new Orbera 365 that is the same balloon but can sit in the stomach for 12 months. Clinical studies about its efficacy are in progress. Due to the delayed gastric emptying achieved with the balloon, the removal procedure should be preceded by a 24 hours semiliquid diet, in order to avoid “ab ingestis,” chiefly when the procedure is performed in unconscious sedation. Through an esophagogastroduodenoscopy, the Orbera is identified and is removed with a dedicated “grasper” after the completed deflation. Stomach observation is necessary to exclude possible mucosal lesions.8


Pharmacological treatment of symptoms should be considered as a part of a comprehensive strategy of IGB management. During the first 2–3 days, the device could induce symptoms such as nausea, regurgitation or vomiting, and cramp-like epigastric pains. These tend to last only for a short period (2 or 3 days) after balloon insertion and are usually self-limiting. In order to reduce or prevent these distressing adverse effects, all patients must receive an adequate medication based on fluids hydration, proton pump inhibitors, antispasmodic drugs, and antiemetic drugs. A prospective controlled study conducted on 54 patients receiving IGB treatment showed that the use of midazolam combined with ondansetron provides significant reduction of the postoperative nausea and vomiting compared to ondansetron alone.9 In our clinical experience, Aprepitant (125 mg orally the first days, 2 hours before the procedure, and 80 mg the first and second day after placement) induces good control of vomiting episodes. Daily intake of full-dose proton pump inhibitors should be prolonged until IGB removal. POSTPLACEMENT DIET

The postoperative IGB diet should be divided into three steps: For the first day, patients should take fluids only; from the second and up to the sixth to seventh days, a semiliquid

diet (yogurt, mashed potatoes, and puréed vegetables), and generally, at the beginning of the second week return to a normal textured diet, though with caution. The dietetic program, elaborated by nutritionists, is based on a daily intake of about 1000–1200 Kcal (including at least 1 g protein/kg ideal weight), consumed over three main meals and two small snacks. This program has been maintained until removal of the IGB and, in case of nausea, regurgitation or vomiting is indicated to return at semiliquid diet for some days. Our experience shows that the daily consumption of a high volume of vegetables is inadvisable due to their poor digestion. They clog up the gastric cavity and cause regurgitation or vomiting. It is therefore advisable to prescribe vegetables in soup form. Although indications have not yet been fully standardized, this nutritional schedule could reduce the symptoms related to IGB placement.

Patient Follow-Up Follow-up and continued supervision are necessary to prevent possible adverse events. All patients are contacted by phone every day for the first week after IGB placement. Undergoing a nutritional and clinical evaluation on the eighth day and every 2 weeks until the removal, they receive the nutritional program to follow until IGB removal. Before discharge, the patient is made aware of the importance of adequate hydration (water at least 1.5 L/day to sip slowly) and of ongoing urine checks, in order to report quickly the premature rupture of the IGB or a possible valve leak. In case of complication (e.g., blue urine or recurrent vomiting), an immediate clinical evaluation is essential, and an urgent x-ray or esophagogastroduodenoscopy may be indicated in order to exclude the risk of migration of the deflated balloon and bowel obstruction. Moreover, serious side effects with the Orbera IGB are rare, with an incidence of obstruction and gastric perforation of 0.8% and 0.1%, respectively. The confirmation of decubital ulcers or gastrectasia indicates the need to remove the IGB.10

Orbera Outcomes WEIGHT LOSS

To date, the largest trial on Orbera was published in 2005 by the Italian Lap-Band and BIB group (GILB). In this clinical trial, accounting for 2.515 patients with a mean initial BMI of 44.4 kg/m2 and a mean excess weight of 59.5 kg, after 6 months of IGB treatment the mean BMI loss and the mean percentage of excess weight loss (%EWL) was, respectively, 4.9 kg/m 2 and 33.9%. Moreover, during this period, the treatment with Orbera was demonstrated to be effective in resolving or improving obesity-related comorbidities in 44.3% and 44.8%, respectively, while no changes were reported in 10.9% of patients.11

Last-generation intragastric balloons  403

In a multicenter Brazilian study of the IGB, 323 patients (mean BMI 38.2 kg/m2) who completed 6 months of followup after Orbera showed highly significant reductions in BMI (−5.3 kg/m2) and a %EWL of 48.3%.12 The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee performed systematic reviews to evaluate the Orbera clinical outcome in terms of weight loss. Based on a meta-analysis of 17 studies including 1.683 patients, the %EWL at 12 months was 25%. Three Randomized Clinical Trials (RCTs) compared %EWL in patients who received the Orbera IGB, showing a mean difference in %EWL in patients who received the Orbera IGB over controls of 26.9% (p = 0.001). Based on a recent review, seven studies (409 patients) reported the weight loss kinetics during IGB placement. Mean weight losses after 3 and 6 months of Orbera treatment are 12.9 ± 0.8 and 16.0 ± 0.6, respectively. These data indicate that the most weight loss occurs in the first 3 months, suggesting that the mechanism of action is more active at the beginning of treatment.10 Moreover, Orbera is a repeatable treatment, after an IGBfree period. The effectiveness of a second Orbera balloon placement was investigated in clinical trials. Scientific literature reported that at the end of the second IGB treatment, after a 1-month IGB-free period, patients continued to lose weight, and as compared to patients treated with diet alone, there was a significant reduction in weight loss parameters.13,14 Although the second IGB therapy results in a continuous weight loss, its magnitude was smaller than that of the initial therapy. METABOLIC OUTCOMES

The metabolic effects of Orbera IGB placement were examined in several studies. Data from the Italian Lap-Band and BIB group (GILB) showed that diabetic patients undergoing IGB treatment achieved a resolution or improvement in 32.8% and 54.8%, respectively. A prospective study of Forlano et al. analyzed the metabolic effect of the device on ameliorating some components of the metabolic syndrome in 130 obese patients. The results showed a significant improvement of blood glucose, insulin, triglycerides, and alanine aminotransferase and of the value of the homeostatic model assessment index.15 In a prospective, controlled parallel arm, 66 obese adults were randomized to receive either the IGB for 6 months in addition to a behavioral modification program of diet and exercise, or the behavioral modification program alone. The authors reported statistically significant and clinically relevant improvements in weight loss and in health outcomes (reduction of waist circumference, improvement in quality of life, and an approximately half remission of metabolic syndrome) in IGB group versus behavioral modification alone group.16 Interestingly, a longitudinal and interventional study on 40 obese/overweight patients found a statistically significant improvement for the metabolic syndrome parameters and pulmonary function variables, leading to a reduction of the restrictive-ventilatory defect.17

Complications The rates of adverse events after Orbera IGB implantation were pooled from a recent review of 68 studies. The early removal rate for the Orbera IGB was approximately 7%. The most common side effects associated with device placement are nausea, vomiting, and abdominal pain, occurring in 33.7% of subjects. These symptoms generally resolved within 7 days of device placement. Serious side effects are rare, with an incidence of bowel migration of 1.4% and gastric perforation of 0.1%. Four deaths were associated with Orbera IGB treatment and are related to gastric perforation or an aspiration event.10

RESHAPE DUO INTEGRATED DUAL BALLOON SYSTEM ReShape Duo (Medical Inc., San Clemente, California) is made as double spheres filled with a total of 900 mL saline, to prevent migration if one sphere deflates. It is endoscopically placed in the stomach and retrieved following 6 months of treatment. The insertion and retrieval procedures average 8 minutes and 14 minutes in duration, respectively. A prospective, randomized, sham-controlled trial of ReShape Duo included 264 participants (ages between 21 and 60 years) with a baseline BMI ≥ 30 and ≤40 kg/m2. The patients were randomized to endoscopic Duo treatment plus diet and exercise (DUO patients) or a diet and exercise regime (DIET patients). After 24 weeks of treatment, DUO patients had the device retrieved. The primary endpoint of the study showed that the DUO patients had a 25.1 ± 1.6%EWL versus 11.3 ± 1.9%EWL of the DIET patients (p = 0.004). Comorbid conditions, such as glucose and lipid profile, blood pressure, and waist and hip circumference, showed significant improvement through the completion of 48 weeks of follow-up. During the study there were no deaths, no intestinal obstructions, and no gastric perforations. In 6% of DUO patients, device deflation was observed, without device migration. Gastric ulceration was found in 35% of treated patients. Although this rate significantly decreased after a minor modification to the device’s distal tip, the incidence of gastric ulceration remains consistent (Figure 69.2).18

LAST-GENERATION INTRAGASTRIC BALLOONS A class of new balloons just arrived on the market. This class includes a procedure-less balloon; this means that it does not require endoscopy or sedation for either placement or removal. The Elipse IGB (Allurion Company, Boston, Massachusetts) is a polyurethane balloon that a patient can swallow easily with a glass of water. This balloon is enclosed in a dissolvable vegetarian capsule attached at a thin catheter (about 75 cm long) used for filling it. Once the capsule is swallowed, its position is confirmed using an abdominal x-ray. If a patient has difficulty swallowing the capsule, a stylet can be fed through the

404  Intragastric balloon

Figure 69.3  Elipse balloon system.

Figure 69.2  Contrast medium abdominal-RX of Intragastric Re-Shape Ballon.

catheter to stiffen it. This balloon has a small radiopaque ring inside, which visualizes before filling it. When it arrives in the stomach, Elipse is filled with 550 cc of solution, and the catheter is removed by pulling it back. After 4 months the valve dissolves, the liquid is lost, and the empty balloon is evacuated spontaneously by the natural way (Figure 69.3). In our study,19 38 consecutive patients were enrolled (female/male 28/10, mean age 46.4 ± 10.6 years, mean weight 109.7 ± 21.9 kg, and mean BMI 38.6 ± 6.7 kg/m2). All patients swallowed the capsule, and after 4 months the balloon spontaneously emptied and was excreted through the digestive tract without upper endoscopy. No serious adverse events were observed during the treatment, 37 balloons were safely excreted in the stool, and 1 balloon was endoscopically removed due to a binge eating disorder not previously diagnosed. In particular, there were not gastric perforations, symptoms of ulceration, intestinal obstructions, or gastrointestinal hemorrhage. The most common adverse event after deployment was nausea. After 16 weeks, the mean weight loss was 12.7 kg, mean percent excess weight loss was 26%, and mean BMI reduction was 4.2 kg/m2. Total body weight loss was 11.6%. We also found a significant reduction in major comorbidities related to metabolic syndrome: blood pressure (p 1.5 cm apart) and >3 cm from radiating tip Perioperative antibiotics Avoid ablation near portal pedicle Avoid ablation near portal pedicle Avoid ablation near portal pedicle Avoid ablation on inferior vena cava Adequate distance between

No Yes Yes Yes Yes No

456  Ablative treatment of liver tumors

Table 75.4  Differences in physical properties of MWA and RFA Frequency Wavelength in tissue Mode of energy transfer

Primary heating mechanism

Secondary heating mechanism



375–480 kHz Meters AC current Requires multiple dispersive electrodes and closed circuit Resistive at highest current density (RF probe tip)

915 MHz–9.2 GHz Centimeters EM waves No circuit required

Conductive heating away from RF probe tip into surrounding tissue Responsible for most of the ablation volume

and a mortality rate of 0.15% and 0.23%, respectively, without significant differences.24 RFA has been the first and most widely used ablation technique for liver lesions. However, clinical study results have shown high rates of recurrences in larger lesions, but (a)


Figure 75.19  Transcutaneous MWA probes used during

minimally invasive ablations (a) can cause full-thickness burns to the abdominal wall insertion site if placed closer than 1.5 cm apart (b).

Dielectric heating within MW near-field (direct effect of EM waves on water molecules) Responsible for most of the ablation volume Conductive heating from MW near-field into surrounding tissue

recurrence rates up to 20% and higher have been reported even for lesions 3 cm or smaller. 25–31 These suboptimal results are being explained by the heat-sink effect seen with RFA, the difficulty of monitoring RFA with intraoperative US, and evidence that some tumor cells might even survive within the observed ablation zone.32–35 The high recurrence rates for thermal ablation of liver lesions seen in the initial experience with RFA have led surgeons to restrict ablation to lesions around 3 cm or less. Several studies have shown that local recurrence rates markedly increase with ablation of hepatic lesions over 3 cm.18,29,30,36,37 Randomized studies comparing RFA and MWA are lacking. A large analysis of all available randomized trials comparing RFA for hepatocellular cancer to surgical resection, to no intervention, to placebo, and to other nonsurgical interventions published in 2013 demonstrated superiority of surgical resection over RFA regarding survival. RFA was also found to carry less complications and shorter hospital stays compared to surgery. RFA was found to be superior to percutaneous alcohol injection for survival. There was not enough data from randomized studies to evaluate superiority of RFA versus MWA or other ablation techniques. The data did not allow any conclusion regarding the role of RFA versus no intervention, chemotherapy, or liver transplantation. 38 A recent retrospective matched cohort analysis comparing MWA and RFA for colorectal cancer metastases of the liver showed a significantly lower initial local recurrence rate for MWA (6% versus 20%) and predicted 2-year recurrence rates (7% versus 18%).39 This confirmed findings by other groups comparing RFA and MWA, showing very low local recurrence rates for MWA of less than 10%.40 Similar results were obtained in a Phase II multi-institutional study demonstrating local recurrence rates after liver lesion MWA of 4% with 47% of living patients showing no evidence of disease at 19 months mean follow-up. Eighty-seven patients underwent 94 liver ablations with the majority performed open and laparoscopically (53%). The average liver lesion size was 3.6 cm (range 0.5–9.0 cm). Individual lesion local recurrence rate was 2.7% (six lesions).41 These results would be very difficult to match with current RFA technology, and it appears that

Videos 457

MWA does have some advantage in terms of lesser local recurrence rates after treatment of liver lesions. Although most of the reported experience on ablation of liver lesions comes from studies with RFA, MWA is gaining acceptance among surgeons because of its favorable results, despite the lack of level 1 evidence.

Results for hepatocellular carcinoma Studies evaluating MWA and RFA specifically in the setting of laparoscopic ablations of liver tumors have shown excellent results equivalent to open ablation procedures. Hepatocellular carcinoma (HCC) is particularly suited for the use of minimally invasive thermal ablation. This is due to the relative small size at diagnosis resulting from increased surveillance of patients at risk and to the fact that HCC carries a relatively higher water content compared to the often fibrotic or cirrhotic liver surrounding it. Most HCCs are diagnosed at the relatively small size of 3 cm or less and thus present with a relative sharp demarcation from the surrounding liver parenchyma without signs of overt invasive growth. Several groups have successfully proved the efficacy of microwave ablation in the treatment of hepatocellular carcinoma.39,40 Incomplete ablation rates for laparoscopic MWA and RFA of HCC vary from 5.6% to 13%. Local recurrence rates are reported between 2.9% and 22%.42–45 Published survival rates after laparoscopic thermal ablation for HCC are around 70%–80% at 1 year and 20%–40% at 3 years.46–48

Results for colorectal liver metastases Liver ablation results for colorectal liver metastases (CRLMs) are less impressive, as these lesions are more difficult to ablate than HCC due to their relative lack of water content and location near large vessels. However, since only 20% of CRLMs are surgically resectable, thermal ablation modalities play an important role in their treatment. Local recurrence rates after laparoscopic ablation of CRLM range from 9.2% to 34%. It has been shown that obtaining larger ablation margins of 2 cm or more reduces the local recurrence rate after CRLM ablation.49–52 Survival rates after laparoscopic CRLM ablation do not reach those observed after resection. For tumors 3 cm or less, the reported survival rate after laparoscopic ablation is 47%53 An interesting study compared survival rates after ablation of CRLM deemed either resectable or unresectable. Those found retrospectively by image analysis to be technically resectable had a 5-year survival rate of 48.7% versus 18.4% for those deemed unresectable.54

ablation due to their very high water content and usually sharp demarcation to the surrounding liver parenchyma. Benign liver lesions in general are not good candidates for thermal ablation as the therapeutic intervention becomes relevant at a relatively large size at which ablation is unlikely to be successful. Hemangiomas and liver cysts should not undergo thermal ablation for treatment. Thermal ablation modalities have evolved into a standard therapy for liver lesions. MWA is increasingly utilized as the primary modality because of its apparent advantages over RFA and other modalities such as cryotherapy and alcohol injections. Single-center studies have demonstrated significant improvements in completeness and local recurrence for MWA,55 although this has never been proven with a prospective, randomized trial. Appropriate patient selection, excellent knowledge of the used ablation system, and image-guidance modality are critical for a successful liver ablation, open or laparoscopic.

CONCLUSION Laparoscopic ablation of liver lesions is a rapidly advancing field in hepatobiliary and oncologic surgery. Although the technology has been available for over 100 years, major advances and development into standards of practice have occurred only recently. The most advanced systems today rely on microwave energy, which provides the most consistent and reproducible results within a very effective time frame. However, these systems are in constant evolution; therefore, the laparoscopic surgeon using these techniques in practice needs to stay flexible and abreast of the technological changes in this field.


Video 75.1  Accurate placement of an active RFA probe

during an open liver ablation procedure and demonstration of the “parallel” placement technique (https://youtu.be/tlMwZocTLTw).

Video 75.2  Parallel US guidance of an MWA probe for ablation of a primary hepatocellular cancer in a cirrhotic liver (https://youtu.be/APgYpKgVcPI).

Video 75.3  Laparoscopic US-guided placements of an

MWA probe in 45° and 90° angles (https://youtu.be/8Jfw1dfC8jk).

Video 75.4  Appropriate laparoscopic placement of MWA

antenna into target lesion at an angle (https://youtu.be/ix7INsn9R1I).

Results for other liver lesions Results for other liver lesions such as secondary metastases from neuroendocrine tumors or other organs are difficult to evaluate because of lack of data. It is noteworthy that neuroendocrine metastases are particularly suited for thermal

Video 75.5  The simultaneous laparoscopic placement of

two MWA probes for the ablation of a larger hepatic tumor. Please note the device that maintains the safety distance of at least 1 cm at the skin insertion site to prevent skin burns (https://youtu.be/​ 603A3JTiCIc).

458  Ablative treatment of liver tumors

REFERENCES 1. D’arsonval JA. CR Soc Biol 1891;43:283–6. 2. Organ LW. Appl Neurophysiol 1976;39:69–76. 3. McGahan JP et al. Invest Radiol 1990;25:267–70. 4. Rossi S et al. Tumori 1990;76:54–7. 5. Siperstein AE et al. Cancer J 2000;6(Suppl. 4):5293–303. 6. Pereira PL et al. Radiology 2004;232:482–90. 7. Chang CK et al. Ann Surg Oncol 2002;9:594–8. 8. Ahmed M et al. Radiology 2011;258(2):351–69. 9. Padma S et al. J Surg Oncol 2009;100(8):619–34. 10. Bhardwaj N et al. Surg Endosc 2010;24(2):254–65. 11. Brace CL. Crit Rev Biomed Eng 2010;38(1):65–78. 12. Gabriel C et al. Chem Soc Rev 1998;27;213–24. 13. Bertram JM et al. Biomed Eng Online 2006;5:15. 14. Hope WW et al. J Gastrointest Surg 2008;12(3):463–7. 15. Hope WW et al. J Surg Res 2009;153(2):263–7. 16. Sindram D et al. J Int Oncol 2010;3(1):46–52. 17. Kuvshinoff BW et al. Surgery 2002;132:605–11. 18. Curley SA et al. Ann Surg 2000;232:381–91. 19. Pawlik TM et al. Ann Surg Oncol 2003;10:1059–69. 20. Lu DS et al. J Vasc Interv Radiol 2003;14(10):​1267–74. 21. Patterson EJ et al. Ann Surg 1998;227(4):559–65. 22. Wright AS et al. Radiology 2005;236(1):132–9. 23. Weber SM et al. Ann Surg Oncol 2000;7:643–50. 24. Bertot LC et al. Eur Radiol 2011;12:2584–96. 25. McGahan JP et al. Invest Radiol 1990;25:267–70. 26. McGahan JP et al. J Vasc Interv Radiol 1992;3:291–7. 27. Sanchez R et al. Surgery 1997;122:1147–55.

28. Jiao LR et al. Am J Surg 1999;177:303–6. 29. Siperstein A et al. Ann Surg Oncol 2000;7:106–13. 30. Curley SA et al. Ann Surg 1999;230:1–8. 31. Bilchik AJ et al. Cancer J Sci Am 1999;5:356–61. 32. Goldberg SN et al. J Vasc Interv Radiol 1998;9:101–11. 33. Huang HW. Med Phyd 2013;40:073303. 34. Cha CH et al. AJR Am J Roentgenol 2000;175:705–11. 35. Solbiati L et al. Radiology 1997;202:195–203. 36. Liu CH et al. Ann Surg Oncol 2014;21(9):3090–5. 37. Gillams AR et al. Abdom Imaging 2005;30:419–26. 38. Weis S et al. Cochrane Database Syst Rev 2013;12:CD00304. 39. Correa-Gallego C et al. Ann Surg Oncol 2014;21(13):4278–83. 40. Martin RC et al. Ann Surg Oncol 2010;17(1):171–8. 41. Iannitti DA et al. Hpb 2007;9(2):120–4. 42. Pepple PT et al. Semin Intervent Radiol 2014;31(2):125–8. 43. Groeschl RT et al. Ann Surg 2014;259(6):1195–200. 44. Swan RZ et al. J Gastrointest Surg 2013;17(4):719–29. 45. Santambrogio R et al. J Surg Oncol 2005;89(4):218–25. 46. Swan RZ et al. J Gastrointest Surg 2013;17(4):719–29. 47. Berber E et al. Surg Endosc 2005;19(5):710–4. 48. Ballem N et al. HPB (Oxford) 2008;10(5):315–20. 49. Aksoy E et al. Surgery 2013;154(4):748–52. 50. Weng M et al. PLOS ONE 2012;7(9):e45493. 51. Berber E et al. Ann Surg Oncol 2008;15(10):2757–64. 52. Kennedy TJ et al. J Surg Oncol 2013;107(4):324–8. 53. Aksoy E et al. Surgery 2013;154(4):748–52. 54. Hammill CW et al. Ann Surg Oncol 2011;18(7):1947–54. 55. Martin RC et al. Ann Surg Oncol 2010;17(1):171–8. 56. Rhim H et al. J Clin Ultrasound 1999;27:221–9.

76 Robotic approach to hepatic resections SUSANNE WARNER AND YUMAN FONG

INTRODUCTION Liver surgery was once considered a dangerous endeavor with prohibitive risks except in dire circumstances. However, with improvements over the last 30 years in anesthesia and critical care, as well as enhanced preoperative imaging and thereby improved surgeon preparation for anatomical considerations of resection, liver resection has become a safe tool for a number of hepatic maladies with a mortality rate of less than 1% in the modern era.1,2 However, the morbidity of open liver resection remains considerable with rates as high as 42%–45% in major series,2,3 and postoperative morbidity has been associated with adverse disease-specific survival.3,4 While morbidity of major liver resection is a significant consideration regardless of technique, minimally invasive liver resection has the potential to minimize adverse events, and portends decreased estimated blood loss, decreased length of stay, and perioperative pain.5–9 The case for minimally invasive techniques in peripheral liver resections (segments II, III, V, and VI) is clear, and most experts agree, this should be the standard of care in the current era.10,11 As worldwide experience with minimally invasive hepatic resection grows, advanced minimally invasive resections are increasingly being performed, and evidence is improving for the safety and feasibility of minimally invasive major hepatectomy (resection of greater than or equal to four segments), and for minimally invasive resection of more cumbersome lesions, like those in segments I and VII.11–14 While laparoscopy is gaining acceptance for hepatobiliary resections, robotic surgery offers unique advantages over laparoscopy, such as enhanced ergonomics, improved range of motion with wristed movement, elimination of tremor, three-dimensional visualization, and an ever-growing armamentarium of tools that are well suited to many different arenas of surgery. Robotic surgery also offers excellent counter points for many of the arguments against minimally

invasive liver surgery. As the “great equalizer,” robotic surgery eliminates tremor and muscular fatigue that can come with operating for long periods laparoscopically, and there are several publications to suggest that the learning curve from open to robotic surgery, while steep, is more quickly surmountable, making the skillset required for advanced robotic surgery much more accessible than that required for laparoscopic intervention.15 Disadvantages of robotic liver surgery include a high fixed cost of the robotic surgical system, and the absence of haptic feedback. However, innovative new platforms are currently in development and with them will come the elimination of a robotic monopoly and hopefully decreased overall systems costs. A review of robot liver surgery published in 2013 found that fewer than 300 cases with credible follow-up and clinical characteristics had been published.16 Other authors have shown that use of a robotic platform in the United States has changed dramatically over the last 8–10 years and is likely to do so in the coming years as well.17 This chapter reviews the current literature regarding robotic liver resection and presents tools utilized to achieve resection.

ROBOTIC VERSUS LAPAROSCOPIC TECHNIQUES IN THE LITERATURE In one of the few currently available matched comparisons between laparoscopic and robotic liver resection, Tsung and colleagues reviewed their own experience comparing 113 laparoscopic matched control patients with 57 robotic liver resection patients and found that the robotic cohort contained substantially more major hepatectomies (37%) than the laparoscopic cohort (7%), and that robotic techniques facilitated pure minimally invasive approach in 93% of attempted patients, whereas a hand-assisted or hybrid approach was utilized in 51% of laparoscopic cases.18 No differences in major complications were seen, and R0

460  Robotic approach to hepatic resections

resection was achieved in 95% of robotic surgeries and 92% of laparoscopic surgeries. However, when robotic and laparoscopic minor liver resections (defined as resection of three or fewer liver segments) were compared, robotic intervention conferred significantly higher estimated blood loss (EBL) (mean 285 versus 50 mL, p = 0.011) and significantly longer operating room time (198 minutes versus 163 minutes, p 6 cma • Cirrhosis/fibrosis presenting technical difficulties with parenchymal transection • Vascular involvement requiring primary repair • Extensive prior abdominal surgery • History of radiation or cholangitis with anticipated periportal inflammation or fibrosis a b

Absolute contraindications • Inability to tolerate pneumoperitoneum • Pulmonary hypertension • Severe chronic obstructive pulmonary disease • Untreated visceral or aortic aneurysmal disease • Other cardiopulmonary comorbidities or ASA>3 • Insufficiently skilled surgeonb • Major vascular involvement requiring extensive reconstruction • Prior extensive hepatic surgery • Child’s B or C cirrhosis

Tumor greater than 6 cm can be considered if peripherally located and/or exophytic. Initial attempts at complex resection should be performed in the presence of an experienced robotic surgeon.

Indications and techniques of robotic liver resection  461

practice to choose position and port placement based on anatomic considerations of resection. For instance, higher lesions may require more reverse Trendelenburg and high right-sided lesions may necessitate rightward shift of ports and even left lateral decubitus positioning. Body habitus must also be considered for each particular patient. Thus, more obese individuals may require ports placed in a more supraumbilical distribution, and more slender patients may require more infraumbilical port alignment. In general, for right hepatic resection, robot docking is performed over the right shoulder, whereas for left hepatic resections the robot is docked over the patient’s head or left shoulder depending on patient habitus and tumor location. Typical room setup and port placements are shown in Figures 76.1 and 76.2. Any robotic liver surgical procedure will have six general phases: (1) Laparoscopic exploration abdominal entry and assessment. During this phase, laparoscopic ultrasonography can be performed prior to robot docking as a part of initial exploration to confirm preoperative imaging

findings and to establish anticipated planes of resection. Alternatively, if a “drop-in” ultrasound probe is put to use, the robot can be docked after initial abdominal surveillance and port placement. (2) Dissection of portal structures is dictated by disease process and location and achievement of vascular control where appropriate. This includes inflow occlusion via selective ligation of portal vein and hepatic arterial branches or Pringle maneuver, and outflow occlusion if sectionectomy or lobectomy is anticipated with encircling and/or ligation of appropriate hepatic vein(s). (3) Hepatic mobilization can be achieved employing a variety of different robotic tools—typically a mix of sharp and thermal dissection with or without a robotic or laparoscopic energy sealing device. (4) Parenchymal transection. As with laparoscopic liver surgery, many groups employ an energy device for capsular entry and then turn to laparoscopic s­ taplers to contain larger vessels and bile ducts. This is guided by ultrasonography. Our practice is to mark out the plane of transection with robotic monopolar scissors Surgeon console

Robot patient cart

Robot vision cart


sthe cart sia

Back table


Figure 76.1  Operating room setup for robotic liver resection.

462  Robotic approach to hepatic resections (a)

R3 R2

R1 C A1



Figure 76.2  Typical port placement for hepatic resec-

tion. (C, camera. R1, R2, R3, robot arms 1, 2, and 3; A1, assistant port, 12 mm; A2, optional second assistant port, 5 or 12 mm. Can shift entire setup rightward for posterior lesions, including camera off midline to patient’s right, with patient in modified left lateral decubitus position as needed. R2 and R3 can be adjusted based on side of lesion, patient body habitus, and liver size and shape.)

or hook (Figure 76.3a and b). The first centimeter or so of parenchymal transection is then performed using monopolar energy. As dissection deepens, a robotic energy device can be used for clamp/crushing as well as vessel and duct sealing. The fenestrated bipolar grasper can assist with any small structures that may be torn (Figure 76.3c). Ultimately, larger pedicles are skeletonized and laparoscopic staplers can be employed. (5) Specimen extraction using a laparoscopic retrieval bag in order to keep the specimen entirely together. If the specimen is large, fascial closure of the extraction site will be necessary to facilitate reinsufflation. (6) Evaluation of resection bed for hemostasis and presence of bile. As with any minimal access surgery, it is helpful to establish predefined criteria for when or if one would convert to an open technique. While circumstances for each patient and each liver are of course unique, general criteria for conversion should include patient instability requiring efficient case completion that is facilitated by open techniques, excessive (>500 mL) blood loss not controllable via robotic techniques or requiring manual compression, unexpected hilar injury during dissection compromising future liver remnant, and cases with unclear anatomy.

OUTCOMES OF ROBOTIC LIVER SURGERY The data here are as yet extremely limited. However, in currently available literature, robotic surgery appears to confer similar advantages as laparoscopy, like decreased length of stay, decreased morbidity, faster return to function, lower narcotic requirement, and in some studies significantly lower EBL,18,26,27 all without compromising oncologic outcomes as


Figure 76.3  Parenchymal transection. (a and b)The transection plane is marked off with robotic scissors or other monopolar cautery source as guided by ultrasound to achieve appropriate margins. (c) Robotic energy device is used for deeper parenchymal division as a clamp/crush and sealing device. Fenestrated bipolar is used to seal smaller cut service vessels and ducts.

compared to open surgery in most instances.19 Currently the absolute patient safety data are unknown. Many surgeons make initial forays into utilization of new techniques, and some have disastrous complications, many of which go

References 463

unreported. An excellent review of available robotic pancreatic surgery literature details inconsistencies even among reported cases.28 For robotic liver surgery, the data are even more sparse.14 Those endeavoring to build a robotic program should ensure that patient safety is prioritized.

REFERENCES 1. Belghiti J et al. J Am Coll Surg. 2000;191(1):38–46. 2. Jarnagin WR et al. Ann Surg 2002;236(4):397–406, ­discussion 7. 3. Ito H et al. Ann Surg 2008;247(6):994–1002. 4. Laurent C et al. Br J Surg 2003;​90(9):1131–6. 5. Nomi T et al. Br J Surg 2015;102(3):254–60. 6. Belli G et al. Br J Surg 2009;96(9):1041–8. 7. Endo Y et al. Surg Laparosc Endosc Percutan Tech 2009;19(5):​ e171–4. 8. Sarpel U et al. Ann Surg Oncol 2009;16(6):1572–7. 9. Aldrighetti L et al. J Surg Oncol 2010;102(1):​82–6. 10. Buell JF et al. Ann Surg 2009;250(5):825–30.

11. Nguyen KT et al. Ann Surg 2009;250(5):​831–41. 12. Gringeri E et al. Surg Laparosc Endosc Percutan Tech 2014;24(6):e233–6. 13. Koffron AJ et al. Ann Surg 2007;246(3):385–92, discussion 92–4. 14. Abood GJ et al. J Hepato-Biliary-Pancreat Sci 2013;​ 20(2):151–6. 15. Hayn MH et al. Eur Urol 2010;58(2):​197–202. 16. Ho CM et al. Surg Endosc 2013;27(3):732–9. 17. Barbash GI et al. N Engl J Med 2010;363(8):​701–4. 18. Tsung A et al. Ann Surg 2014;​259(3):549–55. 19. Lai EC et al. Am J Surg 2013;205(6):697–702. 20. Zureikat AH et al. Adv Surg 2014;48:77–95. 21. Hassan SO et al. J Surg Educ 2015;72:​592–9. 22. Reiley CE et al. J Thorac Cardiovasc Surg 2008;​135(1):196–202. 23. Bao PQ et al. J Gastrointest Surg 2014;18(4):682–9. 24. Lai EC et al. Int J Surg 2012;10(1):11–5. 25. Choi GH et al. Surg Endosc 2012;26(8):2247–58. 26. Giulianotti PC et al. Surgery 2011;149(1):​29–39. 27. Reddy SK et al. World J Surg 2011;35(7):1478–86. 28. Strijker M et al. HPB 2013;15(1):1–10.

77 Laparoscopic staging for pancreatic malignancy AMMARA A. WATKINS AND MARK P. CALLERY

OVERVIEW Pancreatic cancer is a devastating disease with 5-year survival estimates approaching less than 6% for patients with pancreatic ductal carcinoma. Surgery remains the mainstay treatment for resectable disease and confers some survival advantage to the patient. Accurate staging is therefore critical in treatment. The majority of patients with pancreatic cancer undergo radiological staging via computed tomography (CT) imaging. However, a large subset of patients initially deemed resectable (approximately 10%–20%) undergoes unnecessary laparotomy because of underestimation of the extent of cancer after CT staging.1,2 Modern CT imaging appears able to capture unresectable disease well but falls short in predicting resectable disease. Diagnostic laparoscopy was developed as an add-on test to CT to reduce unnecessary laparotomy and subsequent morbidity. 3 While accumulating single institution series have largely favored the use of diagnostic laparoscopy in staging pancreas cancer, there remains significant controversy surrounding its routine or selective use. Those who embrace diagnostic laparoscopy believe that, should unresectable disease be found, palliation is best pursued nonoperatively. Others believe that palliation is best achieved via a surgical, open technique. This chapter focuses on the highest-level data and expert consensus guidelines available on the subject in aims to guide management for patients with pancreatic cancer.

PREOPERATIVE COMPUTED TOMOGRAPHY IMAGING Currently, multidetector CT with three-dimensional reconstruction including vasculature is the preferred method to preoperatively stage pancreatic cancer and identify patients eligible for resection with curative intent.4–6

This is consistent with expert consensus and National Comprehensive Cancer Network guidelines.4,7 Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans are increasingly used as an adjunct to CT scans. However, data are accumulating on their capabilities of determining resection. The use of MRI and PET scans has not demonstrated cost-benefit to warrant routine use and remains controversial in preoperative staging.8 CT remains the gold standard despite some shortcomings. CT has been shown to have a high predictive value of unresectability (90%–100%) with a slightly lower predictive value of resectability (76%–90%).4 This is attributed to CT’s inability to detect occult liver metastasis and peritoneal spread.4 This problem is compounded by the presence of benign small liver lesions such as cysts, hemangiomas, or bile duct hamartomas in normal patients.

PREOPERATIVE MAGNETIC RESONANCE IMAGING Given MRI’s greater soft tissue penetration, MRI does have some advantage over CT in specific scenarios for preoperative diagnosis and staging. In these situations, MRI is a useful adjunct to preoperative CT, particularly in further characterizing indeterminate lesions. MRI is superb in characterizing small masses of the pancreas, specifically those that do not deform the contour of the pancreas or are less than 2 cm.9 It is also useful in characterizing a large pancreatic head without a distinct, visualized mass on CT and in distinguishing chronic pancreatitis and groove pancreatitis from a suspicious tumor.10 Isoattenuating pancreatic cancers and fatty infiltrations of the pancreatic head confused for tumors can also be more reliably diagnosed with MRI.9 Finally, MRI is also helpful in characterizing small hepatic lesions that are difficult to distinguish from benign lesions on CT.9

Contemporary evidence-based analysis  465

DIAGNOSTIC LAPAROSCOPY Studies have demonstrated that approximately one-third of patients presumed to be resectable based on CT imaging will be disqualified for surgery at the time of laparoscopic staging.11,12 Despite the apparent benefits, the value of staging laparoscopy is not universally accepted. Opinions vary from recommending routine use to not performing it under any circumstances. A key goal in patients with advanced pancreatic cancer is to avoid laparotomy if possible and facilitate care into nonoperative palliation to protect quality of life.13 Diagnostic laparoscopy aims to reduce unnecessary laparotomies by providing more in-depth assessment of a patient’s cancer stage. A periumbilical port is placed to insert a 30° angled scope. Assisting trocars in the upper midabdomen or right upper quadrant may also be placed to help visualize all structures. During the procedure, key areas of tumor spread are examined. This includes the falciform ligament, the lesser sac, underneath the transverse mesocolon, along the surface of the bowel, the root of the ligament of Treitz, along the paracolic gutters and pelvis. Ultrasound can also be utilized to identify intrahepatic metastatic lesions, the degree of tumor involvement on the portal vein, superior mesenteric vein, porta hepatis, major arterial involvement, and pathologically involved lymph nodes beyond the boundaries of dissection. Should biopsies be needed to guide neoadjuvant therapy, laparoscopic ultrasound can provide additional visualization of the biopsied site. In the event of locally advanced disease, CyberKnife gold fiducial seeds may also be placed as future targets for stereotactic

Table 77.1  Summary of findings of Allen et al.


radiation. Cytological analysis can also be obtained during diagnostic laparoscopy, although positive results are difficult to evaluate, as there is variation of accuracy at predicting disseminated disease. Furthermore, the results are not usually available in real time. Procedure-related morbidity from diagnostic laparoscopy ranges from 0% to 4%.14 Complications are primarily minor and include wound infections and port site bleeding. Mortality rates are 0% in the majority of the literature.14 Conversions to open are rare,15 and hospital stay is typically brief. 3 As compared to open laparotomy, diagnostic laparoscopy has shorter hospital stay, lower costs, and shorter times to initiation of chemotherapy.14,17 Early concerns of port-site recurrence after laparoscopic procedures for cancer patients have now been dismissed. Numerous studies report a 0%–2% incidence of port-site recurrences which is similar to open explorations for cancer patients.14

CONTEMPORARY EVIDENCE-BASED ANALYSIS The highest-level available data are systematic reviews of cohort studies.14,18 The most recent systematic review is within the Cochrane Database assessing accuracy of diagnostic laparoscopy following CT scanning.18 Data from the systematic review are summarized in Table 77.1. Fifteen studies (1,015 patients) were included in this meta-analysis. Median pretest probability for unresectable disease was 40.2% across all studies (indicating 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease

systematic review


Patients aged 15–87 years with potentially resectable pancreatic or ampullary carcinoma on CT


Centers in the United States, Germany, United Kingdom, Japan, and Israel

Index test

Diagnostic laparoscopy with histologic confirmation

Number of studies


Summary sensitivity

68.7% (95% CI 54.3%–80.2%)

Overall risk of bias


Pretest probability from included studies

Post-test probability of unresectable disease for Percentage of patients for whom patients with a negative test result (95% CI) unnecessary laparotomy may be avoided 6.1 (4.2–9.2) 11.3 13.9 (9.8–20) 20.3 17.3 (12.4–24.5) 23.0 34.4 (26.2–44.8) 28.4 58.2 (48.6–58.3) 23.6

Minimum = 17.4 Lower quartile = 34.2 Median = 40.3 Upper quartile = 62.8 Maximum = 81.8 Interpretation

With pretest probabilities of 17%, 40%, and 82%, adding laparoscopy to CT scan for the preoperative staging of pancreatic cancer avoids 11, 23, and 24 unnecessary laparotomies out of 100 laparotomies. These pretest probabilities are the minimum, middle, and maximum values obtained from included studies.

Source: Modified from Allen VB et al. Cochrane Database Syst Rev 2013;11:CD009323.

466  Laparoscopic staging for pancreatic malignancy

at laparotomy). The summary sensitivity for diagnostic laparoscopy was 68.7% (95% CI, 54.3%–80.2%). The calculated post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12–0.24). These data indicate that if a patient is said to have resectable disease after CT scanning and diagnostic laparoscopy, there is only a 17% probability that their cancer will be unresectable. This is in comparison to a 40% probability to the standard practice of CT scan staging alone. A subgroup analysis of patients with pancreatic cancer yielded similar results.18 The post-test probability of unresectable disease after being considered resectable after CT scanning and diagnostic laparoscopy was 18% compared to 40% for those receiving CT scan alone.18 This is to say that on average, diagnostic laparoscopy with subsequent histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection with curative intent is planned. This review is not without weaknesses. The majority of studies have low methodological quality, and there is notable heterogeneity between the studies. Additionally, 11 of the 15 articles were conducted more than 10 years ago.18 This may have implications for the systematic review’s applicability to modern, improved CT imaging capabilities. That would also presume that CT capacity to detect occult metastasis has improved over the same time period; however, this remains in question. Nevertheless, this is the highestlevel and most current data available in guiding treatment that is consistent with the only other systematic review on the topic. 14 Prior systematic review has found diagnostic ­laparoscopy may avoid unnecessary laparotomy in 4%–36% of patients.14

EXPERT CONSENSUS GUIDELINES The Expert Consensus statement4 on the topic advocates selective laparoscopy rather than routine use on the basis of clinical predictors that optimize diagnostic yield.19 Larger tumors and tumors of the neck, body, and tail of the pancreas that are more likely to metastasize are recommended to undergo staging laparoscopy.20 Additionally, equivocal masses on CT and patients presenting with high carbohydrate antigen (CA) 19-9 often signify metastatic disease.16 It is therefore recommended that selective laparoscopy be pursued among patients with characteristics highlighted in Table 77.2. For patients with locally advanced unresectable pancreatic cancer without radiographic evidence of distant metastasis, staging laparoscopy may also be used to rule out subclinical metastatic disease to optimize treatment selection. Data are accumulating on the usefulness of peritoneal cytology at the time of diagnostic laparoscopy. When positive cytology does upstage the patient’s disease to AJCC

Table 77.2  Patient characteristics that would benefit from selective laparoscopy

• Pancreatic head tumors >3 cm • Tumors of the pancreas body and tail • Equivocal findings on CT • High CA 19-9 levels (>100 U/mL) • Worrisome clinical features (marked weight loss and/or pain, hypoalbuminemia) Source: Data from Callery MP et al. Ann Surg Oncol 2009;16:1727–33.

Stage IV, this affects disease progression and survival. Diagnostic accuracy of cytology is variable at centers, and many surgeons remain skeptical. The current expert consensus recommendation is that further studies on molecular and genetic marker analysis are needed before positive cytology results are treated as Stage IV disease.

SUMMARY AND OVERALL RECOMMENDATION Based on the available highest-level data and expert consensus guidelines, staging laparoscopy with ultrasound should be selective. It should be pursued for patients with pancreatic head tumors larger than 3 cm, tumors located in the body or tail of the pancreas, high CA-19-9 levels, and those with CT scans representing equivocal metastatic disease.

REFERENCES 1. Lillemoe K et al. Ann Surg 1999;230:​328–30. 2. Mayo SC et al. J Am Coll Surg 2009;​208:87–95. 3. Stefanidis D et al. Ann Oncol 2006;17:189–99. 4. Callery MP et al. Ann Surg Oncol 2009;16:​1727–33. 5. Reinhold C. J Gastrosintest Surg 2002;6:133–5. 6. Lu DS et al. Am J Roentgenol 1997;168:1439–93. 7. Tempero M et al. J Natl Compr Canc Netw 2010;8:972–1017. 8. Goh B. Ann Surg 2006;243:709–10. 9. Raman SP et al. Cancer J 2012;18:511–22. 10. Wong JC et al. Clin Gastroenterol Hepatol 2008;6:1301–8. 11. Conlon C et al. Ann Surg 1996;223:134–40. 12. Jimenez R et al. Arch Surg 2000;​135:414–5. 13. Potter M et al. Surg Oncol 2000;9:103–10. 14. Chang L et al. Surg Endosc 2009;23:231–41. 15. Hunerbein M et al. Surg Endosc 1998;12:921–5. 16. Karachristos A et al. J Gastrosintest Surg 2005;9:1286–92. 17. Jayakrishnan TT et al. HPB 2015;17:​131–9. 18. Allen VB et al. Cochrane Database Syst Rev 2013;11:​ CD009323. 19. Pisters P et al. Br J Surg 2001;88:325–37. 20. Vollmer C et al. Ann Surg 2002;235:1–7.

78 Robot-assisted minimally invasive pancreaticoduodenectomy ALESSANDRA STORINO, TARA S. KENT, AND A. JAMES MOSER

INTRODUCTION Surgical care of patients with periampullary tumors has been in the phase of evolution since Walter Kausch first pioneered pancreaticoduodenectomy (PD) for ampullary carcinoma in 1909. The first phase consisted of major revisions to Kausch’s original procedure, which made surgical resection of the pancreatic head technically feasible: Whipple’s introduction of a single-stage technique to restore gastrointestinal (GI) continuity in 1935; and Longmire’s incorporation of pylorus preservation in 1978. The second phase began in the 1970s with rapid reductions in postoperative mortality made possible by improvements in intensive care medicine at specialized centers of excellence.11 The third phase began in 1994 when Gagner and Pomp performed the first laparoscopic PD, which was clearly the most ambitious application of minimally invasive surgery since its inception by Muehl in 1984.17 Although recent series of minimally invasive PD demonstrate outcomes comparable to open PD in selected patients, widespread adoption of laparoscopic techniques has been delayed and remains concentrated at specialized centers.1 The slow implementation of laparoscopic PD demonstrates the need to update surgical training for complex surgical procedures and overcome design limitations of current laparoscopic instrumentation. These instrument limitations have been partially reduced by robotic technologies incorporating magnified stereoscopic visualization, elimination of the surgeon’s tremor, and reproduction of the natural motion of intracorporeal instruments. Computer-controlled instrumentation allows complex resections and reconstructions to be performed with minimally invasive techniques duplicating traditional open methods. The first reports of robot-assisted pancreatic resection appeared in 2003. Giulianotti et  al.

published results on 13 pancreatic resections in Europe4, while Melvin et al. published a description of a robotic resection of a pancreatic neuroendocrine tumor in the United States.5 Subsequent series of robot-assisted PD demonstrate the safety and feasibility of this technical approach, and emerging comparative effectiveness data between open and minimally invasive PD demonstrates preliminary equivalence.2

SAFETY AND SELECTION Safety and transparency of surgical outcomes are critical during early adoption of a new surgical procedure. All potential candidates for robotic PD should participate in a registry approved by an institutional review board (IRB). Procedures should be performed by an expert team familiar with open PD and capable of venous resection and reconstruction whenever indicated. We advise creating a surgical team with advanced minimally invasive skills and believe that proficiency in robot-assisted PD is not achieved until approximately 50 cases have been performed. Surgical trainees are incorporated into the surgical team in a stepwise fashion, as their training and expertise with robotic technology permit. The positioning challenges and access issues created by the current generation of large, immobile robotic instruments deserves comment. Patients with active cardiovascular disease and renal insufficiency are not ideal candidates. The procedure requires reverse Trendelenburg positioning with its effects on preload, urine output, and blood pressure. Bleeding from major vessels in this position is potentially hazardous and must be controlled rapidly without undocking. Proper preparation by the anesthesia team is required because the patient is not accessible once the robot is positioned. Adequate intravenous (IV) access, invasive monitoring lines, and

468  Robot-assisted minimally invasive pancreaticoduodenectomy

endotracheal and nasogastric intubation must be obtained and safeguarded during the procedure. Finally, the expected pathology and anatomy of the underlying lesion must be considered. It is a general rule that the most difficult resections require the simplest reconstructions. For example, obstructing lesions causing biliary and pancreatic duct dilation and parenchymal fibrosis are associated with the least challenging reconstructions but raise the risk of adherence to the portal vein (PV) with increased risk of venous injury.

THE PREOPERATIVE CHECKLIST The patient is placed in the supine position on a split leg table to maximize instrument access for the seated laparoscopic surgeon (Figure 78.1). The robotic console should be located to permit a direct line of sight between the robotic surgeon, the laparoscopic surgeon, and the scrub technician for communication purposes. This cannot be emphasized enough, as remote surgery creates uncharacteristic communication challenges for the surgical team. A nasogastric tube and urinary catheter are required. The right arm is tucked to prevent collisions between the patient’s shoulder and the robot. The patient’s left arm is outstretched to afford anesthesia access to the pulse oximeter, blood pressure cuff, and arterial line. Body temperature is maintained with an upper body warming blanket.

TROCAR PLACEMENT Trocar placement is designed to facilitate the procedure that occurs in three phases: staging laparoscopy, laparoscopic mobilization of the pancreatic head, and robot-assisted resection and reconstruction. Once resectability is confirmed, seven ports are required (Figure 78.2).

Figure 78.2  Suggested location of ports for robot-

assisted pancreaticoduodenectomy. A 5.5 mm optical separator is initially inserted in the left upper quadrant and replaced later with a robotic cannula (R1); the remaining two robotic ports (R2, R3) are located in the right abdomen, with a flexible liver retractor elevating segment 4 through the right anterior axillary line trocar (L). The camera port is the 12 mm epigastric trocar inserted to the right of the midline (C). The laparoscopic surgeon operates two assistant ports: a 5 mm trocar (A1) in the right lower quadrant, and a 15 mm trocar in the left lower quadrant (A2) typically inserted through GelPOINT access device for specimen extraction. The LigaSure is operated from (A2).

Peritoneal entry is achieved with a 5 mm optical separator in the left subcostal region. This later becomes a robotic trocar (R1). A 12 mm camera port is inserted 2–3 cm to the right of the midline superior to the umbilicus to expose the lateral border of the portal vein and uncinate process (C). Two 5 mm ports in the right upper abdomen quadrant are eventually converted to 8 mm robotic trocars (R2 and R3). The liver retractor is inserted through a 5 mm port in the right anterior axillary line (L). Assistant ports (A1 and A2) are placed in the right and left lower quadrants. A GelPOINT device (Applied Medical, Rancho Santa Margarita, California) is used to seal a 6 cm incision made either in the left lower quadrant or upper midline for the extraction of the pancreatic head (A2), as well as to provide ready access for sponges and the passage of needles and staplers.


Figure 78.1  Operating room setup. (a) Surgical technician. (b) Laparoscopic surgeon sitting between the legs of the patient. (c) Console surgeon operating the robot. (d) Surgical trainee or observer. (e) Anesthesiology team. (f) Supporting equipment.

Like open surgery, the robotic technique uses four-handed cooperation to expose critical structures that may be distorted by tumor, obesity, and/or pancreatitis. Avoiding and safely controlling hemorrhage from major vessels require strong familiarity with the anatomy as well as skilled collaboration between the laparoscopic and console surgeons.

Stepwise surgical technique  469

Step 1: Mobilization of the Right Colon and Pancreatic Head Gravity is used to retract the hollow viscera during the laparoscopic phase, during which we use a 45° angled laparoscope, atraumatic graspers, suction, and the LigaSure (Covidien, Boulder, Colorado) (Figures 78.3a and b). The right colon is mobilized to expose the duodenum crossing beneath the mesenteric vessels. The pancreatic head is elevated from the retroperitoneum (Kocher maneuver) (Figure 78.3a) up to the origin of the superior mesenteric artery (SMA), and the ligament of Treitz is divided from the right beneath the mesenteric vessels whenever possible. The extent of the peritoneal reflection along the proximal jejunum may require mobilizing the proximal jejunum in the inframesocolic compartment. After the mesentery of the proximal jejunum is divided, the pancreatobiliary limb is measured, and the site of the future duodenojejunostomy is located approximately 50–60 cm downstream by tacking the jejunum to the stomach in the correct orientation (Figure 78.3b) with an EndoStitch (Covidien, Boulder, Colorado).

Step 2: Docking the Robot After mobilizing the pancreatic head and dividing the jejunum, the robot (Intuitive Surgical, Sunnyvale, California) is used for the portal dissection and subsequent reconstruction. The robot is docked directly over the patient’s head with arms 2 and 3 on the patient’s right, ensuring that the liver retractor does not conflict with the inferior robotic arm.

Step 3: Dissection of the Porta Hepatis With the robot in position, antegrade cholecystectomy may first be required to remove a dilated gallbladder, which prevents dissection of the portal structures. The common hepatic artery (CHA) lymph node is then mobilized and (a)

resected to expose the superior border of the pancreas, the CHA, and the gastroduodenal artery (GDA) origin (Figure  78.4). The right gastric artery is identified and divided to complete the mobilization of the duodenum. The origin of the GDA is cleared of surrounding tissue and temporarily occluded to confirm inflow from the CHA (either visible pulsation or laparoscopic B-D mode ultrasound captured in the patient console). The GDA is ligated proximally with a 2–0 silk tie and divided with a vascular load of the stapler (Figure 78.4a). With the GDA divided and the CHA in view, the proximal duodenum is cleared of the right gastroepiploic arcade and prepyloric lymph nodes and divided with a linear cutting stapler (Figure 78.4b). The gastroepiploic pedicle is divided with a vascular stapler, preserving the vessels along the greater curve of the stomach but keeping the prepyloric lymph nodes in continuity with the specimen. With the duodenum out of the way, the common bile duct is elevated to expose the PV and encircled with a vessel loop. The portal lymph nodes are swept away from the hepatic arteries and bile duct and into the specimen. The lateral margin of the bile duct is inspected to identify a replaced right hepatic artery. The bile duct is divided with a stapler to prevent a bile leak, which will obscure the operative field during dissection along the SMA. The distal bile margin is sampled for frozen section.

Step 4: Mobilization of the Superior Mesenteric Vein and Division of the Pancreatic Neck With the portal dissection complete, the inferior border of the pancreas is cleared of overlying areolar tissue to expose the superior mesenteric vein (SMV). Robotic scissors dissect the SMV-portal vein away from the posterior surface of the pancreas under direct vision. An articulated grasper is used to pass an umbilical tape around the pancreatic neck to prevent venous injury during pancreatic transection (Figure 78.5). The transverse pancreatic arteries are suture ligated at the inferior and superior borders of the pancreas (b)

Figure 78.3  (a) Kocher maneuver. Reflection of the duodenum and pancreatic head from the retroperitoneum with dissection of

the adventitia surrounding the SMA to expose the inferior vena cava and the aorta. 1: Inferior vena cava. 2: Rejected duodenum and pancreatic head. 3: Common bile duct lymph node. (b) Preliminary creation of the duodenojejunostomy. The jejunum is marked with sutures to locate the future duodenostomy 40 cm downstream from the bilioenteric anastomosis. The jejunum is marked in the correct orientation and tacked to the stomach to maintain its correct orientation after docking the robot. 1: Stomach. 2: Jejunum.

470  Robot-assisted minimally invasive pancreaticoduodenectomy (a)


Figure 78.4  (a) Ligation of the gastroduodenal artery. 1: Gastroduodenal artery. 2: Right hepatic artery. 3: Caudate lobe of the liver. 4: Portal vein. 5: Duodenum. 6: Common hepatic artery. (b) Transection of the first portion of the duodenum for pylorus-preserving pancreaticoduodenectomy. 1: Antrum of the stomach. 2: Pylorus. 3: First portion of the duodenum.

Tiny arterial branches are divided with the LigaSure device, whereas larger vessels are controlled proximally with a silk tie or clip and then transected distally with the LigaSure (Figure 78.6b). This exposure permits suture control of bleeding with 4–0 or 5–0 Prolene (Ethicon Endo-Surgery, Cincinnati, Ohio) using R1. The laparoscopic surgeon uses ports A1 and A2 to deploy the LigaSure and clear the field of blood with suction. The specimen is placed within a large specimen bag and extracted through the GelPOINT. The retroperitoneal margin is irrigated and inspected for bleeding. Gold fiducials are placed in cases of suspected or known malignancy.

Figure 78.5  Division of the pancreatic neck. An umbilical tape is used to maintain venous exposure during transection. 1: Pancreatic neck. 2: Pancreatic body. 3: Superior mesenteric vein. 4: Stomach.

using 2–0 silk. The pancreas is divided with cautery scissors. Cautery is not used to transect the pancreatic duct so that a frozen section can be accurately evaluated by pathology. After the pancreas is divided, the SMV continues and is dissected free of overlying fat and small vessels proximally into the root of the small bowel mesentery. The origin of the right gastroepiploic vein is identified as it enters the SMV and is divided with a vascular stapler or 2–0 silk ties. The jejunum is divided to free the duodenal mesentery. The robotic Maryland dissector is used to ligate venous tributaries to the uncinated process using a combination of ties, LigaSure, or clips.

Step 5: Vascular Disconnection of the Pancreatic Head The pancreas is elevated from the retroperitoneum with a “hanging maneuver” performed by the third robotic arm (R3) to rotate the SMA into view. Once the superior pancreaticoduodenal vein has been ligated, the only remaining structures are the arterial tributaries to the pancreas arising. The adventitia of the SMA is identified using the robotic Maryland dissector (Figure 78.6a). Retroperitoneal lymph nodes lateral to the SMA are divided using the LigaSure.

Step 6: Restoration of Gastrointestinal Continuity Restoring GI continuity reproduces the open technique with the sole substitution of multifilament absorbable 5–0 suture. The proximal jejunum is inspected to be sure there has been no inadvertent devascularization during division of the duodenal mesentery. The pancreaticobiliary limb is pulled beneath the vessels and the degree of tension evaluated prior to creating the pancreatic anastomosis. A two-layer, endto-side, duct-to-mucosa pancreaticojejunostomy (Figure 78.7a) is performed using a modified Blumgart technique. Transpancreatic 2–0 silk horizontal mattress sutures are used to anchor the seromuscular layer of the jejunum to the pancreatic parenchyma while preventing potential parenchymal tears. Interrupted sutures (5–0 Vicryl) are placed around the pancreatic duct to maximize visualization during subsequent creation of the anastomosis. A small jejunal enterotomy is made with cautery scissors, and an interrupted duct-to-mucosa anastomosis is completed in a parachute style. A pancreatic duct stent may be placed in small ducts to ensure duct patency (Figures 78.7a and b). The anastomosis is completed with an anterior layer of 2–0 silk sutures using the needles left in place from the posterior row. Next, the stapled end of the bile duct is resected. A ­single-layer end-to-side hepaticojejunostomy (Figure 78.7c) is created with interrupted 5–0 Vicryl in the case of a small duct. A running technique employing 4–0 V-Loc (Covidien,

Stepwise surgical technique  471 (a)


Figure 78.6  (a) Dissection of the adventitia to expose the SMA. Once the pancreatic neck is transected, the superior mesenteric

vein is exposed and venous tributaries ligated and divided to expose the superior mesenteric artery. 1: SMV. 2: Adventitia surrounding the SMA. 3: Head of the pancreas. 4: Neck of the pancreas. 5: Splenic vein traveling parallel and posterior to the tail of the pancreas. 6: Confluence of the SMV and SV to form the portal vein. (b) Division of the SMA arterial tributaries to the pancreatic head. 1: Portal vein. 2: SMA. 3: Tributary of the SMA to the pancreatic head. 4: Distal pancreas. 5: Mobilized duodenum. Note the vascular bulldog clamp in position on a large superior pancreaticoduodenal vein branch. (a) (b)



Figure 78.7  (a) Cannulation of the pancreatic duct. 1: Pancreatic remnant and cannulated pancreatic duct (arrow). 2: Portal

vein. 3: Loop of jejunum for pancreaticojejunal anastomosis. (b) Duct to mucosa pancreaticojejunostomy. The pancreas and the jejunum are approximated above the portal vein. The previously cannulated duct is anastomosed to the intestinal mucosa. 1: Pancreatic tail. 2: Jejunum, biliary limb. 3: Portal vein. (c) End-to-side hepaticojejunostomy. The end of the hepatic duct is anastomosed to the lateral wall of the jejunum. 1: Hepatic duct. 2. Jejunum, biliary limb. 3: Foramen of Winslow and inferior vena cava. (d) Antecolic two-layer duodenojejunostomy. 1: Lumen of the first portion of the duodenum. 2: Lumen of the jejunum, alimentary limb.

Boulder, Colorado) is used for thick-walled ducts larger than 8 mm in diameter when visualization is optimal. Finally, an antecolic two-layer duodenojejunostomy is performed with a posterior layer of interrupted seromuscular 2–0 silk followed by full-thickness running 3–0 V-Loc after the duodenum and jejunum are opened (Figure 78.7d). The status of the duodenal mucosa is checked to ensure viability. A Connell technique is used to complete the anterior wall of the anastomosis, after which an anterior row of seromuscular sutures is placed.

In patients with fragile nutritional status, a transgastric feeding jejunostomy tube is placed using a standard Stamm technique. After hemostasis is ensured, and all surgical foreign bodies are accounted for, two round 19F surgical drains are placed—one anterior and one posterior to the biliary and pancreatic anastomoses. The robot is undocked, and the GelPOINT site and other ports are closed. The skin is closed with a monofilament subcuticular closure followed by sterile dressings. The patient is awakened, extubated, and transferred to the recovery room for overnight observation.

472  Robot-assisted minimally invasive pancreaticoduodenectomy

LIMITATIONS OF CURRENT TECHNOLOGY Time-tested techniques for open pancreatic resection can be implemented in a minimally invasive fashion with the assistance of robotic technology. However, current platforms have several important limitations, the most significant of which is the inability to operate in multiple quadrants of the abdomen. This limitation is compounded by the inability to change the position of the table once the robot is docked, meaning that gravity cannot always be used effectively as a retractor of the viscera. The size and location of current robotic arms limit their freedom of motion and degrade the enormous potential of robotic assistance. Trocar placement is critical to minimize interference between the arms and conflicts with the laparoscopic surgeon seated at the bedside. The lack of tactile feedback prolongs the learning curve and may lead to excess tension and crushing of tissues. Compensating for the lack of tactile feedback requires subtle visual clues reflecting tension on tissue, blood vessels, and fine suture material. This skill requires a significant learning curve and is rapidly

perishable without ongoing practice. Finally, exchanging surgical instruments is a cumbersome process that disrupts the flow of the operation and prolongs the operating time.

POTENTIAL ADVANTAGES OF MINIMALLY INVASIVE PANCREATICODUODENECTOMY PD is one of the most complex procedures in abdominal surgery. PD requires wide exposure of structures, gentle dissection and manipulation of vasculature, and thorough knowledge of the anatomy to reconstruct the biliopancreatodigestive tract. Given its high complexity and steep learning curve, robotassisted pancreatoduodenectomy (RAPD) has been adopted at a slow pace by selected centers despite the popularity of minimal access techniques for other operative procedures. Retrospective outcomes of open pancreatoduodenectomy (OPD), laparoscopic pancreatoduodenectomy (LPD), and RAPD are shown in Table 78.1. At this early stage of widespread adoption, RAPD requires a longer operative

Table 78.1  Blood loss, operative time, and conversion rates for pancreatoduodenectomy in the literature Type of study

Type of procedure

Operative blood loss (mL)a

Operative time (hours)a

Conversion rate (%)

Literature review Literature review

LPD (n = 146) RAPD (n = 131)

142.8 440

7.3 8.5

46 16.4

Retrospective, single center Retrospective, single center

OPD (n = 1423)

Median: 800

Median: 6.3


OPD (n = 1000)

RAPD (n = 50)

Median: 8.8 (in 1970s) and 5.5 (in 2000s) 7


Retrospective, two centers Prospective cohort Retrospective, single center

Median: 1090 (in 1970s) and 700 (in 2000s) 394

RAPD (n = 34) RAPD (n = 200)

220 Median: 250

10 Mean: 8

0 6.5

Buchs et al.15

Prospective cohort

RAPD (n = 44) OPD (n = 39)


RAPD (n = 20) OPD (n = 67)

Bao et al.16


RAPD (n = 28) OPD (n = 28)

Chen et al.6


RAPD (n = 60) OPD (n = 120)

7.4 (RAPD) versus 9.3 (OPD); p = 0.0001 8.2 (RAPD) versus 4.4 (OPD); p = 0.01 Median: 7.2 (RAPD) versus 6.8 (OPD); p = 0.04 Median: 6.8 (RAPD) versus 5.4 (OPD); p = 0.001


Lai et al.12

387 (RAPD) versus 827 (OPD); p = 0.0001 Median: 247 (RAPD) versus 774.8 (OPD); p = 0.03 Median: 100 (RAPD) versus 300 (OPD); p = 0.0001 Median: 400 (RAPD) versus. 500 (OPD); p = 0.005

Study Literature reviews Gagner and Palermo13 Strijker et al.8 Noncomparative studies Winter et al.11 Cameron et al.10

Giulianotti et al.7 Boggi et al.14 Boone et al.9


Comparative studies




Notes: LPD, laparoscopic pancreatoduodenectomy; OPD, open pancreatoduodenectomy; RAPD, robot-assisted pancreatoduodenectomy. See the reference number in the first column. a Mean operative blood loss and mean operative time are depicted unless otherwise specified.

References 473

time than OPD. However, as expertise is achieved, the differences tend to disappear or become clinically insignificant. Conversion rates during RAPD vary between 0% and 35%, with lower conversion rates achieved as expertise is acquired (Table 78.1). A prospective matched series found longer mean operative times in the RAPD group when compared to OPD (410 ± 103 versus 323 ± 80 minutes; p = 0.001), however, when comparing the last cases of both cohorts, no differences in the mean operative times were found (340 [98] versus 324 [92] minutes; p = 0.981).1 Similarly, overall median blood loss was lower in the RAPD group when compared to OPD (400 versus 500 mL; p = 0.005), differences which became more distinct among the latest robot-assisted cases due to technical refinements resulting from the learning curve: 200 mL (IQR 100–450 mL) for RAPD and 500 mL (IQR 300–700) for OPD (p = 0.002).3 Reported blood loss during RAPD ranges from a low of 250 mL to a high of 500–600 mL, which compares favorably with reported open series.

Postoperative complications Complication rates after RAPD are similar to those of OPD (38%–41%) and LPD (16%–37%) at expert centers. Major complication rates, defined as Clavien-Dindo classification ≥3, have been reported in the 15%–26% range. The most common complications are pancreatic fistula, delayed gastric emptying, bile leak, gastrointestinal anastomotic leak, intra-abdominal bleeding, intraperitoneal fluid collection, and afferent loop obstruction.1 Surgical site infection is more common in the open group (1.7% versus 12.5%; p = 0.033). Pancreatic fistula incidence has been reported between 13.3% and 35%, but a recent study by Boone et al. shows a grade B/C pancreatic fistula rate of 6.9% in a high-volume center. No significant differences between RAPD and OPD have been observed in postoperative complications, pancreatic fistulae, bleeding, reoperation, biliary leaks, or delayed gastric emptying. Reoperation rates after RAPD are 3.3%–4% and similar to OPD. Reports on perioperative mortality rate for RAPD range between 1.7% and 3.3% as previously reported for the open and laparoscopic approaches (1.3%–2.5%).

Oncologic outcomes Margin negative resection rates after RAPD for cancer range between 79% and 100%, while the number of lymph nodes harvested ranges between 14 and 32. Several studies have compared resection margins and node harvest after RAPD and OPD without finding inferiority. No port-site recurrences have been reported in the literature. Survival is no different after RAPD than OPD.1

The learning curve A recent retrospective review of 200 RAPD performed in a high-volume institution demonstrated a three-phase

model of improvement in operating time. 3 Mean operative time was 581 ± 81 minutes for the first 80 procedures; 444 ± 73 minutes between cases 81 and 140, and 390 ± 75 minutes for cases 141–200. This 33% improvement in operative time was achieved over 6 years as compared to OPD series showing a similar decrease in operative time (37%) achieved over three decades (from 528 minutes in the 1970s to 330 minutes in the 2000s).3 Similar reductions in blood loss after RAPD and OPD were observed.1 The conversion rate decreased 10-fold at case 20 (35.0% versus 3.3%; p 5 mm) to the abdominal cavity, and at the same time allows for laparoscopic assistance via 5 mm ports to avoid access trauma and morbidity. The traditional laparoscopic rectal resection rectopexy has the following operative steps:11 ●●


●● ●●


Dissection and mobilization of the rectum under preservation of the rectal peritoneal tissue Deep mobilization and dissection of the retrovaginal area toward a possible rectocele to lengthen and fully mobilize the scar tissue, which has been developed by the rectal prolapse over years Dissection of the redundant sigmoid colon for resection Traditional laparoscopic sigmoid resection and circular stapling for descendo-rectostomy Pexy of the pararectal peritoneum at the promontorium using non-resorbable suture material and peritoneal adaptation

After establishing a capnoperitoneum via a Veress needle and necessary safety tests, a periumbilical port was introduced into the abdominal cavity. Two additional 5 mm ports were brought into the right lower quadrant for dissection of the colon and rectum. Via these ports instruments for dissection, hemostasis and energy delivery could be used. The dissection of the mesentery was performed stepwise under laparoscopic control to ensure that the pelvic nerve plexus was not in danger and the dissection planes could be followed (Figure 94A.1). In rectal prolapse,

Figure 94A.1  Transanal Endoscopic Applicators (TEAs) in different sizes as transanal trocar with a 3 cm diameter.

it is most important to dissect the rectum distally in the retrovaginal area and free the rectum from all adhesions and scar tissue that have developed over the years. This will allow for an oral mobilization of the rectum toward the promontorium and will also ensure the removal of the prolapse. Time needs to be invested in the careful dissection in this part of the operation to have a high ­probability for a successful result. A sigmoidoscopy can be performed to make sure this bowel segment is clean before opening the sigmoid in the abdominal cavity. If it was not completely clean, it could be improved by rinsing the rectum and sigmoid with water. Afterwards, bougies of the sizes 25, 28, and 33 were introduced into the anus and rectum up to the sigmoid colon to widen the proximal rectum. A careful bougienage of the rectum facilitates the following maneuvers. Then the anvil of a 28 mm circular stapler was introduced into the rectum with a special grasper and maneuvered more proximal up the descending colon to the future anastomotic site (Figure 94A.2). The next step was the transanal introduction of a Transanal Endoscopic Applicator (TEA), which allows for safe introduction of endoscopes, linear staplers, and grasping devices, and specimen removal (Figure 94A.3).11 This was followed by an incision of the colon— usually the distal sigmoid—at the distal anastomotic site. Here, a transanally introduced linear stapler can exit the colon into the abdominal cavity and was used to transect the proximal end of the sigmoid segment, which needs to be resected (Figure 94A.4). At this point, the surgeon manipulates the instruments transanally and transabdominally to coordinate the different surgical steps. With the left hand, he/she uses a grasper to hold the tissue at the descending colon to position the stapler. With the right hand, he/she manipulates the linear stapler, which was introduced into the bowel via the TEA. The TEA itself has a handle, which is held quite flexibly by a second assistant to follow the movements of the surgeon. Via the transanally positioned

The transanal operative technique  575

Figure 94A.2  In total 3 trocars are used for the ta-CR technique: 1 camera port and 2 working ports (5 mm).

Figure 94A.3  The anvil is positioned intraluminally

with a transanal grasper prior to resection at the future proximal anastomotic site.

TEA instrument, the application, removal, and changing of ­stapling cartridges were technically rather easy to perform. During transection of the colon, care was taken to keep the anvil positioned just proximal from the stapling transection line in order to be there for the proximal anastomosis later. Once the redundant sigmoid was transected proximally at the descending colon, the proximal colon stump was grasped and opened with scissors at a small spot near the staple line. The intraluminal anvil was grasped through the bowel wall and stabilized. The central pin of the anvil was penetrated through the bowel wall at the small opening at the staple line. Thus, the proximal colon was ready for later anastomosis.

Figure 94A.4  Stapling and division of the colon via the transanal trocar.

Now the distal anastomotic site was completely transected with scissors and/or an energy device. If the bowel still carried some stool, the distal bowel could be closed by another linear stapler via the rectum using the TEA. Once the sigmoid segment was resected and free of detachments, a grasper was advanced via the TEA to reach for the specimen in the abdomen. Then the specimen was pulled through the luminal opening at the distal rectosigmoid stump, via the rectal lumen and via the TEA to the outside. After removal of the specimen transanally, a purse-string suture was placed at the distal rectosigmoid stump to complete the anastomosis with the circular stapling device. The TEA was removed and a circular stapler was inserted transanally and advanced to the distal rectosigmoid opening, carrying the purse-string suture. The central pin was opened and the purse-string suture was tied down around the central pin. Furthermore, the anvil was connected to the stapler, followed by approximating and firing the device in the usual manner under laparoscopic visual control. Thus, the actual anastomosis could be performed under the same conditions that laparoscopic surgery can provide. After finishing the anastomosis, a rectopexy was added in the usual technique with non-absorbable sutures between peritoneal, pararectal tissue, and the sacral bone at the promontorium using the 5 mm ports, straight needles, and mini-instruments. After the control of hemostasis, inspection of the anastomosis, and leak test with air and water as well as placement of drainage, the procedure was finished by removal of the three ports. The patients could drink water and tea on the evening of the operation and were given fluids, including protein drinks, on the first postoperative days. Usually on the third postoperative day, enteral feeding started with soup, semisolid food and, if they tolerated it well, subsequently also solid food. The initial clinical experience of the past years shows a safe introduction of this NOTES-associated technique into clinical practice.11

576  Technique of transanal-assisted colon resection and rectopexy

DISCUSSION Laparoscopic operations may require port sizes of 10–15 mm for stapler applications and mini-laparotomies for removal of specimens. This can cause wound problems and hernias in up to 22% of patients.12,13 Transanal endoscopic surgery was introduced by Gerhard Buess.14 With Transanal Endoscopic Microsurgery (TEM) and the specially developed instrument set, an operative endoscope is inserted into the anal canal to the rectum. Through this platform, surgical removal of rectal and distal sigmoid tumors is possible. A more simple transanal system with similar abilities is the TEO (Transanal Endoscopic Operation) system.15 The latter system can be used with regular laparoscopic instruments. It is quite easy to handle and can be used by any laparoscopic surgeon, since it is similar to working on a mono-port. With the advent of the NOTES concept, we used this TEO port to train on more complex transanal operations such as a sigmoid resection. We decided to use a transanal trocar with a smaller diameter to avoid any possible long-term functional problems.11 Transanal Hybrid-NOTES procedures must be safe; therefore, stepwise transformation from a current laparoscopic procedure with multiple ports and a mini-laparotomy for specimen retrieval to a transanal Hybrid-NOTES procedure with less ports and no incision for the specimen retrieval is necessary. With the introduction of Transanal Hybrid Colon Resections, postoperative long-term anorectal functional problems would be not acceptable.16 As a consequence, the authors have developed a special TEA with a smaller diameter of 30 mm, from which anorectal functional problems are not to be expected. The diameter of a 33 bougie is most frequently used in colorectal surgery for stapling with absolute minimal side effects regarding functional problems. As a consequence, the authors have chosen a diameter of 30 mm for the TEA to be in a safe range.11 None of the patients developed more severe functional defects especially regarding incontinence postoperatively. NOTES and Hybrid-NOTES approaches have been reported in the literature in the past years for colorectal surgery.17–28 The important idea came from Whitford, Sylla, and Lacy, who reported about their initial experimental work on transanal techniques to operate in the abdomen.17–21 Their experience showed that transanal approach to dissect the rectum and further up into the abdominal cavity is quite safely possible. The advantages of the transanal route, with reduced diameter and easy access to the pelvis, and the advantages of laparoscopy, with excellent overview using transabdominal camera position, are combinedly used in clinical practice with the hybrid technique.11 This allows for excellent maneuverability and triangulation from 3 and 5 mm graspers, good exposure for 5 mm energy devices, and a safe handling of the tissue. Morbidity of 5 mm ports is minimal and that of 3 mm ports is negligible. If the transanal orifice approach can be used for all tools with a diameter greater than 5 mm and the actual opening in the bowel for transanal intra-abdominal access can be later used for anastomosis, an ideal solution

can be reached. The possible benefits of this Hybrid-NOTES technique compared to traditional laparoscopic colectomies are less wound infection problems, less hernia frequency, and possible quicker recovery for daily activities.22–28 This has to be proved in ­comparative studies.

CONCLUSIONS Transanal hybrid colon resection seems, from this initial experience, a feasible and safe method of Hybrid-NOTES procedure, which has been introduced into clinical practice. The good quality of laparoscopic overview, the delivery of energy for safe dissection, and the advantages of instrument triangulation can be used. In addition, abdominal access trauma is limited to maximum 5 mm ports with low probability of subsequent morbidity by using the advantage of a natural orifice via the transanal route for all other manipulations requiring an access larger than 5 mm such as staplers, endoscopes, and specimen retrieval.


1. Madiba TE et al. Arch Surg 2005;140:63–73. 2. Wu JS. Curr Probl SURG 2009;46:602–716. 3. Johnson E et al. ISRN Gastroenterol 2012;2012:824671. 4. Conston ECJ et al. Ann Surg 2015;262:742–8. 5. Tou S et al. Cochrane Database Syst Rev 2015;24(11):CD001758. 6. Carvalho MEC et al. Am Surg 2018;84(9):1470–5. 7. Rattner D et al. Surg Endosc 2006;20(2):329–33. 8. Fuchs KH et al. Surg Endosc 2013;27:1456–67. 9. Saad S et al. Surg Endosc 2011;25(8):2742–7. 10. Leroy J et al. J Gastrointest Surg 2011;15(8):1488–92. 11. Fuchs KH et al. Surg Endosc 2013;27:746–52. 12. Härkki-Siren P et al. Obstetrics and Gynecology 1999;94(1):94–8. 13. Yamamoto M et al. JSLS 2011;15(1):122–6. 14. Buess G et al. Am J Surg 1992;163:63–9. 15. Lirici MM et al. Surg Endosc 2003;17(8):1292–7. 16. Allaix ME et al. Br J Surg 2011;98(11):1635–43. 17. Sylla P et al. J Gastrointest Surg 2008;12(10):1717–23. 18. Denk PM et al. Gastrointest Endosc 2008;68(5):954–9. 19. Leroy J et al. Surg Endosc 2009;23(1):24–30. 20. Sylla P et al. Surg Endosc 2010;24(8):2022–30. 21. Sylla P et al. Surg Endosc 2010;24(5):1205–10. 22. Wolthuis AM et al. Hum Reprod 2011;26(6):1348–55. 23. Arezzo A et al. Surg Endosc 2013;27(9):3073–84. 24. Wolthuis AM et al. World J Gastroenterol 2014;20(36): 12981–92. 25. McLemore EC et al. Surg Endosc 2016;30(9):4130. 26. Deijen CL et al. Tech Coloproctol 2016;20(12):811–24. 27. Penna M et al. Ann Surg; 2017;266(1):111–7. 28. Zattoni D et al. Techniques in Coloproctology 2018; https:// doi.org/10.1007/s10151-018-1806-1.

95 Laparoscopic transabdominal preperitoneal inguinal hernia repair BRIAN JACOB AND ALEXANDRA ARGIROFF

INTRODUCTION Inguinal hernias remain one of the most common problems that present to the general surgeon. There are many ways to approach them, from observation to a variety of surgical repairs. Currently, the tension-free open repair with mesh and laparoscopic repair are considered to be of equal efficacy and results. Of the laparoscopic repairs, the two most commonly used are the total extraperitoneal (TEP) and the transabdominal preperitoneal (TAPP) techniques. Each has its own advantages and disadvantages, and the comparison of the two is beyond the scope of this chapter. The choice between the two procedures remains surgeon preference. The TAPP repair does offer surgeon and patient advantages that make it preferable in certain clinical scenarios, and in many surgeons’ hands, it is the go-to choice for primary inguinal hernias. The technical steps, as well as the indications and complications of TAPP, as well as the supporting evidence, are discussed in this chapter.

without previous gas insufflation). Once the abdomen is insufflated, two more 5  mm trocars are introduced laterally under direct vision on each side of the abdomen, just below the level of the infraumbilical trocar (Figure 95.1). Step 2. If there is an incarcerated inguinal hernia, the contents are gently reduced. If there are adhesions of omentum or intestine locally to the peritoneum, adhesiolysis does not need to be performed unless the adhesions interfere with the ensuing operation.1

TECHNICAL ASPECTS A TAPP repair is similar to a TEP repair in the important steps of identifying hernia defects, reducing hernia contents and sac, and mesh placement. Where they differ is access to the preperitoneal space, and for the TAPP, closure of the peritoneal flap. There is variation in how the procedure is done and little to no evidence for strict guidelines on how the surgery should be performed. However, there are basic principles that the International Endohernia Society (IEHS) recommends1: Step 1. The peritoneal cavity is accessed and insufflated. This can be done with open Hasson technique, Veress needle, direct trocar insertion, or visual entry (with or

Figure 95.1  Introduction of two more 5 mm trocars laterally under direct vision on each side of the abdomen, just below the level of the infraumbilical trocar.

578  Laparoscopic transabdominal preperitoneal inguinal hernia repair

Figure 95.2  Internal inguinal ring. Step 3. A peritoneal flap is created to enter the preperitoneal space surrounding the spermatic cord. Electrocautery using the hook dissector or laparoscopic scissors can be used to score the peritoneum and enter the preperitoneal space starting about 3–4 cm superior to the internal inguinal ring (Figure 95.2). This flap is then extended medially to the level of the median umbilical ligament and laterally to the level of the anterior superior iliac spine. It is extended inferiorly through the avascular areolar tissue to about 2–3 cm inferior to Cooper ligament, at the level of the superior arch of the pubic bone. The full extent of the pelvic floor should be dissected to ensure no occult direct or femoral hernias are present. Adequate space should be made to place a 10 × 15 cm piece of mesh (Figure 95.3). Step 4. The pubic symphysis is identified, and the adherent areolar tissue is cleaned off between the symphysis and the pubic tubercle and Cooper ligament. At this time, the adipose tissue against the undersurface of the transversalis fascia of the direct space can begin to be cleaned off to assure there is no direct hernia. Step 5. The dissection should be carried out laterally, with the dissection of the areolar connective tissue between the peritoneal flap and the transversalis muscle fibers at the level of the anterior superior iliac spine. Once this lateral space is created, the peritoneal edge can be followed medially until it meets the cord elements in a male (or round ligament in a female) and an indirect hernia can be ruled in or out. Step 6. The adherent tissue to the spermatic cord is dissected off of the medial and lateral aspects of the hernia sac. Identification and preservation of the cord elements are key. Begin with the lateral surface by pulling the peritoneal sac medially, teasing the tissue off of the peritoneum. While doing this, the vascular supply and the vas

Figure 95.3  Adequate space should be made to place a 10 × 15 cm piece of mesh.

deferens can be identified and preserved. To perform the medial dissection, the peritoneal sac can be pulled laterally and anteriorly. Understanding the precise location of the iliac vein is important during this dissection. Step 7. The peritoneal edge of the hernia sac is reduced off of the cord completely and down to a level below the iliac vessels. The advantage of the peritoneal flap created for the TAPP at this stage is that it allows you to appreciate the reduction of the hernia sac more easily from within the peritoneal cavity. In exceptional cases with a very large and chronically incarcerated hernia sac, the sac can be transected at the level of the internal inguinal ring to prevent injury to the cord structures. An attempt should be made to close the peritoneum on the proximal end (with an Endoloop, Endoclips, or suture), if possible, but you can leave the end within the canal open and patent. Step 8. Look for and reduce and/or excise any cord or preperitoneal lipomas. IEHS recommends reducing and excising any cord lipomas or preperitoneal lipomas in the direct or femoral spaces, as these are a common cause of “recurrent” hernias. Step 9. A “critical view” is obtained before inserting the mesh, simply assuring a completely dissected myofascial orifice where you can see the symphysis in the midline, Cooper ligament, and the femoral and direct space. You should also see the cord elements without any remaining tissue medially, the completely cleared internal ring, and the edge of peritoneum and hernia sac clearly reduced below the level of the iliac vessels. Step 10. Mesh insertion. The mesh should measure a minimum of 10 × 15 cm. It is OK for the corners to be rounded or preshaped. For a larger hernia, a larger mesh can be used. The decisions of what mesh to use (lightweight versus heavyweight, large pore versus small pore, etc.), and what fixation material to use if any (no

Special applications for TAPP approach  579

Figure 95.4  The surgeon should assure that the mesh crosses the midline medially, and that inferiorly there is enough peritoneum dissected below the level of the iliac vessels.

Figure 95.5  Once the mesh is in place, the peritoneal flap needs to be closed and reapproximated.

fixation, permanent tacks, absorbable tacks, or fibrin glue) are beyond the scope of this chapter and remain surgeon preference. However, for TAPP, with a hernia defect larger than 4 cm, the IEHS recommends fixating the mesh. The mesh should lay flat and should not fold upon itself. The surgeon should assure that the mesh crosses the midline medially, and that inferiorly there is enough peritoneum dissected below the level of the iliac vessels. This will avoid hernia recurrence under the mesh (Figure 95.4). Step 11. Once the mesh is in place, the peritoneal flap needs to be closed and reapproximated. This can be done using staples, tacks, running suture, or fibrin glue. There is no evidence to show superiority of one method. The important aspect of this step is to ensure the peritoneum is completely closed in order to avoid contact of bowel with mesh. If there is difficulty in reapproximating the peritoneal edges, the insufflation should be decreased to as low as possible, still providing enough domain to comfortably work (Figure 95.5). Step 12. Finally, after assuring hemostasis and no injuries to peritoneal structures (particularly bowel and mesentery), the infraumbilical fascia should be closed.

SPECIAL APPLICATIONS FOR TAPP APPROACH Incarcerated and strangulated hernias A TAPP is particularly advantageous in managing an incarcerated or strangulated inguinal hernia. By performing a TAPP repair in these scenarios, the surgeon can evaluate the bowel properly and can even spare the patient a bowel resection more often than with an open repair. The bowel can be

reduced, and while the hernia is being repaired, adequate time passes to observe if the bowel is viable or not. If the segment of bowel remains ischemic, it should be resected, and the IEHS recommends extracorporeal resection and anastomosis. The use of mesh after finding a true strangulation or bowel ischemia remains at the discretion of the surgeon, though employing a permanent synthetic material in a clean-contaminated or contaminated field carries a risk of chronic mesh infection and is therefore best avoided. An absorbable material is probably the safest choice if the field is clean-contaminated. If the field is contaminated, then it is best to stage the repair or perform a primary tissue repair without mesh.

Scrotal hernias and large hernia sacs Inguinal scrotal hernias are probably more common than typical reporting might indicate. Small scrotal hernias that are reducible can be approached initially via the TEP procedure. But the larger, incarcerated, or chronic scrotal hernias, especially those with large-diameter necks, are sometimes better approached using a TAPP or open technique. A TAPP repair provides a great view of the incarcerated contents, and it usually allows for a straightforward reduction. To reduce the volume of hernia sac in the canal, the retained sac can be pulled intrapreperitoneally and tacked to the lateral edge to the anterior abdominal wall. This can decrease the incidence and size of seroma formation. Patients with these types of hernias should be warned about seromas, as they are fairly common. In these large hernias, a partial hernia sac can be left in situ in the scrotum if it is not possible to safely reduce it.

580  Laparoscopic transabdominal preperitoneal inguinal hernia repair

Recurrent hernias For experienced laparoscopists, a recurrence after a previous TEP or TAPP approach demands a TAPP. Some surgeons will always resort to an open anterior approach for a patient with a recurrence. During the laparoscopic dissection, if an additional open incision will help with mesh removal or cord preservation, it may be added to at this point. Debating which procedure is best to perform after a recurrence has been extensively evaluated in the literature and is beyond the scope of this chapter, but it is clearly dependent on surgeon experience. For recurrences, the IEHS recommends TAPP, if feasible.

Patients with previous Pfannenstiel or lower midline incisions Some patients with previous Pfannenstiel or lower midline incisions will not have a peritoneal layer and thus are not candidates for a TEP repair. In such situations, a TAPP is the only laparoscopic repair possible. In addition, some Pfannenstiel incisional hernias will feel on palpation like inguinal hernias, when the defect is, in fact, midline. A preoperative computed tomography scan can help differentiate between the two. Using a laparoscopic approach allows for an accurate diagnosis and repair concomitantly. Of note, a history of prostatectomy carries a small but not insignificant risk of bladder injury, and dissection should proceed cautiously in that region.

COMPLICATIONS AFTER TAPP APPROACH Inguinodynia Pain following a hernia repair is less commonly reported after laparoscopic hernia repair compared to open repair. Generally, pain after an inguinal hernia repair is caused by the material inserted (mesh, tacks, or sutures), an inadequately reduced hernia, or a missed lipoma or hernia. The pain resulting from inserted mesh, fixation tacks, or sutures can be caused by direct irritation from the material, or by adjacent nerve damage. In a laparoscopic repair, the nerves at risk are the lateral femoral cutaneous nerve, the genital branch of the genital femoral nerve, the ilioinguinal nerve, and the iliohypogastric nerves. To avoid neuropathic pain from a TAPP, if mesh is fixated, no tacks or sutures should be placed laterally below the level of the anterior superior iliac spine.

Seroma formation in large defects Large cavernous defects, both direct and indirect, run the risk of forming large seromas. While these are self-limited, they can last many months and be uncomfortable for patients. One way to minimize these from forming is to take

the redundant attenuated transversalis fascia, pull it into the preperitoneal space, and fixate it to Cooper ligament with a permanent tack.

Small bowel obstruction Small bowel obstruction is possible, though very rare. It can occur from a loop of bowel herniating through a defect in the peritoneum, or adhering to the peritoneal closure fixation material. Patients who present with nausea and vomiting in the postoperative period should be aggressively evaluated to rule out this entity.

Urinary retention TEP and TAPP have a higher incidence of urinary retention than an open repair done under local anesthesia with sedation. This is likely due to the necessity of general anesthesia for laparoscopy. IEHS recommends fluid restriction (less than 500 cc intravenous fluids) during the operation to reduce the risk of urinary retention.

Port-site hernias As the TAPP repair violates the peritoneal cavity, it is no surprise that more port-site hernias occur with this repair as compared to the TEP. Adequate fascial closure of all trocar sites larger than 5 mm should be done to prevent this complication.

Visceral injuries Additionally with TAPP, visceral injury is more common than with TEP or an open repair, although it is still uncommon.

DISCUSSION Overall, there is no evidence showing superiority of TAPP versus TEP, but there are some small differences. A metaanalysis of a hernia database including over 17,000 patients found that the postoperative complication rate for TAPP versus TEP repair was slightly higher. However, this was determined to have an association with the higher rate of large hernia defects and scrotal inguinal hernias that were repaired using TAPP.2 Additionally, one prospective randomized study of almost 300 patients found that TAPP was associated with longer operative time and higher incidence of early postoperative pain compared to TEP, but TEP was associated with more seroma formation. Overall, long-term outcomes were comparable between the two.3

References 581

Finally, a Cochrane review of TEP versus TAPP determined that TAPP is associated with higher rates of portsite hernias and visceral injuries; however, there were more conversions to open repair with TEP. Importantly, it found no economic difference between the two. The intraoperative and general postoperative complication rates, as well as reoperation rates, were similar for the TEP and TAPP repairs.4

CONCLUSION A TAPP technique offers solutions to the complex and common problem of repair of inguinal hernias. It has similar

efficacy and complication rates as the TEP repair. In a skilled laparoscopic surgeon’s hands comfortable with this technique, the TAPP offers a unique skill set for approaching specific complications of inguinal hernias.


1. Bittner R et al. Surg Endosc 2011;25(9):2773–843. 2. Köckerling F et al. Surg Endosc 2015;29(12):3750–60. 3. Bansal VK et al. Surg Endosc 2013;27(7):2373–82. 4. Wake BL et al. Cochrane Database Syst Rev 2005;(1):CD004703.

96 Laparoscopic component separation RUSSELL C. KIRKS, JR. AND DAVID A. IANNITTI

INTRODUCTION Incisional hernia complicates approximately 10%–20% of planned laparotomies and up to 35% of emergency procedures.1 The optimal technique of ventral incisional hernia repair has evolved over time from primary suture repair with attendant risk of recurrent hernia to repairs incorporating reinforcing mesh. Fascial approximation with recreation of the linea alba and mesh reinforcement has been shown to be superior to suture repair.2–4 Hernias whose size precludes full medialization of the rectus muscles present a challenge to surgeons. Other difficult scenarios include closure of a longterm open abdomen following trauma or abdominal catastrophe, and the management of a hernia defect after excision of infected mesh used in a previous ventral hernia repair. In 1990, Ramirez, Ruas, and Dellon presented a case series of patients treated for massive incisional hernias with a new technique presented as the “components separation method.”5 The described components are the layers of the abdominal wall, which were further investigated in the paper with a cadaveric study. As classically described, the medial borders of the rectus musculature were brought together in the setting of a massive hernia by dividing the external oblique aponeurosis (EOA) and reflecting the external oblique muscles laterally so that these lateralanchoring muscles would allow medialization of the rectus. As described by Ramirez et al.,5 10 cm of rectus medialization was accomplished by unilateral division of the EOA; therefore, with bilateral EOA component separation, a defect 20 cm in size could be closed primarily by suturing the medial borders of the rectus to recreate the linea alba. The authors, plastic surgeons by training, advocated for this technique in large ventral hernias to obviate the need for pedicled flaps of fascia and muscle from other sites that were used to patch the residual defect when full apposition of the rectus muscles was not possible during conventional repair of giant ventral hernias (Figure 96.1).

This technique began with a midline incision and adhesiolysis to free intestinal adhesions from the fascial edge. In order to access the linea semilunaris to perform component separation, lipocutaneous flaps were raised with electrosurgical devices. Dissection was continued laterally until the linea semilunaris and an additional 2–3 cm of external oblique muscle were exposed prior to division of the EOA. This initial report includes division of neurovascular bundles that supply the lipocutaneous flaps; this creates a large dead space between the anterior abdominal wall musculature and the overlying complex of adipose tissue and skin. Though the initial report and case series of 11 patients published by Ramirez et  al. 5 reported no wound-related complications, subsequent case series using the open components separation (OCS) technique described by these authors reported wound complications of up to 62%.6–9 Variation in hernia size,5–8 mesh utilization,10–13 definitions of severity of wound complications, and length of followup between case series complicate the formation of definite conclusions, but an accepted wound complication rate of approximately 30% led to some surgeon reticence to incorporate the components separation technique as described by Ramirez et al. into clinical practice for massive hernias. The major morbidity of anterior component separation incorporating EOA division is wound-related morbidity due to the extensive lipocutaneous undermining and dead space creation required to access the EOA. Though “perforator”preserving (or vessel-preserving) techniques are described, raising the lateral lipocutaneous flaps compromises the vascular supply to the overlying adipose tissue and skin while simultaneously leaving the resulting dead space in communication with the incision used to repair the hernia defect. Though subcutaneous drains are routinely employed to drain the dead space created by this dissection, the series listed describes a high rate of wound-related complications ranging from cellulitis to wound breakdown requiring operative debridement and revision. These high levels of

Laparoscopic component separation technique: Intermuscular approach (Maas/Rosen)  583 2 1

1 1







result in a shorter length of stay. In a series comparing seven hernias repaired by LCS with thirty repaired via the open technique, Lowe et al. described a laparoscopically assisted percutaneous method for accessing and dividing the EOA.15 This technique utilizes expanding dissection balloons to expose the anterior abdominal wall and represents a laparoscopic-assisted version of the OCS technique in which the anterior surface of the EOA is directly visualized and divided. This technique was subsequently modified by Maas in 200116 and later by Rosen in 200717 to incorporate dissection between the external and internal oblique muscles. Here, the dissection balloon is placed between layers of the abdominal wall so that external oblique release is performed by dividing the posterior surface of the EOA rather than by addressing its anterior surface as described by Ramirez et al.5 and Lowe et al.15



Figure 96.1  A cross-sectional representation of the

muscular and fascial layers of the abdominal wall provided in Ramirez et al.’s 1990 description of open components separation. The external oblique aponeurosis is divided and the external oblique muscle reflected laterally to facilitate medialization of the rectus abdominis (RA) muscle for coverage of the midline hernia defect. (Reprinted with permission from Ramirez OM et al. Plast Reconstr Surg 1990;86[3]:519–26.)

wound-related complications also resulted in reticence to place synthetic mesh for hernia reinforcement. Some early series describing component separation hernia repairs utilized expanded polytetrafluoroethylene (ePTFE) mesh with high rates of infection requiring mesh excision14; this further limited the widespread use of mesh in early series until biologic or semisynthetic materials became more extensively developed and widely available. In addition to optimizing operative sterility practices and patient-related factors, such as eliminating tobacco use prior to elective component separation hernia repairs, two additional techniques were developed to combat the woundrelated morbidity associated with component separation: posterior component separation (PCS) and laparoscopic component separation (LCS). In 2000, Lowe et al. presented the first description of laparoscopic anterior component separation.15 Acknowledging the wound-related morbidity of open external oblique release, this group hypothesized that a percutaneous laparoscopic-assisted technique would minimize vascular soft tissue damage with resulting flap hypoperfusion and would result in fewer wound complications, decreased pain, and improved cosmesis, which would

With the patient in the supine position, a midline laparotomy is performed and the hernia reduced. The hernia sac is excised. Adhesions of bowel to the posterior abdominal wall and midline fascia are divided. To perform LCS, the locations of the inferior costal margin, 11th rib, and anterior superior iliac spine (ASIS) serve as palpable landmarks. A small incision is made 5 cm medial to the ASIS, and blunt dissection is used to expose the anterior abdominal wall at the expected location of the linea semilunaris. A laparoscopic dissector balloon is placed into this incision and inflated to create a space superficial to the anterior abdominal wall. Once the space is created to the level of the inferior costal margin, a second incision is made 2 cm caudal to the inferior costal margin inline with the ipsilateral lower abdominal incision. A trocar is placed in this location, and a second trocar is placed 3 cm superior and medial to the first laparoscopic incision. The dissection exposes the EOA, and the muscle is divided progressively until it has been released from the costal margin to the level of the ASIS. The muscle is then retracted laterally; this typically requires blunt mobilization to facilitate lateral reflection of the external oblique muscle. Prior to completing the midline fascial reapproximation, closed suction drains are left in the developed space (Figures 96.2 and 96.3).

LAPAROSCOPIC COMPONENT SEPARATION TECHNIQUE: INTERMUSCULAR APPROACH (MAAS/ROSEN) After entering the abdomen through a midline laparotomy, resecting the hernia sac, and dividing adhesions to the posterior abdominal wall and midline fascia, palpation along the unilateral rectus muscles from the abdominal incision identifies their lateral border. A 2  cm transverse incision

584  Laparoscopic component separation

Figure 96.2  As described originally by Lowe et al.,


an inguinal hernia balloon dissector is placed superficial to the anterior abdominal wall and expended to create a space whose inferior surface is the abdominal wall at the level of the linea semilunaris; the superior and lateral borders are adipose tissue. (Reprinted with permission from Lowe JB et al. Plast Reconstr Surg 2000;105[2]:720–9; quiz 30.)

is made at the expected site of the midpoint of the linea semilunaris and is carried down through the subcutaneous tissues until the EOA is identified. The aponeurosis is elevated, and an incision in the EOA is made lateral to its insertion along the lateral edge of the anterior rectus sheath. The internal oblique muscle is reflected posteriorly, and the dissecting balloon is introduced and inflated. As described

Figure 96.3  Once the space is created anterior to the

abdominal wall, additional trocars are placed for retracting/dissection instruments and an energy device or shears to divide the EOA. (Reprinted with permission from Lowe JB et al. Plast Reconstr Surg 2000;105[2]:720–9; quiz 30.)

by Maas et al.,16 the balloon is removed and the EOA is elevated with retractors; a 30° laparoscope is then inserted into the plane developed between the oblique muscles. Division of the EOA is performed from the pubic symphysis to the inferior costal margin via instruments inserted through the single skin incision previously utilized for introduction of the balloon dissector. As described by Rosen et  al.,17 a two- to three-trocar approach is utilized for component separation. A 1–2 cm incision is made lateral to the lateral border of the rectus muscles 2–3 cm caudal to the inferior costal margin, and dissection through the subcutaneous tissues exposes the EOA. The EOA is elevated between clamps and incised in the superolateral to inferomedial direction of the fibers of the EOA. The internal oblique muscle is then visualized, and an expanding balloon dissector is introduced between the EOA and the internal oblique muscle; a small amount of blunt dissection may be required to create a pocket for initial balloon placement. The space is created by insufflating the balloon toward the inguinal region. Confirmation of the correct location of dissection is accomplished by analyzing the orientation of the muscle fibers forming the anterior and posterior confines of the created space. The anterior wall is composed of the external oblique muscle with inferomedial fibers, while the posterior wall should have superomedially oriented fibers of the internal oblique muscle. The balloon dissector is then replaced by a balloon-tipped trocar, through which the expanded space is maintained via pneumoinsufflation to 12–14 mm Hg. Additional dissection of this intermuscular plane is carried out bluntly as needed with a 30° laparoscope to expose the areas in which the working ports are inserted. Two 5 mm working ports are then placed under laparoscopic visualization for retraction and division of the EOA. The first is placed at the level of the umbilicus in the posterior axillary line; an alternative location for this port is one-third of the distance from the costal margin to the ASIS but also in the posterior axillary line.18 The second trocar is placed lateral to the rectus sheath cephalad to the inguinal ligament. Under laparoscopic visualization via the superior port, the intermuscular plane is fully developed from the external oblique muscle insertions on the lower ribs to the pubic symphysis and medial inguinal ligament. Full exposure of the intermuscular space will reveal the lateral rectus sheath as the medial extent of the space and will continue laterally to the posterior axillary line (Figure 96.4). Under laparoscopic visualization, the external oblique muscle release is performed as described by Rosen17 with laparoscopic shears coupled with cautery; alternatively, an ultrasonic dissector may be employed. The energy device is deployed through the medial incision, and dissection is visualized through either the superior or inferior incision. Changing laparoscope location may be required to visualize the cephalad or caudal extents of the dissection. The incision is made at the junction of the external oblique muscle and aponeurosis and performed from the superior insertions of the EOA along the inferior ribs to the pubic

Laparoscopic component separation technique: Intermuscular approach (Maas/Rosen)  585

Aponeurosis of external oblique


Cranial External oblique Dissecting balloon Internal oblique Transverse abdominis


Figure 96.4  Interoblique balloon dissection technique described by Rosen et al.

The space is directly accessed by incising the external oblique aponeurosis. The dissection balloon is inserted and serially inflated and desufflated, progressing from the initial subcostal incision toward the inguinal ligament. (Reprinted with permission from Rosen MJ et al. Hernia 2007;11[5]:435–40.) 17

symphysis. Once full fascial release has been accomplished and the space has been inspected for hemostasis, a closed suction drain is introduced into the space and the cutaneous incisions are closed. The technique is repeated on the contralateral side for maximal rectus medialization (Figure 96.5). An alternative technique combining the approach of Rosen et  al.17 with that of Clarke19 is utilized in our

institution. This begins with a 2 cm incision and dissection to the EOA at the inferior costal margin and insertion of a balloon dissector deep to the EOA. The balloon is then sequentially inflated, delated, and advanced, progressing caudally to develop the intermuscular space. Once the space is developed to the level of the inguinal ligament, the balloon dissector is removed, and a narrow “S” retractor is used to elevate the EOA. A 5 mm 30° laparoscope is introduced Camera port Cranial



External oblique

Rectus Instrument port Internal oblique

Figure 96.5  After developing the interoblique space, the balloon dissector is replaced with a balloon trocar. Additional ports are placed for retraction and scissors or an energy device are used to divide the external oblique aponeurosis. Dividing attachments on the lower costal margin and pubis may require instrument and camera exchange between trocars. (Reprinted with permission from Rosen MJ et al. Hernia 2007;11[5]:435–40.)

586  Laparoscopic component separation (a)


Figure 96.6  (a) A 2 cm incision is made 2–3 cm caudal to the inferior costal margin in the midclavicular line at the expected location of the edge of rectus. This is confirmed by palpating the lateral extent of the rectus muscle from the midline incision. A balloon dissector is inserted into the intermuscular space and sequentially inflated, deflated, and advanced caudally to separate the external and internal oblique muscles. (b) The orientation of the laparoscope and instruments used to perform external oblique release.



Figure 96.7  (a) Laparoscopic appearance of the intermuscular space. The edge of rectus is seen as the right lateral border of

the space, while the internal oblique muscle is seen inferiorly. The external oblique aponeurosis is seen as the superior border of the space. (b) Division of the external oblique aponeurosis exposes the adipose tissue between the aponeurosis and the abdominal skin.

into the space, and the EOA is visualized as the “roof” of the space. A laparoscopic hook electrocautery device is introduced into the space, and the EOA is progressively divided from the inguinal ligament to the inferior costal margin as the laparoscope and cautery device are withdrawn from the inguinal region toward the incision at the inferior costal margin. The intermuscular space is not insufflated in this technique. This avoids the routine use of a balloon port and additional flank or lower abdominal incisions and trocars, and may compare favorably in terms of procedure cost (Figures 96.6 and 96.7). While this minimally invasive, two-incision laparoscopic component separation may be performed to aid with closure of an open abdomen, it could also be used in elective repair

of a ventral hernia. Combining this measure with laparoscopic ventral hernia repair allows for primary fascial closure prior to mesh placement.

OPEN VERSUS LAPAROSCOPIC COMPONENT SEPARATION: COMPARISON OF OUTCOMES Given a historical wound morbidity rate ranging from 20% to 62%,6–8,10,11,20 development of a minimally invasive component separation technique as outlined has focused on differences in wound complications, such as wound infection, seroma formation, skin necrosis, and wound dehiscence. Hernia recurrence, ranging from 8% to 32%

Open versus laparoscopic component separation: Comparison of outcomes  587

in open series,6,11 has also been examined along with hospital length of stay. Though animal models comparing laparoscopic and open anterior component separation suggest that laparoscopic release of the external oblique muscle achieves approximately 86% of the myofascial advance obtained through open release, 21 initial studies such as that by Lowe15 comparing open and endoscopic component separation identified no difficulty in obtaining rectus medialization and defect coverage with a median defect size of 315 cm 2. Variations in hernia defect size, use and type of mesh reinforcement, length of postoperative follow-up, and inclusion of an institutional open component separation arm are reported in series detailing outcomes after laparoscopic component separation. The definitions of major wound complications also vary between studies. While Lowe’s initial case series reporting the anterior approach to laparoscopic component separation reported no wound complications and a hernia recurrence rate of 14%,15 the intermuscular approach described by Rosen et al. reported a wound complication rate of 29%.17 Notably, Rosen’s 2007 study was performed for the treatment of recurrent hernias with active infection requiring mesh excision; no recurrences were noted in this series with a short followup period. The institutional experience with open and laparoscopic anterior component separation reported by Harth in 201022 and subsequently in 201123 demonstrates decreased wound complication rates (27% LCS versus 50% OCS in 2010; 28% LCS versus 46% OCS in 2011). Hernia

recurrence reported in the earlier Harth study was similar between arms (27% LCS versus 27% OCS).22 Decreased wound-related morbidity was reinforced by Giurgius et al. in a case series comparison of the two techniques with a resulting significant decrease in woundrelated morbidity (19% LCS versus 57% OCS, p = 0.03); a single hernia recurrence in the LCS group (5%) and no recurrence in the open cohort (p = NS) were reported.24 In 2013, Fox et al.25 also reported a decreased wound-related morbidity in their retrospective series comparing 18 LCS with 26 OCS procedures. The wound complication rate was decreased in the LCS group compared with the OCS group (6% LCS versus 27% OCS, p = NS) with an accompanying decrease in hernia recurrence rate (17% LCS versus 27% OCS, p = NS).25 Similar results were reported by Albright et al. and Ghali et al., who found decreased wound complications in the laparoscopic group.26,27 In Albright’s series, surgical intervention for wound complications was performed exclusively in the OCS group. Given lower rates of wound morbidity and infection with the endoscopic technique, several authors recommend this approach for thick abdominal walls with expected lipocutaneous ischemia should OCS be performed, 22 in the case of infected mesh in the midline with or without recurrent hernia,17,26 or for multiple recurrent ventral hernias with no history of components separation. The size of the hernia defect must also be considered during operative planning, as full mobilization with OCS may be required for defects approaching 20 cm in size (Table 96.1).

Table 96.1  Summary of population and outcomes of referenced series of hernia repairs completed with the component separation technique Author


Wound morbidity, Number (%)

Hernia recurrence, Number (%)

Defect size, median, cm2

Ramirez et al.5 Lowe et al.15 Girotto et al.10 de Vries Reilingh et al.6 Borud et al.7 Rosen et al.17 Ko et al.8 Harth and Rosen22

11 OCS 7 LCS 96 OCS with onlay mesh 43 OCS 12 OCS 7 LCS 200 OCS 22 OCS 22 LCS 22 OCS 32 LCS 14 OCS 21 LCS 50 OCS 57 LCS 26 OCS 18 LCS 58 OCS with onlay mesh 74 OCS with preperitoneal mesh

0 0 25 (26) 14 (33) 6 (50) 2 (29) 86 (43) OCS: 11 (50) LCS: 6 (27) OCS: 10 (46) LCS: 9 (28) OCS: 8 (57) LCS: 4 (19) OCS: 16 (32) LCS: 8 (14) OCS: 7 (27) LCS: 1 (6) 19 (33) 10 (14)

0 1 (14) 21 (22) 12 (28) 1 (8) 0 (0) 43 (22) OCS: 6 (27) LCS: 6 (27) – – OCS: 0 (0) LCS: 1 (5) OCS: 4 (8) LCS: 2 (4) OCS: 7 (27) LCS: 3 (17) 4 (7) 3 (4)

216 315 140 234 10–15 cm wide 338 – 392 OCS 324 LCS – – – – 273.8 ± 193.6a 405.4 ± 186.8a – – – 299 ± 161

Harth et al.23 Giurgius et al.24 Ghali et al.27 Fox et al.25 Singh et al.11 Klima et al.12

Abbreviations: LCS, laparoscopic component separation; OCS, open component separation. a Defect size reported as mean ± standard deviation.

588  Laparoscopic component separation

OPEN VERSUS LAPAROSCOPIC COMPONENT SEPARATION: COMPARISON OF QUALITY OF LIFE Large ventral hernias can cause pain, physical limitation, and psychosocial difficulties for patients; the size of giant ventral hernias or patient comorbidities such as diabetes, tobacco use, previous infection, or previous failed repairs may make surgeons reluctant to pursue elective repair. Hernia size and history of recurrence, however, are two factors that influence the choice of component separation when repair is undertaken. Compared with bridging mesh techniques, recreation of the musculofascial abdominal wall via primary fascial approximation improves the function of the abdominal wall and decreases hernia recurrence.9,10,28 Though wound complications and recurrence are followed in surgical series describing hernia repair with component separation, restoration of abdominal wall function, patient mobility and activity, and minimization of discomfort are also goals of repair. A retrospective review of traditional OCS repairs and minimally invasive component separation identified higher rates of postoperative pain when the minimally invasive technique was used.19 In this population, quality of life (QOL) after ventral hernia repair in the setting of component separation has been analyzed prospectively alone29 or compared with patients who underwent open ventral hernia repair with mesh12,14 to better characterize differences in QOL after hernia repair with or without component separation. Varying methods of assessing QOL are employed between  the studies. Thomsen issued a questionnaire addressing general health and wellness as well as herniaspecific fields, including hernia-related pain, gravity, and mobility limitation during various movements and body positions. A verbal rating scale was also employed to assess patient-perceived impairment of mental and physical health.29 Pre- versus postoperative analgesic and alcohol consumption were also assessed. In this case series of 19 patients undergoing primarily bilateral (94.7%) endoscopic component separation, 15 patients (78.9%) were available for follow-up at 2 and 6 months after surgery. The authors found a decrease in mean alcohol consumption, while 12 patients (80%) reported stable or decreased analgesic consumption at long-term follow-up. No subgroup analysis was performed to establish the effect of postoperative complications on long-term QOL, and no comparison group of patients whose hernia was repaired via open component separation was available. Klima et  al. assess QOL in patients undergoing OCS compared with that reported by patients undergoing open ventral hernia repair without component separation.12 In this study, the Carolinas Comfort Score (CCS) is employed to assess QOL, pain, hernia-related movement limitation, and mesh sensation during eight daily activities. This study compared QOL as measured by the CCS at 1 month and up to 12 months after surgery in cohorts of patients

undergoing open ventral hernia repair with (n = 74) or without (n = 154) component separation. QOL outcomes by aggregate CCS score and by category (pain, movement limitation, and mesh sensation) were equivalent at the measured time points, which suggests that hernia repairs requiring component separation for fascial closure do not adversely affect QOL in short- or long-term follow-up when compared with standard ventral hernia repair procedures. In this series, wound morbidity was higher in the component separation group, including skin dehiscence and seromas that required intervention; however, these patients were not isolated for subgroup QOL analysis.

ROBOTIC POSTERIOR COMPONENT ­SEPARATION TECHNIQUE: TRANSVERSUS ABDOMINIS RELEASE Posterior component separation may be utilized when defect size does not require anterior component separation, after previous anterior component separation with recurrent ­hernia, or in patients at high risk of wound complication following an open anterior component separation.20 Early reports of robot-assisted ventral hernia repair focused on assessment of feasibility and safety. The dexterity of the surgical robot was cited as a potential improvement over traditional laparoscopic ventral hernia repair with mesh, because tackers were replaced by continuous intracorporeal suture fixation of the mesh to the abdominal wall (intraperitoneal onlay) with a resulting potential decrease in the chance of postoperative pain. Robotic primary closure of the defect, also differing from laparoscopic ventral hernia repair, was cited as a potential benefit.30,31 Robotic ventral hernia repair with mesh has also modified traditional laparoscopic ventral hernia repair by developing preperitoneal flaps for mesh placement and subsequent running peritoneal closure to avoid intraperitoneal mesh placement; as described by Sugiyama et al., the defect itself is not closed due to size.32 The robotic platform has now been utilized to perform posterior component separation procedures involving the posterior rectus sheath: the Rives-Stoppa retrorectus hernia repair and the transversus abdominis release (TAR).33 Robotic Rives-Stoppa repairs with component separation have been described with three ports placed lateral to the linea semilunaris in locations similar to those used for laparoscopic ventral hernia repair. The camera is placed in the central trocar, and the working arms are placed inferior to the lower costal margin and superior to the ASIS. Care must be taken to provide adequate distance from these bony prominences to prevent robotic arm pressure and risk of patient injury. Ideally, working ports should each be placed 8–10 cm cranial or caudal to the camera port location and slightly anterior to the camera. After dividing adhesions of bowel or omentum to the posterior surface of the abdominal wall, the posterior rectus sheath is incised 1 cm lateral to the midline, and the rectus

Adjunctive measures to assist fascial approximation  589

abdominis is reflected anteriorly to develop a retrorectus space while placing downward traction on the posterior rectus sheath fascia. The retrorectus dissection continues laterally until the edge of the rectus muscle at the linea semilunaris is encountered. If Rives-Stoppa–type retrorectus repair is intended, mesh is placed and the posterior rectus sheath is closed in running fashion with absorbable suture. Transversus abdominis release is begun by dividing the fibers of the transversus abdominis (TA) muscle as they insert onto the lateral extent of the anterior surface of the posterior rectus sheath. The muscle is pushed laterally to expose the complex of transversus abdominis fascia and underlying peritoneum. The lateral-to-medial oriented muscle fibers of the TA muscle are visualized, and an initial incision into this layer will expose the muscles. The TA is then divided approximately 1 cm from its medial insertion using monopolar electrocautery-linked Hot Shears (Intuitive Surgical, Inc., Sunnyvale, California). During this portion of the procedure, close attention must be paid to the bowel deep to the muscular division to ensure no thermal injury to the bowel. If possible, neurovascular bundles passing from the interoblique space into the rectus muscles should be preserved to prevent rectus atrophy. As with open posterior component separation, the robotic arms provide downward tension to the posterior rectus sheath, while dissection is carried out bluntly, primarily pushing the TA muscle laterally to create a pocket for the mesh. This dissection separates muscle fibers inserting onto the inferior costal margin and the pubic symphysis for full muscular release. A similar dissection is carried out on the contralateral side, which requires placement of mirror-image lateral abdominal or flank incisions on the contralateral side. Depending on which robotic platform is used, this may require robot undocking and relocation to the opposite side or rotating the operating room table 180° (da Vinci Si, Intuitive Surgical, Inc.) or reorienting the robotic arms with less movement of the robotic tower (da Vinci Xi, Intuitive Surgical, Inc.). After measuring the size of the defect, a piece of mesh allowing adequate defect overlap is introduced into the abdomen and placed in the retromuscular space; this is typically performed through the 12 mm port placed in the contralateral flank that served as the previous camera port. A transabdominal suture may be employed to suspend the mesh while it is unfurled and situated in the retrorectus space with the robotic arms. Mesh fixation can be performed robotically with interrupted or running suture; when performing a Rives-Stoppa repair, mesh fixation can also be performed with tacking devices employed by a bedside surgeon. The mobilized posterior rectus sheath is then closed primarily; this is performed in running fashion with V-Loc suture (Medtronic, Minneapolis, Minnesota). A closed suction drain can be placed between the peritoneum and mesh (TAR) or in the retromuscular space (Rives-Stoppa repair) through one of the working port insertion sites, as muscular mobilization for full TAR has been carried lateral to port placement sites.

Figure 96.8  Port placement for robotic posterior com-

ponent separation. The hernia defect is shaded. Eight millimeter robotic arms (1,2) with a central 12 mm camera port are placed in the lateral abdomen. An assistant port (A) can also be used for retraction assistance, initial adhesiolysis, or introduction of the mesh. (Figure reproduced with permission from Intuitive Surgical, Inc., Sunnyvale, California, 2016.)

A 21-patient series reported by Warren et  al. found equivalent incidence of surgical site infection with shorter hospital length of stay by comparing patients treated with open versus robotic retrorectus repair with mesh.33 Fewer wound infections were observed in the robotic group; however, this difference did not reach statistical significance. No difference was found in hospitalization cost between the two groups; this observation may be due to shorter hospital length of stay in the robotic group or decreased cost of robotic surgery over time. Further studies with longer follow-up periods are required to fully describe outcomes following robotic posterior component separation compared with the open and endoscopic component separation techniques (Figure 96.8).

ADJUNCTIVE MEASURES TO ASSIST FASCIAL APPROXIMATION Primary fascial closure of a prolonged open abdomen or in hernias with extensive loss of abdominal domain may be complicated by lateralization of the abdominal wall musculature and fascia. Though component separation may be required in these patients, even a maximal 20 cm release afforded by bilateral external oblique release may be inadequate to fully approximate the midline fascia. In these select settings, preoperative interventions have been employed to expand the abdominal wall or to allow improved relaxation of lateralized muscle and fascia.

590  Laparoscopic component separation

Though McAdory et  al. have described administering progressive preoperative pneumoperitoneum with inert medical gas via a laparoscopically placed transabdominal catheter to prepare patients with abdominal loss of domain for the increased intra-abdominal pressure that accompanies reconstitution of the abdominal wall,34 injection of botulinum toxin into the lateralized musculofascial complex has been more extensively described as a preoperative method to facilitate abdominal wall reconstruction. Building on imaging evidence of hernia defect size decrement with onabotulinumtoxinA (Botox, Allergan, Dublin, Ireland) injections into the lateral abdominal musculature, 35 Elstner et al. report a case series of ultrasoundguided bilateral transversus abdominis, internal oblique, and external oblique Botox injections prior to laparoscopic ventral hernia repair with mesh for patients with large ventral incisional hernias.36 This study found a significant decrease in hernia defect size resulting from the muscular relaxation, a technique that the authors term a “chemical components relaxation.” Six patients in this series required LCS with partial external oblique release to achieve midline fascial reapproximation without tension. There were no complications relating to Botox injection, and all defects were closed.36 Botulinum toxin injection represents an adjunctive technique that is safe and effective in patients with large defects in whom component separation may not fully cover the defect based on preoperative imaging. When performed, components relaxation of the lateralized musculofascial complex is performed at least 3 weeks prior to planned hernia repair to optimize muscular relaxation. The components relaxation effect typically lasts for up to 3 months. A similar approach has also been incorporated into the management of the open abdomen by Zeilinski et al. who perform ultrasound-guided abdominal wall musculature Botox injections in patients with an open abdomen or patients undergoing repeated procedures.37 The authors advocate the use of this technique to avoid bridging mesh placement and to avoid extensive dissection and traditional components separation in patients recovering from recent critical illness or trauma. Performing traditional component separation in this setting may preclude future options for hernia repair should a hernia develop. Especially in patients with risk factors for wound complications, a combination of Botox injection and LCS may allow for fascial approximation while mitigating the wound morbidity of OCS.

CONCLUSION Component separation to obtain fascial closure is a useful technique in the setting of large ventral hernias, open abdomen closure following trauma or multiple abdominal procedures, or after excision of infected mesh. To mitigate the substantial wound morbidity associated with classical open component separation by external oblique

release, laparoscopic component separation and posterior component separation techniques are attractive options. Detailed knowledge of the fascial and muscular layers of the abdominal wall is required to perform these procedures. Though wound morbidity is lowered by the use of laparoscopic techniques, hernia recurrence with primary tissue repair remains higher than in series of open ventral hernia repair with preperitoneal or retromuscular mesh reinforcement. To optimize hernia repair and lower recurrence, the use of mesh reinforcement of the midline closure is suggested.

REFERENCES 1. Deerenberg EB et al. Hernia 2015;19(1):89–101. 2. Luijendijk RW et al. N Engl J Med 2000;343(6):392–8. 3. Burger JW et al. Ann Surg 2004;240(4):578–83; discussion 83–5. 4. Korenkov M et al. Br J Surg 2002;89(1):50–6. 5. Ramirez OM et al. Plast Reconstr Surg 1990;86(3):519–26. 6. de Vries Reilingh TS et al. J Am Coll Surg 2003;196(1):32–7. 7. Borud LJ et al. Plast Reconstr Surg 2007;119(6):1792–8. 8. Ko JH et al. Arch Surg 2009;144(11):​1047–55. 9. DiCocco JM et al. J Am Coll Surg 2010;210(5):​686–95, 95–8. 10. Girotto JA et al. Plast Reconstr Surg 2003;112(1):106–14. 11. Singh DP et al. Surg Innov 2014;21(2):137–46. 12. Klima DA et al. Surg Innov 2014;21(2):147–54. 13. Hood K et al. Am J Surg 2013;205(3):322–7; discussion 7–8. 14. de Vries Reilingh TS et al. World J Surg 2007;31(4):756–63. 15. Lowe JB et al. Plast Reconstr Surg 2000;105(2):​720–9; quiz 30. 16. Maas SM et al. J Am Coll Surg 2002;194(3):388–90. 17. Rosen MJ et al. Hernia 2007;11(5):435–40. 18. Ross SW et al. Surg Technol Int 2014;24:167–77. 19. Clarke JM. Am J Surg 2010;200(1):2–8. 20. Pauli EM et al. Hernia 2015;19(2):285–91. 21. Rosen MJ et al. Am J Surg 2007;194(3):385–9. 22. Harth KC et al. Am J Surg 2010;199(3):342–6; discussion 6–7. 23. Harth KC et al. Surg Endosc 2011;25(9):2865–70. 24. Giurgius M et al. Hernia 2012;16(1):47–51. 25. Fox M et al. Am J Surg 2013;206(6):869–74; discussion 74–5. 26. Albright E et al. Am Surg 2011;77(7):839–43. 27. Ghali S et al. J Am Coll Surg 2012;214(6):981–9. 28. Abrahamson J et al. Lancet 1989;​1(8642):847. 29. Thomsen CO et al. Scand J Surg 2016;105(1):11–6. 30. Allison N et al. World J Surg 2012;36(2):447–52. 31. Gonzalez AM et al. Int J Med Robot 2015;11(2):120–5. 32. Sugiyama G et al. JSLS 2015;19(4):1–3. 33. Warren JA et al. Prospective, observational, cohort study of robotic Rives-Stoppa retrorectus incisional hernia repair. In: First World Conference on Abdominal Wall Hernia Surgery, Milan, Italy, April 25–29, 2015. 34. McAdory RS et al. Am Surg 2009;75(6):504–8; discussion 8–9. 35. Farooque F et al. ANZ J Surg 2016;86(1-2):​79–83. 36. Elstner KE et al. Hernia 2016;20(2):209–19. 37. Zielinski MD et al. Hernia 2013;17(1):101–7.

97 Biomaterial considerations in laparoscopic hernia repair BRENT D. MATTHEWS



Since the first publications of laparoscopic repair of inguinal hernias (1992) and ventral hernias (1993) with mesh, these minimally invasive techniques have evolved significantly due to technical advancements in the procedures. 2,14 Patients may experience a reduced length of stay and lower incidence of wound morbidity after laparoscopic ventral hernia repair and less postoperative pain and an earlier return to work after laparoscopic inguinal hernia repair compared to open techniques. 3–6 Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) revealed that utilization rates of laparoscopy for inguinal hernia repair and ventral hernia repair are 27% and 22%, respectively.1,23 In recent years, innovative designs in mesh and fixation devices have facilitated the use of laparoscopy for inguinal and ventral herniorrhaphy. More specifically, novel materials altered to manipulate the fiber size and pore size, thus mesh density (g/m 2), or prosthetic material designs having partially absorbable composite materials and absorbable or nonabsorbable barrier layers for intraperitoneal placement are design modifications to provide patient-centered alternatives to mesh selection. A surgeon’s understanding of the structural aspects of mesh designs and their potential influence on patient outcomes such as hernia recurrence, functionality, and postoperative pain is critical. This chapter provides an overview of prosthetic material designs for laparoscopic inguinal and ventral hernia repair with an appraisal of implications on clinical outcomes important to hernia patients and the surgeons who provide care for them.

Mesh composition Permanent prosthetic materials are typically utilized for elective laparoscopic inguinal and ventral hernia repair. Completely resorbable or biologic meshes will not be referenced in this chapter. These single-polymer meshes are most commonly composed of polypropylene, polyester, or polytetrafluoroethylene. Examples are PROLENE Mesh, Ethicon Inc., and ProLite Mesh, Atrium Medical Corp., representing polypropylene; Parietex Lightweight Monofilament Polyester Mesh, Covidien, Ltd., representing polyester; and INFINIT Mesh, W.L. Gore & Associates Inc., representing polytetrafluoroethylene. A unique feature for several meshes utilized for laparoscopic inguinal hernia repair is a three-dimensional or anatomically curved mesh to mimic the contour of the inguinal floor. 3DMax, Bard/Davol Inc., and PROLENE 3D Patch, Ethicon Inc., are polypropylene meshes with such designs. Such designs are not available for laparoscopic ventral hernia repair. The most comprehensive categorization of permanent synthetic mesh for inguinal and ventral hernia repair was recently introduced by Deeken and Lake.9 Reinforced meshes are constructed of a permanent and resorbable polymer. Per Deeken and Lake, the function of these resorbable fibers is to provide a gradual transfer of load back to the native tissue (abdominal wall or inguinal floor) as the repair site remodels, regenerates native tissue, and integrates through the interstices/pores of the mesh.9 Many of the low-density or “lightweight” meshes have this

592  Biomaterial considerations in laparoscopic hernia repair

feature, such as polypropylene-based meshes ULTRAPRO Mesh, Ethicon Inc., and SERAMESH PA, Serag-Wiessner. Barrier meshes, most appropriate for laparoscopic intraperitoneal onlay ventral hernia repair, are either composite or noncomposite. The barrier function is to minimize adhesions or ingrowth into the mesh, since it is exposed to the viscera (stomach, small intestine, colon, liver, and bladder). Composite meshes are composed of two discrete layers, the structural mesh and the antiadhesion barrier, with the two layers sewn or vacuum-pressed together.9 An example of a permanent barrier, composite mesh is Composix, Bard/Davol Inc., and resorbable barrier, composite meshes are C-QUR Mesh, Atrium Medical Corp. (Figure 97.1a), Ventralight ST Mesh, Bard/Davol Inc., or Parietex Composite (PCO) Mesh, Covidien, Ltd. Noncomposite, barrier meshes are composed of a single layer of material that exhibits antiadhesion characteristics on one side and tissue ingrowth features on the other side. An example of this type of mesh is DUALMESH Biomaterial, W.L. Gore & Associates Inc. (Figure 97.1b).



Figure 97.1  Laparoscopic ventral hernia repair: (a)

Resorbable barrier, composite mesh (C-QUR Mesh [Atrium Medical Corp.]). (b) Noncomposite, barrier mesh (DUALMESH Biomaterial [W.L. Gore & Associates Inc.]).

Biomechanical characterization The unique combination of parameters, such as size and shape of the interstices/pores (mm 2) and filament type, diameter (µm), thickness (mm), and density (g/m2), determine the mechanical properties of prosthetic mesh. The morphometric or mechanical properties can ultimately have consequences on mesh integration or the inflammatory reaction. This could subsequently alter the stability of the mesh-tissue interface, impact hernia recurrence rates, or cause chronic pain. There is still a significant gap in relating mechanical properties of prosthetic materials to clinical outcomes. Nevertheless, a fundamental understanding of mesh properties has been elucidated over the past 5 years through investigative partnerships between surgeons and engineers. Using standard techniques described by ASTM International and the in vitro application of relevant physiologic loads to simulate abdominal wall function, the physicomechanical properties of mesh utilized for laparoscopic inguinal and ventral hernia repair have been characterized.7,8 Mechanical properties such as suture retention strength (N), tear resistance (N), tensile strength (MPa), burst strength (N/cm), and strain (%) have been calculated to depict differences in the materials based on the combination of parameters previously described. In addition, the effect of repetitive loading on the mechanical properties of these materials has been determined.10 Any deterioration of the tensile strength of the mesh or an increase in the ability of the mesh material to stretch with repetitive loading could potentially lead to a less desirable functional result or hernia recurrence. Through these studies, important differences were discovered in the physicomechanical properties of polypropylene, polyester, polytetrafluoroethylene, partially absorbable, and barriercoated meshes frequently used for laparoscopic inguinal and ventral hernia repair. In general, as the density of mesh increases (ultra lightweight to lightweight to medium weight to heavyweight), the mechanical properties of the materials can be described as becoming stronger, stiffer, and less elastic. This does not necessarily equate to a more favorable clinical outcome. Other interesting properties arose, such as anisotropy, the property of being directionally dependent, implying different mechanical properties when oriented in different directions. The clinical relevance of these studies is described later, but the characterization and categorization of these materials have provided a basic understanding of how the structural aspects of each mesh design potentially influence functionality, outcome, and failure. Thus, it will be critical that future clinical trials be performed to assess patient-centered outcomes related to different mesh types based on their unique or differentiable mechanical properties. Laparoscopic ventral hernia repair and, to a lesser extent, laparoscopic inguinal hernia repair are dependent on fixation to provide acute tensile strength immediately following repair. A combination of suture and mechanical fixation for

Biomaterial performance in laparoscopic hernia repair  593

laparoscopic ventral hernia repair and mechanical fixation for laparoscopic inguinal hernia repair is typically applied. This ensures mesh stability to prevent migration of the mesh during tissue integration and short-term failure. The consequences of mechanical fixation on the physicomechanical properties of mesh are only now being evaluated.15,26 Many of the meshes evaluated exhibited damage in the form of reduced tensile strength and increased extensibility after the application of tacks (mechanical fixation). Higher-density meshes (“heavyweight”), which had smaller pore size and larger filaments, were influenced negatively by the application of a mechanical fixation device (helical titanium tacks) compared to the larger-pore and smaller-filament meshes. In addition, altering the deployment angles of different tackers affected the acute mesh-tissue fixation strength in vitro. As the number of mechanical fixation devices available for clinical use has increased over the past 5 years, these studies highlight the need to more fully understand what combination of mechanical fixation and mesh type is optimal to provide the most durable repair. Alternative types of fixation, such as fibrin sealants, have been evaluated. Used most frequently for laparoscopic inguinal hernia repair in the preperitoneal space and rarely for laparoscopic ventral hernia repair against the peritoneum, the effectiveness of fibrin sealant as a fixation device for mesh fixation is likewise altered by the composition and physical structure of the mesh in relationship to the mesh-tissue interface. Although likely effective with certain circumstances, fibrin sealants are currently not U.S. Food and Drug Administration-approved for mesh fixation, considered “off-label” use in the United States, and should be used cautiously with certain materials.

BIOMATERIAL PERFORMANCE IN LAPAROSCOPIC HERNIA REPAIR There are a considerable number of preclinical studies evaluating the biocompatibility and performance of mesh for laparoscopic hernia repair. Features such as adhesion formation, adhesion tenacity, mesh contracture, tissue integration (mechanical/histologic), and inflammatory response have been characterized to differentiate the materials to support clinical decision-making. Unfortunately, translating this information from experimentation in vivo (rodent, rabbit, canine, and porcine) to patients has significant limitations. Although preclinical studies are critical to safeguard safety and efficacy of biomaterials prior to clinical use, differences in anatomy, biomechanics, and physiologic response restrict the translation of results. Additionally, conflicts of interest between industry, who typically support these preclinical studies, and translational researchers potentially limit the reliability of these studies and likely impede the reporting of negative outcomes. Longitudinal, postmarket clinical trials evaluating biomaterials for laparoscopic inguinal and ventral hernia repair without comparative, case-matched cohorts also have similar limitations.

Nevertheless, numerous prospective, randomized trials of laparoscopic inguinal hernia repair evaluating the effect of biomaterials on clinical and quality of life outcomes have been completed. Unfortunately, there is a major gap in comparative clinical outcomes research evaluating biomaterials for laparoscopic ventral hernia repair. A summary of clinical trials evaluating biomaterials for laparoscopic inguinal and ventral hernia repair follows.

Laparoscopic inguinal hernia repair Sajid et al. completed a systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh following laparoscopic inguinal hernia repair.21 Primary outcomes from the 11 prospective, randomized clinical trials were recurrence, physical function, and quality of life. Hernia recurrence rates were similar for lightweight and heavyweight meshes. However, lightweight mesh reduced the incidence of chronic groin pain, groin stiffness, and foreign body sensations. In a prospective, randomized clinical trial with 3 years follow-up, Peeters et al. analyzed the effects of lightweight and heavyweight meshes on male fertility, chronic pain, and recurrence after laparoscopic inguinal hernia repair.19 Recurrence rates were comparable between lightweight and heavyweight mesh. In addition, quality of life (SF-36) and chronic pain (McGill Pain Questionnaire) were similar. There was a decrease in sperm motility in patients after laparoscopic inguinal hernia repair with a lightweight mesh compared to patients operated on with a heavyweight mesh at 1 year postoperative follow-up. This particular outcome was not present at 3 years follow-up. In a prospective, randomized clinical trial comparing lightweight polypropylene to heavyweight polyester mesh for laparoscopic inguinal hernia repair, Wong et  al. reported similar clinical outcomes for discomfort, foreign body sensation, and recurrence during long-term follow-up.25 This was an unusual comparison, as virtually all trials have evaluated the same polymer. There was a significantly higher incidence of seromas in the heavyweight polyester group. The TULP trial, a prospective, double-blind, randomized control trial was completed to assess chronic postoperative pain, quality of life, and recurrence following implantation of a lightweight and heavyweight polypropylene mesh in laparoscopic total extraperitoneal inguinal hernia repair.12 In this cohort of 950 patients, the incidence of pain was defined according to the International Association for the Study of Pain. The presence of relevant pain (greater than 4 on a numeric rating score of 0–10) was significantly higher in the lightweight mesh group after 1 and 2 years’ follow-up. In addition, the recurrence rate was significantly higher in the lightweight group (2.7%) compared to the heavyweight group (0.8%). No differences in foreign body sensation or quality of life scores were detected between the lightweight and heavyweight groups.

594  Biomaterial considerations in laparoscopic hernia repair

Although lightweight mesh was developed to decrease the foreign body response (inflammation and contracture) and improved mesh-tissue compliance to optimize patientcentered outcomes, most level 1 clinical studies have not revealed a clinical advantage over heavyweight mesh for laparoscopic inguinal hernia repair. In fact, in some instances, lightweight mesh has an unfavorable outcome. Clinical trials evaluating lightweight and heavyweight mesh for open inguinal hernia repair differ in clinical and quality of life outcomes. Therefore, it is imperative for surgeons to have a clear understanding of the clinically relevant and meaningful outcomes for patients so that benefits from advances in biomaterial technology can be applied when performing a minimally invasive or open approach.

Prospective, randomized, or case-matched clinical trials comparing meshes utilized for laparoscopic ventral hernia repair have not been completed. This will likely require registries such as the Americas Hernia Society Quality Collaborative (AHSQC), Herniamed German Registry, Danish Hernia Database, or others to report clinically pertinent outcomes. In fact, the latter two postmarket surveillance registries noted a similar finding to an interim safety analysis of a randomized controlled trial that closed after the enrollment of 25 patients due to a 20% recurrence rate after 6 months in one cohort (lightweight mesh/absorbable tacker—strap design) compared to 0 recurrences in the other group (lightweight mesh/absorbable tacker—screw design).18 Subsequently, the mesh with a 20% recurrence rate was voluntarily recalled by the manufacturer. An additional consideration when assessing mesh utilized for laparoscopic ventral hernia repair is the effectiveness of the barrier. In a clinical trial, this can only be evaluated accurately through reoperation (Figure 97.2).

Effectiveness can be determined by complication avoidance (enterotomy) and operative efficiency (operative time, conversion rates from laparoscopic to open). Jenkins et al. and Patel et al. have reported findings on laparoscopic reexploration after intraperitoneal placement of mesh. In both studies, the most common reason for laparoscopic reexploration was a recurrent ventral hernia.11,17 Jenkins et al. reported an enterotomy and cystotomy rate of 1.4% and 1.4%, respectively. Only 2.8% of cases were converted to an open procedure. A metric of operative efficiency, adhesiolysis time/mesh surface area (min/cm2), favored the noncomposite, barrier mesh over the permanent barrier, composite mesh and resorbable barrier, composite meshes in this pilot study. The rate of enterotomy/small bowel resection was 4% in the Patel et  al. study. This was primarily due to small intestine-mesh adhesions in patients who presented with a small bowel obstruction. The rate of bowel obstruction and small bowel resection was lowest in the noncomposite, barrier mesh cohort. Sharma et al. reported a 5% access injury rate and 6.3% conversion rate from laparoscopic to open in 76 patients who had intraperitoneal mesh.22 Although the types of mesh encountered at re-exploration were identified, metrics to differentiate effectiveness of the barriers were not provided. Anecdotally, central mesh failure after a bridged laparoscopic ventral hernia has been described24 (Figure 97.3). It has been reported after mesh reinforcement with lightweight polyester mesh during open ventral hernia repair.20 Postoperative abdominal wall bulging seems to be more pronounced after bridged laparoscopic ventral hernia with lightweight versus heavyweight mesh, but once again this has not been substantiated by outcomes studies. Clinical trials evaluating primary fascial closure versus nonclosure of hernia defect during laparoscopic ventral hernia repair with mesh have not demonstrated a decrease in hernia recurrence.16 The long-term effectiveness of lightweight mesh for laparoscopic ventral hernia repair remains unknown.

Figure 97.2  Adhesions of small intestine to a resorbable

Figure 97.3  Central mesh failure 14 months after

Laparoscopic ventral hernia repair

barrier, composite mesh (PROCEED Surgical Mesh [Ethicon Inc.]) 23 months after laparoscopic ventral hernia.

laparoscopic ventral hernia repair with a lightweight, resorbable barrier, composite mesh.

References 595

CONCLUSION It is essential that surgeons appreciate aspects of mesh design and its impact on patient outcomes. A novel mesh package label to include physical properties (base material, barrier, pore size, and weight) and biomechanical properties (stiffness, tear strength, and ball burst strength) has been proposed by Kahan and Blatnik to improve surgeon recognition and differentiation of the numerous materials available.13 Knowledge of biomaterials’ effect on outcomes is more applicable to laparoscopic inguinal hernia repair, as hernia recurrence and quality of life outcomes (functionality, postoperative pain, etc.) have been demonstrated in clinical trials to be impacted by mesh selection. There is a significant gap in clinically relevant, patient-centered outcomes evaluating biomaterials utilized for laparoscopic ventral hernia repair. Postmarket surveillance will be the responsibility of registries such as the AHSQC that ­collect patient-centered data and provide ongoing performance feedback to clinicians with improvement based on analysis of collected data and collaborative learning. The recently launched AHSQC ORACLE (Outcomes Reporting App for CLinician and Patient Engagement) will also guide surgeons on mesh selection for laparoscopic ventral hernia repair.

REFERENCES 1. Aher CV et al. Surg Endosc 2015;29:1099–104. 2. Arregui ME et al. Surg Laparosc Endosc 1992;2:​53–8.

3. Bittner R et al. Surg Endosc 2014;28:380–404. 4. Bittner R et al. Surg Endosc 2011;25:2773–843. 5. Bittner R et al. Surg Endosc 2014;28:2–29. 6. Bittner R et al. Surg Endosc 2014;28:353–79. 7. Deeken CR et al. J Am Coll Surg 2011;212:68–79. 8. Deeken CR et al. Surg Endosc 2011;25:1541–52. 9. Deeken CR et al. J Mech Behav Biomed 2017;74:411–27. 10. Eliason BJ et al. J Am Coll Surg 2011;213:430–5. 11. Jenkins ED et al. Surg Endosc 2010;24:3002–7. 12. Burgmans JPJ et al. Ann Surg 2016;263:862–6. 13. Kahan LG et al. J Am Coll Surg 2018;226:117–25. 14. LeBlanc KA et al. Surg Laparosc Endosc 1993;3:39–41. 15. Lerdisirisopon S et al. Surg Endosc 2011;25:3890–7. 16. Papageorge CM et al. Surg Endosc 2017;31:4551–7. 17. Patel PP et al. Surg Endosc 2017;31:823–8. 18. Pawlak M et al. Surg Endosc 2016;30:​1188–97. 19. Peeters E et al. Hernia 2014;18:361–7. 20. Petro CC et al. Hernia 2015;19:155–9. 21. Sajid MS et al. Am J Surg 2013;205:726–36. 22. Sharma A et al. Hernia 2018;22:343–51. 23. Thiels CA et al. J Surg Res 2017;210:59–68. 24. Van Besien J et al. Acta Chir Belg 2016;116:313–5. 25. Wong JC et al. Asian J Endosc Surg 2018;11:146–50. 26. Zihni AM et al. Surg Endosc 2015;29:1605–13.

98 Laparoscopic incisional and ventral hernia repair BRUCE J. RAMSHAW, LISA A. CUNNINGHAM, AND H. CHARLES PETERS

INTRODUCTION Abdominal wall hernias are a common, yet complex, problem encountered by general surgeons. Despite the large volume of hernia repairs performed, there remains no clear consensus on any single best technique. Issues that contribute to this lack of agreement include advancements in laparoscopic technology, the influx of new mesh materials onto the market, and an increasingly complex patient population. Over the last two decades (1995–2015), the laparoscopic repair of ventral and incisional hernias has been validated by several published clinical studies and is one of the more common laparoscopic procedures performed.1–6 It is based on the principles of the Rives-Stoppa repair, in which mesh is placed deep to the hernia defect and fixed with wide mesh coverage to healthy abdominal wall fascia using full-thickness permanent sutures. In contrast to open repair, the laparoscopic approach places mesh inside the peritoneal cavity, rather than in the retrorectus position, a technique made potentially safer by the advent of new bilayered biosynthetic materials that promote tissue ingrowth on one side and minimize the potential for ingrowth on the other. This positioning of mesh against the posterior aspect of the abdominal wall with wide overlap of the hernia defect has a potential mechanical advantage over previously described inlay and onlay techniques. Intra-abdominal pressures disperse forces over the entire abdominal wall, potentially holding the mesh in place if there is adequate overlap. Laparoscopic ventral hernia repair allows for clear visualization of the entire anterior abdominal wall, wide mesh coverage beyond the defect, and secure fixation to abdominal wall fascia.

INDICATIONS Standard indications for operative hernia repair include symptomatic hernia, a bulge or deformity causing a poor

cosmetic appearance, risk of incarceration and/or strangulation, and abdominal wall dysfunction. First, if the hernia causes pain and discomfort such that it limits a patient’s ability to perform activities of daily life or significantly decreases quality of life, repair should be considered. Second, hernias can create a bulge in the abdominal wall that negatively affects appearance, and these can be repaired for cosmetic reasons, if the risks of surgery are not prohibitive. Third, abdominal wall hernias carry a risk for incarceration and strangulation of visceral organs. Risk of incarceration or strangulation likely varies based on several factors, including defect size, location, hernia characteristics, and history of previous incarceration. The fourth indication usually occurs in combination with one of the others, and that is abdominal wall dysfunction. The abdominal wall plays an important role in balance, ambulation, lifting, and many other activities of daily life. A ventral hernia can displace the abdominal wall musculature from its typical anatomical location, creating an uncoordinated abdominal wall with the potential for loss of form and function. The presence of abdominal wall dysfunction that inhibits the performance of activities of daily life and decreases quality of life should prompt consideration for operative repair.

PREOPERATIVE PLANNING Patient selection and timing of surgery are factors that can contribute to successful outcomes and attempt to avoid complications. A laparoscopic approach may be a choice in nearly all patients with a ventral hernia; however, surgeon experience and patient selection should be considered, as many hernia repairs require advanced laparoscopic skills, and an open approach may be a better choice in some circumstances. More challenging situations should be avoided early in a surgeon’s learning curve, including patients with multiple comorbidities; multiple previous attempts at hernia

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repair; previous intra-abdominal placement of mesh; the presence of enterocutaneous fistulas; chronic hernias with loss of abdominal domain; and hernias in atypical locations such as suprapubic, flank, and parastomal hernias. Regardless of surgeon experience, conversion to an open repair is not a failure or complication if performed using good surgical judgment for the benefit of the patient. As with any surgical procedure, patients should be counseled regarding the potential risks and benefits of surgery and should have appropriate expectations about the postoperative course, recovery, and potential complications. It is normal to have pain at incision sites and at suture and tack fixation sites after surgery. In most cases, this will necessitate hospital admission for adequate control of pain. In some patients, particularly those at high risk for conversion to open surgery and for large defects, a transversus abdominis plane (TAP) block or placement of an epidural catheter for pain can be helpful. For larger hernia repairs, repair of incarcerated hernias, or repairs that require extensive intraabdominal adhesiolysis and bowel manipulation, hospital admission should be anticipated for adequate pain control and while awaiting return of bowel function. One important risk to discuss with patients is the potential for bowel injury and the subsequent changes in management should it occur. This is particularly important for patients with large hernia defects, multiple comorbidities, multiple previous abdominal surgeries, multiple previous abdominal wall hernia repairs, and previous placement of mesh. Such patients need to be prepared for the possibility of conversion to an open operation, delayed mesh placement, and prolonged inpatient hospitalization. All patients with morbid obesity are counseled regarding the increased risk of complications, including an increased risk for hernia recurrence. Obese patients are encouraged to lose weight prior to hernia repair and are often sent for bariatric consultation. Those actively using tobacco are referred for cessation therapy, and hernia repair is typically delayed until smoking cessation has been achieved.

EQUIPMENT AND MATERIALS One important consideration in performing a laparoscopic ventral hernia repair is the choice of prosthetic material to be used in the repair. Although there is no ideal mesh, a mesh designed for laparoscopic intra-abdominal placement would be strong and durable, resist infection, be immunologically inert, and have dual-surface properties such that the abdominal wall side will facilitate tissue ingrowth and incorporation into the fascia and muscle, and the peritoneal side will minimize adherence to the visceral organs and prevent ingrowth of tissue. Any macroporous mesh placed in an intraperitoneal position should be avoided because of the potential long-term risk of bowel erosion, fistula formation, and small bowel obstruction. There are several mesh products available that are appropriate for intra-abdominal

placement. Most mesh selection is based on personal experience and anecdotal evidence, as a paucity of human data are available comparing the long-term outcomes of different mesh products. Collection of real-world outcomes with various mesh products will allow for the potential to match types of mesh and techniques with patient subpopulations using complex systems science tools such as predictive, dynamic algorithms. Although this type of use of data is common in other industries, it has not yet been utilized in health care.

OPERATIVE TECHNIQUE After induction of general anesthesia, the patient is positioned supine on the operating room table with arms tucked at the sides. Prophylactic antibiotics against skin flora are routinely given, and an orogastric tube is placed for gastric decompression, as well as a Foley catheter for decompression of the bladder. Sequential compression devices and subcutaneous heparin are utilized for deep venous thrombosis prophylaxis based on individual patient risk factors. Monitors are placed based on the location of the hernia defect(s). The patient is shaved, prepped, and draped widely to allow for the lateral placement of ports, usually beyond the anterior axillary line. A plastic protective drape is often used to help avoid mesh-to-skin contact. Several methods may be used to gain safe entrance into the peritoneal cavity, including the open Hasson technique, a Veress needle technique, and direct laparoscopic guidance using a dilating optical port. We routinely use blunt digital dissection through a 12 mm skin incision at either the left or right costal margin at the tip of the 11th rib, which usually corresponds to the anterior axillary line. A 10 mm balloon-tip port is then used for secure port placement. Insufflation with CO2 is begun at this point. We have recently begun using a low-pressure insufflation system, typically with a maximum pressure setting of 8 mmHg (although for obese patients the setting may need to be higher). This may help reduce postoperative gas-related symptoms such as shoulder pain. We routinely place two or three additional 5-mm ports, depending on the size and location of the hernia defect(s). For midline hernias, ports are placed in the lateral abdominal wall, which allows for broad coverage of the hernia defect with mesh. All adhesions to the abdominal wall are typically lysed using blunt and sharp dissection, although some surgeons do use energy sources for lysis of adhesions. Electrocautery or other energy sources should be used sparingly to avoid inadvertent thermal injury to visceral organs. Bleeding may be controlled with pressure, hemoclips, or electrocautery after all nearby visceral organs have been safely identified and cleared away. Usually, a plane can be developed between the abdominal wall and the adherent abdominal contents, which allows for safe and gentle dissection. When no discernable plane is apparent, the abdominal wall is sacrificed in order to protect the bowel. This dissection is performed cautiously to minimize the risk of an identified bowel injury,

598  Laparoscopic incisional and ventral hernia repair

or more importantly, an inadvertent unidentified injury to the bowel. If an enterotomy occurs, the injury should be repaired either laparoscopically or through an open incision, and then the adhesiolysis may be completed. The surgeon must use his or her best judgment to determine the need for converting to an open operation and for the appropriate timing of mesh placement. Although there are reports of placing mesh after bowel injury, our preferred practice is to delay mesh placement. We have, based on various factors, proceeded with mesh placement after laparoscopic repair of the enterotomy, admitted these patients, placed them on intravenous antibiotics for several days, and then returned to the operating room on day 3, 4, or 5 for delayed mesh placement if no signs of sepsis were apparent; we have also converted to an open operation in some cases. If a strategy to delay mesh placement is chosen and a reoperation is performed within 3–5 days, there are generally minimal to no adhesions, and repeat adhesiolysis adds little time or morbidity to the operation. After adhesiolysis, the boundaries of the fascial defect are identified, and the hernia contents are reduced. This can be done with gentle traction using atraumatic laparoscopic graspers and external manual compression on the hernia. If omentum is incarcerated within the hernia, the major risk associated with reduction is bleeding. This can be managed with pressure, hemoclips, ENDOLOOPs, or electrocautery. If bowel is incarcerated in the hernia or densely adherent to the hernia sac, excess tension should be avoided, as this could cause a traction injury to the bowel. Sharp dissection may be necessary to dissect the bowel free from the hernia sac. In some cases, it may be necessary to open the fascial defect with sharp dissection to adequately and safely reduce the hernia contents. The viability of incarcerated bowel is then assessed, and necrotic or nonviable bowel is resected. For most hernias, further dissection and exposure of the posterior abdominal wall surrounding the fascial defect are necessary prior to the placement of mesh. This may involve division of the falciform ligament and median umbilical ligament and/or mobilization of the bladder and exposure of the pubic symphysis and the Cooper’s ligaments. This is performed with electrocautery or ultrasonic dissection because of the vasculature present within these structures. Ultimately, this creates a musculofascial surface against which the prosthetic mesh is placed. At this point, the fascial edges of the hernia defect should be identifiable circumferentially, which allows for accurate measurement of the hernia defect. A spinal needle placed perpendicularly through the abdominal wall is used to mark the fascial edges. The pneumoperitoneum is decreased, and the defect is measured. The hernia can also be measured intracorporeally using a sterile plastic ruler, instrument, or suture. If multiple hernias are present, the maximal distance between all defects is measured as long as they are close together. Alternately, separate meshes may be used for defects that are far apart from each other. A mesh designed for intraabdominal placement is then selected to overlap all fascial

defect margins by at least 5 cm. It is trimmed, as necessary, and then marked for orientation and placement of sutures. The four cardinal permanent sutures are placed equidistant around the mesh, usually at the superior, inferior, and bilateral positions. Markings on the plastic drape or skin help to plan the site of externalization of the cardinal stay sutures. The mesh is then rolled like a scroll along its horizontal axis with the sutures tucked in the middle. Next, a 5 mm grasper is inserted through a port opposite the 10 mm balloon port and is brought through the abdominal wall at the balloon port site. The 10 mm port is removed, the mesh is placed in the grasper, and the grasper is brought into the abdomen with the mesh. An external clamp can help push the mesh through the 10 mm incision site, and a 5 mm laparoscope may also be used to visualize mesh insertion. The balloontip port is then reinserted, and the mesh is unfurled and oriented inside the abdomen using the markings on the plastic drape or skin as a guide. The cardinal sutures are then brought through the abdominal wall at predetermined positions using a transfascial suture passer. There are several mesh deployment devices on the market. These devices may help make mesh placement and positioning more efficient and more accurate. The individual sutures at the cardinal sites are brought through the fascia approximately 1 cm apart, which allows for that portion of the abdominal wall to be incorporated into that suture. After each pair of sutures is brought through the abdominal wall, they are clamped with a hemostat. The next suture site is identified by grasping the mesh and bringing it up to the abdominal wall while applying tension to the sutures clamped in the hemostat. In this manner, adjustments are made for a more accurate, tension-free placement of the mesh. After all four cardinal sutures are brought through the abdominal wall, tension is applied, and the mesh is evaluated for position. When the mesh is appropriately placed, the tension on the sutures should create a diamond shape on the undersurface of the mesh. If this does not occur, one or more sutures should be adjusted. This is performed by releasing the suture from the hemostat, pulling the sutures back into an intra-abdominal position, and then repositioning them using the suture passer. With the cardinal sutures tied holding the mesh in place, the border of the mesh is then tacked to the abdominal wall at 1 cm intervals. This precludes bowel or other abdominal contents from slipping over the edge and herniating above the mesh, before the process of mesh incorporation and neoperitonealization occurs. Although a variety of absorbable fixation devices are now available, patients with thick scar tissue, dense abdominal walls, and the use of expanded polytetrafluoroethylene mesh may require a permanent tacker for adequate fixation. Additional permanent transfascial sutures are then placed at 3–5 cm intervals around the outside of the mesh for further fixation. For large single defects, sutures may be spaced more closely together compared with defects that are small or multiple small “Swiss cheese”–type defects. These are placed using a transfascial suture passer in

Laparoscopic myofascial separation of components and advancement flaps  599

a fashion similar to that previously described for the initial sutures. At the conclusion of the procedure, the mesh should tautly approximate and follow the curve of the abdominal wall without wrinkles. A final survey is performed to ensure that hemostasis is achieved and to assure that no other injuries have occurred. If bowel viability was in question before, it is reevaluated. If nothing further needs to be performed and no injuries are identified, then the 10 mm balloon-tip port is removed, and the fascial defect at that site is closed laparoscopically using a 0 Vicryl suture. Alternatively, a port closure device may be used. The remaining ports are removed under visualization, and pneumoperitoneum is evacuated. Skin incisions are closed with absorbable sutures, and the skin at the transfascial suture sites is inspected and released from the deep tissues with a hemostat to eliminate any permanent skin puckering. The Foley catheter and orogastric tubes are removed in the operating room for small defects. For larger defects, the Foley catheter may be maintained for an additional 24–48 hours if indicated, and the patient is not discharged.

POSTOPERATIVE CARE Postoperative care is supportive while awaiting return of bowel function. Patients with small hernias requiring minimal manipulation of bowel during surgery can be started on a clear liquid diet immediately, given oral pain medications, and potentially discharged on the day of surgery or the day after once adequate pain control is achieved. Those patients with large, chronic hernias, or those with incarcerated bowel, and those who require long and arduous adhesiolysis generally take liquids and/or ice chips initially in small amounts and are supported with intravenous fluids and intravenous or epidural pain control. Early ambulation and appropriate prophylaxis against deep venous thrombosis are recommended based on the risk profile for each patient, and all patients are offered an abdominal binder when ambulating for the first several weeks as well as ice and/or heat for their comfort. Follow-up in the clinic is scheduled for 2–4 weeks after discharge from the hospital.

VARIATIONS OF STANDARD TECHNIQUE: DEFECT CLOSURE One criticism of the laparoscopic technique for ventral hernia repair is that the hernia defect is not closed, and the hernia sac is left in place, essentially guaranteeing the formation of a postoperative seroma. However, these are often asymptomatic and are of no clinical concern. The published data show a postoperative seroma rate as high as 56% based on clinical examination and 100% when evaluated radiographically by ultrasound.7,8 The laparoscopic ventral hernia repair also leaves some patients with an abdominal wall bulge and persistent abdominal wall dysfunction. This is not a complication of

the operation, because the hernia defect is appropriately covered, and the risk for incarceration and strangulation is eliminated. However, this is a limitation of the operation if the patient has a negative opinion of how he or she looks. In at least one study, there was evidence of dissatisfaction due to these issues.9 The lack of medialization of the rectus muscles may also have a negative impact on abdominal wall function. In an attempt to improve cosmetic and functional outcomes and ultimately improve patient satisfaction, we have started performing a primary closure of the fascial defect using absorbable sutures prior to mesh placement in select patients. After complete adhesiolysis, reduction of hernia contents, and exposure of the entire fascial defect, absorbable sutures are placed in a figure-eight fashion through the abdominal wall to close the hernia defect. A 2 mm skin incision is made over the hernia, a 0 polydioxanone suture is brought through the abdominal wall and healthy fascia 1 cm from the edge of the hernia and is then brought back through the other side of the hernia at a similar position using a transfascial suture passer. This is then repeated once with the same suture such that a figure-eight configuration is performed. This is repeated at 1 cm intervals until the entire defect is closed. After all sutures have been placed, the pneumoperitoneum is evacuated, and the sutures are tied down. Pneumoperitoneum is then reestablished, and the suture line is inspected for integrity. In addition to performing primary fascial closure, we still place a mesh with dimensions similar to what would be placed in the absence of fascial closure for broad coverage.

LAPAROSCOPIC MYOFASCIAL SEPARATION OF COMPONENTS AND ADVANCEMENT FLAPS In a smaller group of select patients, a bilateral laparoscopic myofascial separation of components and advancement is performed prior to repair of the hernia. The initial port placement is performed two fingerbreadths below the costal margin at the anterior axillary line. A transverse incision is made through the skin followed by subcutaneous dissection until the external abdominal oblique musculofascial layer is exposed. This layer is incised with electrocautery, and digital dissection is performed to establish a space between the two muscle layers. A 10 mm dilating balloon is inflated under visualization with a 10 mm, 0° laparoscope. Appropriate position is verified by visualization of external and internal oblique muscle layers coming together medially at the edge of the rectus sheath. Next, the balloon is deflated, a 10 mm balloon-tip trocar is placed, and pneumatic insufflation is started with carbon dioxide set at a pressure of 10 mmHg. A 5 mm port is then inserted inferiorly at the lateral aspect of the intramuscular space created. Either a hook or scissors connected to electrocautery can be used to completely incise the external oblique musculofascial layer 1–2 cm lateral to the rectus sheath. This is performed superiorly to several centimeters above the costal margin and inferiorly toward the pubis. In some

600  Laparoscopic incisional and ventral hernia repair

cases, this may require placement of an additional 5 mm medial port. To ensure maximal release and advancement, the incision is carried anteriorly through the Scarpa layer of the subcutaneous tissue. During dissection, extra care must be taken superiorly to maintain hemostasis, as this area above the costal margin is muscular and well vascularized. Ultrasonic dissection may be more hemostatic than electrocautery in this area.

ROBOTIC VENTRAL/INCISIONAL HERNIA REPAIR Recently (2010–present), the laparoscopic robotic system has been used to perform minimally invasive ventral/ incisional hernia repair using a traditional laparoscopic approach (with robotic internal suturing of the mesh to the abdominal wall instead of using tacks) and a robotic transversus abdominis release (TAR) type of abdominal wall reconstruction. Advantages of the robot for traditional lap ventral hernia repair include ease of defect closure with robotic suturing techniques and the potential to replace traditional methods of fixation with a running robotic suture between the edge of mesh and abdominal wall, potentially resulting in less pain. Concerns about this technique include costs and the ability to consistently get sutures into the musculofascia with a laparoscopic approach. A robotic TAR has the potential advantage to avoid wound and mesh complications. Concerns are cost and the mounding of skin and soft tissue for wide defects.

that cause bleeding or chronic pain. Anchoring transfascial sutures are placed above the pubic tubercle and superior to the iliopubic tract. The remaining overlap of mesh can then be secured to the Cooper’s ligaments bilaterally with tacks. Lateral fixation with sutures and tacks should be placed superior to the iliopubic tract bilaterally. Flank hernias are defined as abdominal wall defects that occur between the costal margin and the iliac crest lateral to the anterior axillary line and medial to the spine. These may be challenging to diagnose by physical examination alone, since some of these patients will have a persistent flank bulge after a flank incision due to muscle atrophy in the absence of a hernia. A computed tomography (CT) scan may be helpful for diagnosis and preoperative planning. Adequate paraspinous musculature needs to be present to allow for posterior mesh fixation. To repair a flank hernia, the patient is positioned in the lateral decubitus position with the hernia side up. Initial access and ports are placed in the midline with additional ports placed as needed. The lateral posterior peritoneum is dissected to allow access to the retroperitoneum and to expose the psoas and paraspinous muscles. This may require medial mobilization of the colon, kidney, and ureter. For larger hernia defects, inferior dissection to expose the Cooper’s ligament and iliopubic tract and superior dissection to the diaphragm may be necessary. Once the entire hernia defect is exposed and measured, mesh appropriate for intraperitoneal placement is selected and trimmed to allow for at least 5 cm of hernia overlap. The mesh is secured with transfascial sutures and tacks in a fashion similar to ventral hernia repair. The posterior suture closest to the spine is the first suture placed, as this is the most critical suture due to spatial limitations.



Ventral hernias extending superiorly to the xiphoid process or inferiorly to the pubic tubercle pose an additional challenge for the laparoscopic surgeon. Epigastric hernias usually require high division of the falciform ligament for adequate exposure of the entire fascial defect. Anchoring transfascial sutures are not usually placed above the costal margin because of the risk for bleeding and chronic pain. In this situation, the sutures are placed lower on the mesh in position with the costal margin, and the superior aspect of the mesh is tacked near the diaphragm. It is critical that the mesh has adequate overlap of the fascial defect; however, care should be taken to avoid injury to the pericardium. The initial superior suture is usually placed several centimeters below the top edge of the mesh and fixed at the xiphoid process. This allows the top portion of the mesh to provide overlap to the diaphragm. Complete visualization of suprapubic hernias may require mobilization of the bladder and exposure of the pubic tubercle and bilateral Cooper’s ligaments. Similar to transabdominal preperitoneal inguinal hernia repair, care must be taken not to place sutures and tacks in positions

Laparoscopic repair of ventral and incisional hernias is a well-established procedure that has been validated by several large retrospective case series and smaller prospective randomized trials. The majority of these studies favor the laparoscopic technique over conventional open repair with mesh because of a reduction in wound complications, mesh infections, and lower rates of hernia recurrence. One of the earliest large studies to evaluate laparoscopic repair of ventral/incisional hernias included a retrospective review of 850 consecutive patients from four surgeons.10 This series represented a cross-section of patients with ventral hernias, including the extremes of age, morbid obesity, various comorbidities, and previous attempts at hernia repair. The average operative time was 120 minutes, and 3.6% of patients required conversion to an open operation. Intraoperative complications included intestinal or bladder injury in 1.7% and 1 perioperative mortality due to a myocardial infarction on postoperative day 1. The most common postoperative complications included prolonged ileus in 3%, prolonged seroma in 2.6%, and prolonged pain in 1.6%. Over an average follow-up of 20 months, the recurrence rate was 4.7%,

References 601

which compared favorably to the wide-ranging 12%–52% recurrence rate seen with open ventral hernia repair. There have now been many prospective, randomized trials comparing laparoscopic and open ventral/incisional hernia repairs. Overall, these studies conclude that the laparoscopic repair of ventral hernias is a safe, feasible, and effective alternative to open ventral hernia repair. A major advantage of the laparoscopic approach is the decreased wound and mesh complication rate. Some studies also suggest a lower length of stay and recurrence rate for the laparoscopic approach. The most common complications after laparoscopic ventral hernia repair are prolonged ileus, prolonged seroma, and prolonged pain. However, the most feared complication is enterotomy, particularly a missed enterotomy, which can be a deadly event. A literature review of 3,925 patients after laparoscopic ventral hernia repair showed an overall enterotomy rate of 1.78%, the majority of which were identified at the time of surgery.11 The mortality rate for all laparoscopic ventral hernia repairs was 0.05%. If an enterotomy occurred and was identified, the rate was 1.7%, and for a missed or delayed enterotomy, the mortality rate was 7.7%. Prompt recognition of enterotomy intraoperatively, as well as early suspicion for missed or delayed enterotomy postoperatively based on patient presentation, is essential to limiting this complication and minimizing mortality.

APPLYING PRINCIPLES OF CLINICAL QUALITY IMPROVEMENT In the past 4 years, we have applied the principles of clinical quality improvement to the group of patients with ventral/incisional hernia who undergo laparoscopic ventral hernia repair. Some of the process improvement attempts we have implemented include a multimodal perioperative pain and enhanced recovery program, including the use of long-acting local anesthetic nerve blocks; low-pressure pneumoperitoneum; and preoperative optimization of the patient’s medical, nutritional, and emotional states. We

also applied the principles of predictive analytics to identify patient groups at high risk of recurrence (prior recurrence, high body mass index, etc.) and use a more durable mesh with permanent fixation in these patients. We also employ a patient-centered team approach for care, with a patient care manager who engages the patient and family in a shared decision process in an attempt to determine the optimal treatment decision for each patient. As part of the decision process, patients are offered watchful waiting with strategies to manage their hernia nonoperatively, and open operations, including abdominoplasty with abdominal wall reconstruction, in addition to a laparoscopic approach.

SUMMARY The laparoscopic technique for ventral and incisional hernia repair is safe and effective and can be appropriately applied to most patients. It can have the benefits of shorter operative times, decreased complications, shorter hospital stays, and lower recurrence rates. New techniques are evolving that may further decrease complications, improve abdominal wall function and cosmetic result, and ultimately increase patient satisfaction.


1. Forbes SS et al. Br J Surg 2011;96(8):851–8. 2. Pierce RA et al. Surg Endosc 2007;21(3):378–88. 3. Bingener J et al. Arch Surg 2007;142(6):562–7. 4. Sosin M et al. Am J Surg 2014;208(4):677–84. 5. Mason RJ et al. Ann Surg 2011;254(4):641–52. 6. Colavita PD et al. Ann Surg 2012;256(5):714–22. 7. Zhang Y et al. World J Surg 2014;38:2233–40. 8. Kaafarani HM et al. Am J Surg 2009;198:639–44. 9. Liang MK et al. World J Surg 2013;37:530–7. 10. Heniford BT et al. Ann Surg 2003;238(3):391–400. 11. LeBlanc KA et al. JSLS 2007;11:408–14.

99 Robotic transabdominal preperitoneal inguinal hernia repair FAHRI GOKCAL AND OMAR YUSEF KUDSI

INTRODUCTION Inguinal hernia repair is one of the most common surgeries in the United States, with between 700,000 and 800,000 performed in 2003.1 There has been a progressive evolution of inguinal hernia repair since the description of laparoscopic repair by Ger, who reported a laparoscopic closure technique of the internal ring.2 During the early days of the laparoscopic era, there had been negative outcomes, such as high recurrence rates and postoperative pain; however, minimally invasive inguinal hernia repair gained better outcomes with increasing experience of surgeons. It is believed that some of the primary reasons for those poor results in laparoscopic repair were due to the fact that mesh reinforcement was not routine, as well as postoperative pain resulting from tack placement in the laparoscopic technique.3 The two laparoscopic herniorrhaphy techniques are currently being performed for inguinal hernia repair, whether by the transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach. Both techniques are acceptable treatment options for inguinal hernia repair, although there is insufficient data showing the superiority of one technique over the other.4,5 Several studies have shown that laparoscopic repair has been associated with decreased postoperative pain, earlier return to work, and improved cosmetic outcomes when compared with an open approach.3,6,7 Despite these documented advantages of the laparoscopic approach, the open approach has been favored among surgeons in North America,8 even for situations where published guidelines recommend a laparoscopic approach, such as bilateral hernia and recurrent hernia. 5,9 The laparoscopic technique requires intracorporeal suturing skills and a long learning curve, which might contribute to surgeons’ preference for an open approach.

The robotic platform with the da Vinci (Intuitive Surgical, Inc., Sunnyvale, California) system has offered three-dimensional vision through a computer interface, a stable platform, and increased dexterity with 7° of freedom at the articulating wrist to facilitate minimally invasive surgery. In the matter of robotic suturing and knot tying, a study showed that surgeons were significantly faster than they were at standard laparoscopy.10 Moreover, the robotic platform, with advanced ergonomics for the surgeon, permits difficult cases to be performed. For these reasons, the robotic transabdominal preperitoneal (rTAPP) approach may have a role in complex inguinal hernia repair, such as recurrent cases after prior posterior repair (TEP or TAPP), cases with previous prostatectomy, cases that involved an incarcerated nonreducible inguinal hernia even after induction of anesthesia, and cases of scrotal inguinal hernia.9 The safety, feasibility, and reproducibility of the application of the robotic system in performing this procedure have been described in the literature.9,11–14 In this chapter, we discuss the technical aspects of robotic transabdominal preperitoneal repair for inguinal hernias.

PATIENT SELECTION The indications for rTAPP inguinal hernia repair are the same for open inguinal hernia repair. Robotic repair may be appropriate in cases of bilateral inguinal hernias and recurrences. Patients who have unilateral primary hernias are appropriate candidates for this approach when the surgeon is comfortable with the technique. Also, superiority of robot use over open technique has been shown in obese patients.15 The contraindications of this procedure are analogous to the laparoscopy contraindications in addition to the situations that can preclude the use of a mesh, such as grossly contaminated abdominal cavity.

Surgical technique  603

SURGICAL TECHNIQUE Preoperative preparation Preoperative preparation includes thromboprophylaxis, body hair clipping, and prophylactic antibiotics. Foley catheterization is not generally required. We ask all patients to empty their bladders immediately before operation and encourage the anesthesiologist to restrict perioperative fluid to minimize postoperative urinary retention. In cases of a potentially difficult procedure, the bladder may be emptied to minimize the risk of bladder injury as well as to obtain adequate space. The instrument table is set up in the same fashion for every case to provide workflow efficiency.

Patient positioning, access, trocar placement, docking The patient is positioned supine with both arms on the operating table. The patient should be fully secured to the surgical table to prevent slipping off and should be properly padded to obstruct robotic arm collision during operation. After general anesthesia induction, asepsis is achieved via chlorhexidine and the surgical drapes are placed over the patient, providing the entire abdominal area including inguinal region cover. There are a number of techniques to achieve a pneumoperitoneum. Using an open technique (Hasson) at the position of planned first trocar is a valid entry option into the abdominal cavity. However, our preference is that a Veress needle is inserted at Palmer’s point, 1–2 cm below the left costal margin at the left midclavicular line, to obtain pneumoperitoneum. Then the initial port is inserted in the abdominal cavity. Access may also be obtained by optical trocar by using 0° camera. Particular attention must be paid to achieve adequate distance between each trocar and surgical target to prevent robotic arms collision and extensive troubles. For this purpose, the commonly applied rule is that a minimum of 8 cm of distance be maintained between each trocar and an ideal distance of 10–20 cm is suggested between the trocars and the surgical target. Three trocars, two of which are for instruments (we generally utilize bipolar Maryland forceps, monopolar scissors, and needle driver) and one of which is for a camera, are usually used. Apart from conventional laparoscopy, trocars are placed in a horizontal line at 4 cm above the umbilical level, each lateral trocar is positioned in the midclavicular line, and the center trocar is positioned just off the midline (Figure 99.1). It should be emphasized that trocars should not be placed too lateral in patients with a smaller body habitus, as this would cause difficulty when it comes to suturing laterally. At this time, some surgeons prefer introducing the required materials, such as mesh and selected sutures, into the abdominal cavity through one of the trocars in order to minimize robotic arms undocking. After ensuring trocar placement safely and properly, the patient is shifted for final position in 15°–20° of

Figure 99.1  Trocar positioning. Trendelenburg to improve exposure of the working area and to move the abdominal structures from the area of dissection. Slightly flexing the operating table may be beneficial to obtain free movement of the robotic arm in a patient who has a short torso. Patient position should be finalized prior to docking the patient-side cart and must remain constant during operation. The patient-side cart is advanced by an assistant (closely guided by the surgeon) into the correct position, and the docking process is completed after connecting trocars and robotic arms. Of note, with the Si system, the patient-side cart must be positioned at the foot-side of the operating table to achieve “in line” rule, whereas the patient-side cart can be positioned at the patient’s side with the Xi system, as this platform includes an overhead boom allowing the arms to rotate as a group into any orientation.

Initial exposure, preperitoneal dissection, and anatomical landmarks In cases involving intestinal adhesions, we avoid extensive adhesiolysis unless the adhesions obstruct the view. To avoid visceral injury in cases of sliding or irreducible hernias, neither adhesiolysis nor reduction is performed at the beginning of the case; rather, these procedural steps are performed during preperitoneal dissection and mobilization of the hernia content.

604  Robotic transabdominal preperitoneal inguinal hernia repair

Medial umbilical ligament, lateral umbilical ligament, internal inguinal ring, external iliac vessels, inferior epigastric vessels, gonadal vessels, and arcuate line are the initial landmarks in the peritoneal cavity. The inferior epigastric vessels, the internal inguinal ring with the spermatic vessels, and the vas deferens should be identified. These three structures have been named the “Mercedes-Benz star.”16 A curvilinear peritoneal incision is performed by monopolar scissors and a bipolar Maryland to enter preperitoneal space 6 cm above the hernia defect, from the median umbilical ligament to the anterior superior iliac spine (Figure 99.2a). To be able to visualize the Fruchaud myopectineal orifice, dissection is performed in the preperitoneal avascular plane between the peritoneum and the transversalis fascia. The medial extent of dissection is carried out roughly 3 cm beyond the symphysis pubis to the contralateral side to provide sufficient mesh overlap (Figure 99.2b). The lateral extent is the anterior superior iliac spine (Figure 99.2c). The caudal extent is 4 cm below the iliopubic tract at the level of the psoas muscle and 2 cm below Cooper’s ligament (Figure 99.2d). Throughout the preparation of the peritoneal flap, the peritoneum should be tracked gently to avoid tearing due to the fact that there is no haptic feedback in robotic platform. Pressing on the peritoneal flap with the sponge, which is prepositioned in the working area, helps minimize the peritoneal tearing risk as well as control minor bleeding.

If there is a disruption in peritoneal integrity, it should be repaired later by absorbable sutures. The authors’ preference is to first dissect and identify Cooper’s ligament before addressing the rest of the dissection. Cooper’s ligament is a useful landmark, particularly if there is a large hernia sac obscuring the field of dissection. Once this ligament is identified, a lateral dissection of the preperitoneal space is required, leaving the hernia sac dissection until the end. This facilitates identification of the spermatic cord, vas deferens, and the Triangle of Doom. The cord structures are isolated and dissected to identify the indirect hernia sac. This sac is usually found on the anterolateral side of the cord and is adherent to it. The vas deferens and the spermatic vessels should be taken maximum care of when the sac is being separated from the cord. The peritoneal hernia sac and associated adipose tissue from the hernia (pre-, extra-, and retroperitoneal fat) is reduced toward the middle of the psoas muscle (parietalization). It should also be emphasized to take into consideration the importance of preserving the spermatic fascia and lumbar fascia to protect the vas deferens, nerves, and vessels. Careful sharp dissection with sparing use of monopolar energy is essential to avoid inadvertent injuries. The authors prefer to detach the hernia sac completely from the spermatic cord to avoid seroma formation or hernia recurrence (Figure 99.3a). Dissection may be challenging if there





Figure 99.2  (a) Beginning the preperitoneal dissection. (b) The medial extent of dissection. (c) The lateral extent of dissection. (d) The caudal extent of dissection.

Surgical technique  605

are very large hernia sacs like inguinoscrotal hernias. In this situation, the sac may be transected and left in place, being cautious to close the peritoneal defect once the inguinal repair is done. Formation of a hydrocele should be prevented by leaving the distal end of the transected sac open. If the sac is ligated, it should be done at the narrowest point possible to reduce the size of the defect in the peritoneal flap. This allows for an easier closure without deficit. A large indirect sac may be ligated proximally and divided distally, with lower postoperative pain and recurrence rate, but with higher postoperative seroma rate.17 Direct hernia sacs are easier to reduce than indirect sacs (Figure 99.3b). Transversalis fascia, which is a form of pseudosac, may be present after reducing the direct hernia sac. Once the pseudosac is freed, it will typically retract anteriorly into the direct hernia defect. Before placing the mesh, the transversalis fascia is fixated to Cooper’s ligament in order to prevent postoperative seroma formation due to dead space. Suturing in small stitch fashion, passing through the pseudosac, increases the effectiveness of the reduction (Figure 99.3c and d). Alternatively, the primary closure of direct inguinal hernia defects with a pre-tied suture loop can be used.17 More effort should be undertaken to reveal and treat occult synchronous femoral hernia, especially in females undergoing inguinal hernia repair.17 The main anatomical landmarks are shown in Figure 99.4.

Mesh placement, fixation, and peritoneal closure Complete dissection of the retroinguinal space (Bogros’ space) ensures flat placement of the mesh, which covers the entire myopectineal orifice without folding. As recommended by the International Endohernia Society (IEHS) guidelines, mesh size of at least 10 × 15 cm is used. If the patient is big or has a large hernia defect (direct >3–4 cm, indirect >4–5 cm), bigger mesh (i.e., 12 × 17 cm or greater) is used.5 The mesh should cover without wrinkles all potential hernia fascial defects in the groin, including Hesselbach’s triangle, the indirect ring, the femoral ring, and the obturator ring (Figure 99.5a). The authors prefer to use the ProGrip Laparoscopic Self-Fixating Mesh, Anatomical Design (Covidien, New Haven, Connecticut). It is a common practice to use at least three fixating sutures (Cooper’s ligament, medial to the inferior epigastric vessels, superiolateral of the internal inguinal ring) when using non-selffixating mesh. For large direct hernias, if the hernia defect is not closed, besides using larger mesh, additional fixation is required around Hesselbach’s triangle to prevent mesh migration to the hernia defect. These fixations can be performed with intracorporeal sutures, as tacks are generally not required. It should be kept in mind that the mesh should not be fully stretched, since it can shrink in certain degrees (10%–30%). The recurrence





Figure 99.3  (a) Dissection of indirect hernia sac from cord structures. (b) Dissection of direct hernia sac from pseudosac. (c and d) Suturing the direct hernia defect in small stitch fashion, passing through the pseudosac.

606  Robotic transabdominal preperitoneal inguinal hernia repair

Figure 99.4  Main anatomical landmarks: (a) Cooper’s ligament; (b) inferior epigastric vessels; (c) psoas muscle; (d) cord elements; (e) Hesselbach’s triangle (direct hernia site); (f) internal ring (indirect hernia site); (g) femoral canal; (h) obturator canal; (i) Triangle of Doom; and (j) Triangle of Pain.

after TAPP is generally inferiorly, resulting from insufficient coverage of the inferior edge of the myopectineal orifice or from migration of the mesh. Therefore, it is very important to confirm mesh positioning during closure and desufflation. It should be kept in mind that the mesh can fold in on itself by the inferior peritoneal flap during suturing. After adequate mesh fixation and bleeding control are achieved, the next step is to close the peritoneal flap. Rapidly absorbable barbed suture (2–0 V-Loc; Medtronic, New Haven, Connecticut) may be used for this purpose. A running short stitch fashion reduces the risk of small bowel herniation and obstruction in the peritoneal fenestrations. Another benefit of a short-stitch technique for peritoneal closure is that less barbed suture is exposed to the viscera (Figure 99.5b). A down-to-up suturing direction may facilitate this step (Figure 99.5c). During closure, care is taken to suture peritoneum to peritoneum, since suturing peritoneum to fascia of the posterior rectus sheath may cause postoperative protracted pain. For bilateral inguinal hernias, dissection of the preperitoneal space with two separate peritoneal incisions on each side of the median umbilical ligament instead of one long peritoneal incision may facilitate closure of the peritoneal flap; this not only adjusts the anatomical position of the median umbilical fold, it also minimizes the possibility





Figure 99.5  (a) Mesh placement to all potential hernia sites. (b) Closure of the peritoneal flap with rapidly absorbable barbed suture in a running short stitch fashion. (c) Suturing peritoneum to peritoneum from down-to-up direction. (d) Keeping intact the medial umbilical fold in order to prevent inadvertent peritoneal tears during peritoneal closure in bilateral hernia repair.

References 607

of peritoneal tearing as it reduces weight while suturing the edges of the sagged peritoneal flaps (Figure 99.5d). At the end of the procedure, it should be checked that the entire mesh is covered with the peritoneal flap to protect the intra-abdominal structures from exposed mesh. The abdominal cavity is evaluated for signs of bleeding or other complications. The trocars are removed, and the pneumoperitoneum is released. If any, the fascia at the 10 mm or larger trocar insertion site should be sutured to decrease the risk of future incisional hernia. A long-acting local anesthetic agent is injected to trocar sites for management of postoperative pain.

POSTOPERATIVE CARE AND FOLLOW-UP Generally, patients are discharged home on the same day after routine early postoperative care. Patients who require hospital stay usually have preexisting comorbidities that require monitoring after general anesthesia. The authors prescribe oral nonsteroidal anti-inflammatory agents (NSAIDS) for postoperative pain in the majority of patients. There is no need to prescribe narcotics. Patients are encouraged to resume normal activity after operation. It is advised to avoid lifting heavy objects and doing exhausting activities for 4–6 weeks.

Author’s experience (O.Y.K.) There were 118 patients, with a mean age of 58.8 ± 15.4, who underwent rTAPP inguinal hernia repair from March 2013 to October 2015 in our center. Most of these (83, 70.3%) had unilateral hernia. The remaining 35 patients (29.7%) had bilateral hernia, 11 (9.3%) complex hernia, 8 (6.8%) recurrent hernia, and 3 (2.5%) emergent hernia. The mean surgical time (skin-to-skin: first incision to last closure) was 64.46 ± 35.63 min in unilateral and 80.20 ± 31.72 min in bilateral hernia repair. None of the patients needed a conversion to laparoscopic or open surgery. A total of 113 patients were discharged the same day of the surgeries. The cause of staying at the hospital overnight was urinary retention in two patients and social reasons in the remaining three patients. There was no readmission caused by a surgical reason within 30 days. At the 3-month follow-up, four patients had complications. They were symptomatic seroma requiring drainage at the office in two patients and urinary retention requiring catheterization in two patients. At 1-year follow-up, there were no episodes of recurrence, surgical site infection, testicular atrophy, hydrocele, or orchitis.9

REFERENCES 1. Rutkow IM. Surg Clin North Am 2003;83(5):1045–51, v–vi. 2. Ger R et al. Am J Surg 1990;159(4):370–3. 3. Horne CM et al. Surg Clin North Am 2018;98(3):637–49. 4. Kockerling F et al. Surg Endosc 2015;​29(12):3750–60. 5. Bittner R et al. Surg Endosc 2011;25(9):2773–843. 6. Stoker DL et al. Lancet 1994;343(8908):1243–5. 7. Lal P et al. Surg Endosc 2003;​17(6):850–6. 8. Trevisonno M et al. Hernia 2015;19(5):719–24. 9. Kudsi OY et al. World J Surg 2017;41(9):2251–7. 10. Yohannes P et al. Urology 2002;60(1):39–45; discussion 11. Arcerito M et al. Am Surg 2016;82(10):1014–7. 12. Escobar Dominguez JE et al. Surg Endosc 2016;​30(9):4042–8. 13. Iraniha A et al. J Robot Surg 2018;12(2):261–9. 14. Kudsi OY et al. Am J Robotic Surg 2015;2(1):16–21. 15. Kolachalam R et al. Surg Endosc 2018;​32(1):229–35. 16. Roll S et al. Laparoscopic TAPP inguinal hernia repair. In: Hernia Surgery: Current Principles [Internet]. Switzerland: Springer International; 2016:451–9. 17. Bittner R et al. Surg Endosc 2015;29(2):289–321.

100 Robotic ventral hernia repair FAHRI GOKCAL AND OMAR YUSEF KUDSI

INTRODUCTION Ventral hernias are one of the major conditions that require abdominal wall reconstruction, which is a rapidly evolving area of surgical interest. The number of abdominal wall reconstructions performed for ventral and incisional hernias in Europe is estimated to be about 300,000/year and 400,000/year in the United States.1 Abdominal wall reconstruction is performed for the purpose of reestablishing the entirety of the myofascial layer and providing durable coverage while minimizing the risk of hernia recurrence. Several techniques have been practiced for these purposes. The classic open suture techniques are considered only in the presence of very small hernia defects because of high recurrence rates of up to 54% in incisional hernia repair.2 Mesh prostheses help to reinforce or bridge the hernia defect, and they can be placed between all layers of the abdominal wall. Recurrence rates of open mesh techniques are lower (15%– 30%)2; however, there are specific potential drawbacks, such as seroma, hematoma, and mesh infection.3 Mesh replacement with minimally invasive techniques has gained popularity due to the advantages of reducing complication rates related to wide dissection in open surgery. Robotic ventral hernia repair is considered a new approach that unites the principles of both laparoscopic and open ventral hernia repair in the minimally invasive arena. One of the important advantages of the robotic ­platform is to facilitate exploitation of the individual layers of the abdominal wall. In this chapter, we introduce the execution of abdominal wall reconstruction by robot-assisted surgery.

SURGICAL ANATOMY AND MESH POSITIONING Simple suture closure of the defect in the abdominal wall is not enough for providing good outcomes in hernia surgery.

Therefore, current hernia repair techniques focus on restoring abdominal wall anatomy and function. The abdominal wall comprises several different layers, including skin, subcutaneous tissue, fascia, muscle, and peritoneum. After emerging from their insertions, three flat muscles of abdominal wall (external oblique, internal oblique, and transversus abdominis) lie on each side of the rectus muscles. Linea semilunaris is formed by the first complex decussation of their aponeuroses, and they split and pass anteriorly and posteriorly around the rectus muscle to form a stout sheath enclosing it. In the middle, linea alba is formed by the second complex decussation of all aponeuroses. As an important anatomical landmark, the arcuate line is located midway between the umbilicus and symphysis pubis. The anterior rectus sheath above the arcuate line is composed of the external oblique aponeuroses and part of the internal oblique aponeuroses. The posterior r­ ectus sheath includes the internal oblique aponeuroses and the transversus abdominis aponeuroses. Below the arcuate line, the external and internal oblique aponeuroses fuse to form the anterior rectus sheath with the posterior rectus sheath being made up of only fascia transversalis. The peritoneum is the innermost layer of the abdominal wall.4 Innervation of the anterior abdominal wall is via the anterior and lateral cutaneous branches of the ventral rami of the 7th–12th thoracic nerves, which run in a plane between the internal oblique and transversus abdominis muscles. They perforate the posterior lamina of the internal oblique aponeurosis to innervate the rectus. The intraperitoneal onlay mesh (IPOM) placement is described as mesh laid on an anterior abdominal wall deep to the peritoneum after inserting into the abdominal cavity. Since the mesh will directly contact intra-abdominal structures in this position, this side of the mesh should be antiadhesive. In the preperitoneal mesh position, as the name implies, mesh is placed anterior to the peritoneum and posterior to the rectus sheath. When the mesh is placed posterior to the rectus muscles, this position is named as

Robotic intraperitoneal onlay mesh repair  609

retrorectus. In the transversus abdominis release (TAR) technique, which is described later, the retrorectus layer extends laterally between the transversus abdominis muscle (anteriorly) and the transversalis fascia (posteriorly) when the lateral border of the rectus sheath is dissected.5 Figure 100.1 shows each position of the mesh on abdominal wall layers.

Preoperative evaluation A thorough history and physical examination are required before robotic abdominal wall reconstruction, as is usual in all surgical approaches. Modifiable risk factors that can affect the wound healing process (diabetes mellitus, obesity, malnutrition, and smoking) should be investigated and corrected before the elective operation, if possible.6 In general, preoperative routine imaging is not required in the normal workup of a hernia. However, cross-sectional abdominal imaging with computed tomography (CT) may be performed to understand anatomical detail in patients with small-to-moderate incisional hernia and atypical hernia.

ROBOTIC INTRAPERITONEAL ONLAY MESH REPAIR The laparoscopic form of the IPOM repair technique was introduced in 1993.7 The technique of robotic intraperitoneal onlay mesh (rIPOM) repair is based on this conventional laparoscopic method. It has the advantages of lower rates of surgical site infections and decreased hospital stay as compared to the open technique. However, the laparoscopic method might predispose to acute and extended pain because of circumferential tacks and multiple full-thickness transfascial sutures to secure the mesh adequately.8 These kinds of sutures are generally not needed in rIPOM. The mesh should be compatible with intra-abdominal placement; therefore, the use of coated mesh is mandatory to minimize the risk of adhesive complications. In fact, this bridging-type repair does not truly reconstruct the abdominal wall, even if the hernia is repaired. However, performing defect closure might help restore abdominal wall construction and function. Nevertheless, a classical IPOM remains an ideal alternative in patients who have had previous abdominal surgery, and consequently, whose abdominal wall planes are not suitable for reconstruction.

Surgical technique The steps of rIPOM repair are similar to those of conventional laparoscopic repair. PATIENT PREPARATION, POSITIONING, AND INITIAL ACCESS

The patient is positioned supine on the operating table under general anesthesia. Depending on patient- and

hernia-related factors, as well as the preferences of the surgeon and the anesthesiologist, a patient’s arms are placed on the board set at 90° from the trunk. Slight flexing of the bed may be beneficial for patients who have a short torso or where there is limited space to adequately insert the trocars. This maneuver increases the distance between the anterior superior iliac spine and the costal margin. Slightly tilting the operating table toward the cart of the robot may contribute to better visualization of the abdominal wall by the camera and to an increase in the range of the robotic arms’ motion without obstacle. Access to the abdomen and initiating the pneumoperitoneum may be obtained by either closed (a Veress needle and/or an optical view trocar) or open (Hasson) techniques. The authors prefer direct trocar insertion into appropriate localization after establishment of pneumoperitoneum through a Veress needle inserted at Palmer’s point. TROCAR PLACEMENT, ADHESIOLYSIS, DEFECT CLOSURE

The position of the trocars should allow for a full range of motion and anterior abdominal wall suturing. Generally, three trocars, two of which are for instruments and one of which is for a camera, are used. The extent of the hernia defect, anticipation of the edge of mesh, and maintenance of free movement of the robotic arms should be considered when determining the position of the trocars. The trocars should be positioned on either side of the camera trocar; thus, the “double triangle” rule can be ensured, and they should be placed at a distance of at least 8 cm from one another in order to minimize the mechanical interference of the robotic arms with each other. The camera trocar is also recommended to be placed away from the surgical target to achieve the maximal surgical view, ideally 8–10 cm away from the edge of the mesh that will be used. The first trocar is placed in the left upper quadrant along the anterior axillary line, and the remaining two other trocars are placed roughly 6–8 cm away, preferably taking the C-shape, knowing the limitation of the most inferior trocar (Figure 100.2). Any port placed below the level of the umbilicus near the anterior superior iliac spine (ASIS) while working to repair a centrally located hernia often results in arms collision and extensive troubleshooting; thus, the authors prefer to avoid that location for trocar placement. If present, adhesiolysis of the abdominal wall may be necessary to expose the planned hernia defect (Figure 100.3a). Due to the fact that one of the disadvantages of robotic surgery is the loss of haptic feedback, special attention is required to prevent inadvertent bowel injury by way of atraumatic handling. Closing the hernia defect allows more fascial contact area for the mesh and leads to equalization of the pressure and tension along the mesh and the abdominal wall (Figure 100.3b and c). A recent study comparing roboticassisted laparoscopic ventral hernia repair with closure of fascial defect to laparoscopic ventral hernia repair without fascial defect closure showed decreased recurrence rates and complications in the robotic-assisted patient group.8,9

610  Robotic ventral hernia repair (a)




Figure 100.1  Mesh positioning for ventral hernia: (a) intraperitoneal onlay mesh (IPOM); (b) transabdominal preperitoneal mesh (TAPP); (c) retrorectus mesh; and (d) retromuscular mesh with transversus abdominis release (TAR). (Reprinted with permission, Atlas of Robotic Surgery, Cine-Med, Inc., copyright 2018.)

Robotic intraperitoneal onlay mesh repair  611 (a)


Figure 100.2  Trocar positioning for IPOM and TAPP. Closing the defect by a robotic platform provides a strong technical ability. It has been reported that the closure of the fascial defect was performed in 69.3% of cases by robotic surgeons at their initial experience.10 Technically, defects with a diameter less than 10 cm are convenient for primary closure. Reducing pneumoperitoneum pressure to 6–8 mmHg is often necessary. The choice of suture material may vary; in our practice, a long-lasting absorbable barbed suture (STRATAFIX 0 on CT-1 needle, Ethicon, Somerville, New Jersey) is used for primary closure of the hernia defect. The same guideline used for laparotomy closure, which is a small bite technique with taking bites of fascia of 5–8 mm and placing stitches every 5 mm in a shoelace fashion, is preferred.11




A tissue-separating mesh is used in intraperitoneal onlay position. The size of the mesh upholds the principle of maintaining an at least 5 cm overlap in all directions. There are several options to secure the mesh to the abdominal wall, including a combination of tacks and sutures, or securing the mesh to the abdominal wall with circumferential suture fixation. An absorbable suture (2–0) is placed around the mesh in a running fashion (Figure 100.3d). After completion of mesh fixation, the patient-side cart is undocked. The trocars are removed, and the pneumoperitoneum is released. The fascia at the 10 mm or larger trocar insertion site should be sutured to decrease the risk of future incisional hernia. Long-acting local anesthetic agent is injected into trocar sites for management of postoperative pain.

Figure 100.3  (a) Adhesiolysis. (b and c) Hernia defect closure in a shoelace fashion. (d) Mesh fixation with absorbable barbed suture.

612  Robotic ventral hernia repair



The potential complications due to adhesion are reduced to a minimum in the preperitoneal ventral hernia repair technique, since the peritoneal layer is located between the viscera and the mesh. Therefore, using coated mesh is not necessary as in the IPOM technique.12 Instead, a low-cost option in preperitoneal repair with polypropylene mesh is suggested.13

Surgical technique Patient preparation, positioning, initial access, trocar placement, and adhesiolysis are analogous to the previously described procedure.



Monopolar scissors and a bipolar Maryland forceps are used. The peritoneum is grasped and cut at least 5 cm from the defect on the side ipsilateral to the trocars to enter the preperitoneal space. Throughout the preparation of the peritoneal flap, the peritoneum should be tracked gently to avoid tearing. For this purpose, pressing on the peritoneal flap with the sponge, which is prepositioned in the operative field, helps in both controlling minor bleeding and minimizing the peritoneal tearing risk (Figure 100.4a). During the dissection of the peritoneum, which forms the inner layer of the hernia sac, separation of tissues without making peritoneal defects may not always be possible. In the situation of peritoneal integrity disruption, it should be repaired later by absorbable sutures. Preperitoneal dissection should extend at least 5 cm in all directions around the defect to provide adequate mesh layout. It should be kept in mind that the wide dissection of the preperitoneal space allows a large, mobile peritoneal flap for covering the mesh. One of the concerns in robotic TAPP is placing new mesh and keeping the old integrated mesh as part of the posterior layer as it is often fused and difficult to separate. HERNIA DEFECT CLOSURE, MESH PLACEMENT, PERITONEAL FLAP CLOSURE

The hernia defect is closed with a barbed suture as described in IPOM technique after being measured by a ruler (Figure 100.4b and c). Once the rolled or folded noncoated mesh is introduced into intra-abdominal cavity through one of the trocar, it is unrolled or unfolded in the preperitoneal space without any wrinkles or folds. Then, it is circumferentially secured to posterior fascia with a barbed absorbable suture (2–0 V-Loc; Medtronic, New Haven, Connecticut). After adequate mesh fixation and bleeding control are achieved, the next step is to close the peritoneal flap (Figure 100.4d). Rapidly absorbable barbed suture may be used for this purpose. At the end of the procedure, it should be checked that the entire mesh is covered with the peritoneal flap to protect the intra-abdominal structures from exposed mesh.



Figure 100.4  (a) Preperitoneal dissection and pressing

on the peritoneal flap with the sponge. (b) The measurement of the hernia defect by a ruler. (c) The closure of the hernia defect. (d) The closure of peritoneal flap after mesh fixation.

Robotic retromuscular mesh repair  613



The retrorectus repair, which was popularized by RivesStoppa-Wantz, is based on the theory that placement of mesh below the hernia defect and muscles will allow the abdominal pressure to keep the mesh in location.4 In this technique, the posterior rectus sheath is opened just off the linea alba, and the rectus muscle is dissected off the posterior rectus sheath. The posterior rectus sheath is then sewn together in the midline. Once the mesh is placed in this space, its contact with the abdominal structures is excluded. However, being a restricted sheath, the posterior rectus sheath limits the amount of mesh that can be placed laterally as the sheath ends.

Surgical technique For patient preparation, standard principles that were mentioned at the beginning of this chapter are followed. Depending on hernia-related factors such as localization and size, it can be done either by a single- or double-docking method.



The single-docking method can be applied in two different directions of dissection: from caudal to cranial or lateral to medial. The craniocaudal approach can be suitable for upper midline hernias. For this purpose, the patient is positioned on the operating table in a slightly flexed Trendelenburg position to prevent robotic arms’ collusion with the patient’s pelvis and legs. Once pneumoperitoneum is obtained, three trocars are placed across the lower abdomen, following the same principles as previously described (Figure 100.5a). In the lateral-to-medial approach, the dissection is planned from one lateral side to the other lateral side of the rectus sheath. After the placement of the initial trocar into the retromuscular plane in an ipsilateral semilunar line with the open technique, similar to the enhanced-view totally extraperitoneal (eTEP) hernia repair procedure,14 two trocars are aligned in the course of the ipsilateral border of the rectus sheath under the direct camera vision in accordance with the previously mentioned principles (Figure 100.5b). RETROMUSCULAR DISSECTION, APPROXIMATION OF POSTERIOR RECTUS SHEATHS, AND MESH PLACEMENT

In the approach with a caudocranial direction, the content of the hernia sac is reduced and adhesiolysis is completed in order to assess the extent of the hernia defect. The dissection begins with a transverse incision, which is performed through the posterior rectus sheath to enter the retromuscular plane, at least 5 cm below the hernia defect. The incision is extended from the semilunar line on one side, continues to the retromuscular plane contralaterally, and ends at the opposite semilunar line. In order to enter the preperitoneal

Figure 100.5  Trocar positioning: (a) caudocranial approach and (b) lateromedial approach (eTEP).

space behind the linea alba, the medial edges of both posterior sheaths are dissected along the midline (Figure 100.6a). Thus, the right retromuscular space and the left retromuscular space are merged to make an entire compartment. With proceeding dissection, the inferior edge of the hernia sac is encountered. It is not always possible to separate the hernia sac from the subcutaneous tissue. The integrity of the hernia sac should be ensured as far as possible. Dissection is extended at least 5 cm above the hernia sac. If the integrity of the newly developed pocket is deteriorated at any place except the midline, which will be closed later, these holes should be closed with absorbable suture. In the medial direction approach, after completion of ipsilateral retrorectus dissection, the medial edge of the rectus sheath is incised to reach the contralateral rectus sheath, provided that the peritoneum, which is posterior to the linea alba, is kept intact (Figure 100.6b). After completion of retromuscular dissection on the contralateral side, the posterior sheaths are not approximated and only the peritoneal entry

614  Robotic ventral hernia repair (a)



and hernia sac are closed using a 2–0 absorbable barbed suture. The defect is then closed using an absorbable barbed suture in a shoelace fashion, which was previously described (Figure 100.6c). A polypropylene mesh is shaped to occupy the entire retromuscular dissected area and is placed against the anterior abdominal wall (Figure 100.6d). The mesh is secured with a few interrupted absorbable sutures. Minimal fixation is generally enough, since physiological intraabdominal pressure will aid in maintaining the mesh in position. If there is a necessity for greater medialization of the posterior rectus sheath for approximation, proceeding to a robotic TAR technique would be a suitable option.

ROBOTIC TRANSVERSUS ABDOMINIS RELEASE The theory of the TAR technique is based on the posterior component separation technique (PCST), which was first described by Carbonell et al.15 The aim of this technique is to extend the retrorectus dissection plane to outside of the rectus sheath in order to obtain more space for larger meshes. However, the neurovascular bundles that supply the rectus abdominis muscles might be damaged when the dissection proceeds laterally between the internal oblique and the transversus abdominis muscle in this technique. Moreover, the amount of myofascial medialization might be limited to restore the posterior layer. These are accepted as potential drawbacks. In the TAR technique, which was popularized by Novitsky,16 the neurovascular bundles are protected, since the dissection plane proceeds lateral to the semilunar line in the preperitoneal space. Furthermore, the TAR technique allows for significant posterior rectus fascia advancement.

Surgical technique Patients who have midabdominal wall defects (7–18 cm) or lateral defects such as parastomal hernia are good candidates for robotic TAR. (d)


The patient is positioned supine, arms out, and with the bed flexed slightly. Once pneumoperitoneum is obtained, three of six trocars are placed along the anterior axillary line as described in the rIPOM technique (Figure 100.7). After exposing the hernia defect with any necessary adhesiolysis and hernia reduction as described before, the retromuscular dissection is initiated from the contralateral medial edge of rectus sheath (Figure 100.8a) and is carried out laterally to the semilunar line, superiorly to the costal margin, and inferiorly toward the pubic tubercle.

Figure 100.6  (a) Dissection of medial edge of rectus

sheath in caudocranial approach. (b) Dissection of contralateral medial edge of rectus sheath in lateromedial approach. (c) The closure of hernia defect. (d) Mesh placement.


When the lateral border of the rectus sheath is reached, transversus abdominis fascia and muscle are begun to be

Robotic transversus abdominis release  615 (a)


Figure 100.7  Trocar positioning for robotic TAR technique. divided from ∼1 cm medial of the lateral border of the rectus sheath to enter the preperitoneal plane, to keep neurovascular bundles intact. Beginning the initial release of the transversus abdominis fascia at the lateral arcuate line can facilitate finding the correct dissection plane (Figure 100.8b). Typically, continuing the bottom-to-up dissection, fibers of transversus abdominis, which can be easily recognized, are encountered. For the upper abdominal level, incision of the posterior lamella of the internal oblique aponeurosis exposes the medial fibers of the transversus abdominis muscle on the posterior rectus sheath. Then, these fibers are divided from the top to the bottom extent of posterior sheath mobilization (Figure 100.8c). Preperitoneal dissection is extended laterally to approximately the midaxillary line. Subsequently, dimensions of dissection are measured as longitudinal and mediolateral in order to choose an appropriately sized mesh that will be utilized for covering the retromuscular area. The mesh is shaped and is rolled along its longitudinal axis. In order to ensure that its furled form is maintained, one or two sutures, which will be cut before the deployment of the mesh, are placed. The mesh is secured with a few absorbable sutures along the posterolateral abdominal wall after introducing it into the abdominal cavity (Figure 100.8d). Then three trocars are inserted along the contralateral anterior axillar line under direct camera vision, so they are placed above the posterior layer as well as the mesh.




The robot is redocked on the contralateral side. Contralateral retrorectus dissection and TAR are performed as described (Figure 100.9a). At the end of the preperitoneal dissection, the initially placed trocars are brought into the preperitoneal space. Adequate overlap of the hernia defect and any previous midline incision should be provided with retroxiphoidal

Figure 100.8  (a) Contralateral posterior rectus sheath

mobilization. (b) Beginning of the initial release of transversus abdominis fascia at the lateral border of the arcuate line. (c) Dissection of transversus abdominis fibers. (d) Initial mesh fixation at the contralateral side.

616  Robotic ventral hernia repair (a)


or retropubic dissection. It is enough for sufficient TAR dissection to complete it when the two flaps of the posterior sheath lie inferiorly over the viscera. The midline posterior sheath is closed using a 2–0 absorbable barbed suture in a running fashion (Figure 100.9b). The hernia defect is then closed using an absorbable barbed suture (Figure 100.9c). The anterior fascia is approximated with barbed suture. Any peritoneal defects should be closed with absorbable suture. All of these closures are facilitated by reducing the level of pneumoperitoneum to between 6 and 8 mmHg. The previously placed mesh is unfurled, is deployed without any wrinkles, and is secured to the contralateral abdominal wall with absorbable sutures (Figure 100.9d). Pneumoperitoneum is released, and trocars are removed. There is no need to close the trocar sites, as each is covered by the mesh. A placement of a drain is generally not necessary.




Figure 100.9  (a) Contralateral retrorectus dissection

after redocking. (b) The approximation of the posterior rectus sheath. (c) Closure of the hernia defect. (d) Mesh deployment after cutting the stitch that maintains the furled form of the mesh.

1. Sauerland S et al. Cochrane Database Syst Rev 2011;(3):CD007781. 2. Luijendijk RW et al. N Engl J Med 2000;343(6):392–8. 3. Korenkov M et al. Br J Surg 2002;89(1):50–6. 4. Johnson TG et al. OA Anatomy 2014;2(1):3. 5. Parker SG et al. World J Surg 2017;41(10):2488–91. 6. Liang MK et al. Ann Surg 2017;265(1):80–9. 7. LeBlanc KA et al. Surg Laparosc Endosc 1993;3(1):39–41. 8. Kudsi OY et al. Am J Robot Surg 2015;2(1):​22–6. 9. Gonzalez AM et al. Int J Med Robot 2015;11(2):120–5. 10. Gonzalez A et al. Surg Endosc 2017;31(3):1342–9. 11. Muysoms FE et al. Hernia 2015;19(1):1–24. 12. Orthopoulos G et al. J Laparoendosc Adv Surg Tech A 2018;28:434–8. 13. Prasad P et al. Indian J Surg 2011;73(6):403–8. 14. Belyansky I et al. Surg Endosc 2018;32(3):1525–32. 15. Carbonell AM et al. Hernia 2008;12(4):359–62. 16. Novitsky YW et al. Am J Surg 2012;204(5):709–16.

101 Laparoscopic repair of recurrent inguinal hernia BRANDICE DURKAN AND EDWARD H. PHILLIPS

INTRODUCTION Inguinal hernioplasty is the most common surgical procedure performed by general surgeons. Surgeons want to use a repair that is easy to perform, painless, and secure. The widely used nonmesh modified Bassini and the nonmesh Shouldice repairs have been largely replaced by tension-free onlay mesh hernioplasty because of less pain, ease of performance, and a low recurrence rate. However, recurrence remains a problem. Large database studies from Denmark and Sweden show that reoperation rates after primary mesh repair range from 3.1% to 17%.1–4 With the introduction of laparoscopic hernia techniques in the early 1990s, there was hope that recurrence rates would be reduced. However, studies demonstrate that the anterior tension-free mesh and laparoscopic approaches are equal in terms of recurrence in primary inguinal hernias in 5 years follow-up.5-7 Preventing a recurrence after repair of a recurrent hernia is more challenging based on the rate of a second recurrence, which is as high as 33%.8

SELECTING A TECHNIQUE TO REPAIR A RECURRENT HERNIA The main considerations in choosing an approach include the following: 1. Safety/ease of performance 2. Re-recurrence rate 3. Chronic pain incidence 4. Time to return to work/usual activities 5. Predicted cosmetic outcome First, does the hernia need to be repaired? A prospective randomized multicenter trial of watchful waiting versus Lichtenstein repair studied this question.9 Forty-three patients were randomized. At 2 years, only 15 patients (35%) went on to

surgical intervention when symptoms dictated. There were no adverse outcomes associated with delaying the repair.10 Once the decision is made to repair a recurrent hernia, the surgical approach depends on the patient’s symptoms, the type of initial repair, and the experience of the operator. Initial repairs include primary tissue repair (Bassini, McVay, or Shouldice), anterior mesh repair (Lichtenstein-type onlay patch, plug and patch, or Prolene Hernia System), posterior mesh repair (Read, Rives, Stoppa, or Kugel), or laparoscopic (transabdominal preperitoneal [TAPP] or totally extraperitoneal [TEP]). In general, if the initial repair was performed anteriorly, a retroperitoneal repair by laparoscopy or open Cheatle-Henry approach to the preperitoneum is preferable to avoid scar tissue and distorted anatomy. If the repair was performed posteriorly, an anterior repair is preferable.

LAPAROSCOPIC TECHNIQUES Laparoscopic approaches result in less postoperative and chronic pain, shorter hospital stays, and increased patient satisfaction. However, technical difficulty, operative time, and direct costs are increased.11–17

Transabdominal preperitoneal The TAPP approach places mesh in the preperitoneal space with an incision in the peritoneum. Mesh implantation as an underlay repair results in a tension-free repair, thereby reducing pain and, theoretically, recurrence.18,19 Single-institution studies demonstrate re-recurrence rates of 0.5%–3% when TAPP is performed for recurrence after a prior anterior repair. The Danish Hernia Database demonstrated a re-recurrence rate of 1.3% for TAPP versus 11.3% for Lichtenstein approach.4 Mahon et al. found TAP resulted in significantly less early postoperative pain and significantly

618  Laparoscopic repair of recurrent inguinal hernia

less chronic pain compared with open mesh repair.20 All studies consistently show a significant learning curve associated with the TAPP repair. TAPP for recurrent hernia should only be attempted by surgeons who have experience with the technique.1,2,4,20–26 There are little data on TAPP repair of a previous laparoscopic repair, as it is infrequently performed unless the prior mesh needs to be removed, since the peritoneum becomes adherent to the mesh.

Totally extraperitoneal The TEP repair places mesh in the preperitoneal space without an incision in the peritoneum. Like TAPP, the TEP approach is difficult, if not impossible, following prior preperitoneal mesh placement or other preperitoneal surgeries like a radical open prostatectomy. One prospective randomized study with a subset analysis of laparoscopy for recurrent hernia and one prospective controlled, nonrandomized study looking at TEP versus open repair for recurrence support the use of TEP for hernia recurrence of a previous anterior repair.23,27 Incidence of re-recurrence after TEP varies from 0% to 20%, but most series report similar or improved recurrence rates compared with open re-repair.28,29 Examples include one large single-institution study with a re-recurrence rate of 0.3% after TEP.25 Another group had a reoperation rate of 1.3% after TEP for recurrence; this was in contrast to reoperation rates for open tension-free mesh repair of 3.2% and nonmesh repairs of 6.7%.1 Studies show that patients who undergo laparoscopic surgery for recurrence have decreased postoperative pain, earlier return to normal activities, and fewer wound and mesh infections.5,20–23,31–34 There are limited data comparing TAPP and TEP directly. The literature documents a steep learning curve, and only surgeons with experience should approach a recurrent hernia with a TEP technique.1,4,21,24–26,32–34,36–39

Prior anterior repair If the initial repair did not use mesh, either an anterior or posterior approach is acceptable, though a posterior laparoscopic repair avoids the difficulty of dissection of prior scar tissue and altered anatomy. If mesh was used and does not need to be removed, a laparoscopic repair should be used, as the dissection of prior mesh adds to the complexity of an anterior approach. The European Hernia Society recommendations for recurrent hernia are the following: If the previous repair was through an anterior route, consider open preperitoneal mesh or laparoscopic approach (if expertise is present for laparoscopic repair: TEP rather than TAPP).

Prior posterior repair If the previous repair was through a posterior route, an anterior mesh repair is preferable.40

Prior anterior and posterior repair If the patient has had a recurrence following a combined anterior-posterior approach, an open Stoppa-like repair is preferred unless the prior repair did not use mesh. In that situation, an anterior approach with a mesh repair can be performed.

CHALLENGES Incarceration with or without bowel compromise or infection Laparoscopic repair of an incarcerated hernia may be safely attempted; however, there is a high conversion rate to the open approach. There are minimal data to support a laparoscopic approach to the recurrent incarcerated hernia, but it can be attempted in experienced hands.30 An advantage of the laparoscopic approach is the ability to completely evaluate bowel viability, clamp the bowel prior to reduction, and even perform a laparoscopic bowel resection and anastomosis. Even if a TEP approach is used to repair the hernia, the umbilical port may be placed intraperitoneally to view the entirety of the bowel prior to or after the repair. A TAPP or TEP should not be completed with mesh when there is necrotic bowel or peritonitis seen during laparoscopy. Placement of mesh in this setting risks mesh infection and the associated complications of fistula, chronic draining sinus, and an increased recurrence rate. With evidence of infection in the space, a myofascial Bassini or Shouldice repair is recommended (if femoral, a McVay repair).

Risk of testicular injury Testicular atrophy following repair of recurrent inguinal hernia is an important outcome measure that is not well addressed in current literature. It is higher when a combined procedure such as hydrocelectomy is performed. Thorough review of the original operative report aids in decision-making. Although seldom necessary, orchiectomy should be discussed preoperatively. A laparoscopic repair of a recurrence after an anterior repair significantly decreases risk of testicular ischemia through avoidance of cord dissection.35

Recurrence with pain from mesh or nerves If the patient is experiencing symptoms from a “meshoma,” or nerve pain that requires mesh removal or neurolysis/neurectomy, use the approach that was used to place the mesh originally. If nerves need to be cut, an a­ nterior approach is usually preferable unless the operator has experience to perform laparoscopic or open retroperitoneal neurectomy.

References 619

may preclude preperitoneal mesh placement. If performing a laparoscopic repair following prior laparoscopic initial surgery, it may be best to leave the original mesh in place and add a new mesh over any defects resulting from folded, contracted, or misplaced mesh (Figure 101.2). In these settings, it is wise to educate, inform and consent the patient for an anterior approach should that become necessary.


Figure 101.1  Intraperitoneal view of a recurrent direct inguinal hernia. The inferior epigastric vessels are marked with a line. The site of direct recurrence is outlined with a circle. The previously placed mesh (arrow) is densely adherent to the peritoneum, which makes dissection of the preperitoneum a challenge.

When performing a TAPP or TEP repair of a recurrence following a preperitoneal open mesh repair (plug and patch, Kugel, etc.), old mesh will be encountered (Figure 101.1). The prior mesh may be amenable to trimming with scissor, ultrasound scalpel, or electrocautery. However, care must be taken to avoid injury to adjacent structures such as bladder or femoral/iliac vasculature. Peritoneum adherent to the prior mesh

Figure 101.2  The completed TEP laparoscopic repair.

The defect is completely covered. There are no peritoneal suture lines with TEP that come into contact with intra-abdominal contents.

1. Bay-Nielson M et al. Lancet 2001;358:1124–8. 2. Haapaniemi S et al. Ann Surg 2001;234(1):​122–6. 3. Nilsson E et al. Br J Surg 1998;85:1686–91. 4. Bisgaard T et al. Ann Surg 2008;247:707–11. 5. Aeberhard P et al. Surg Endosc 1999;13:1115–20. 6. Chung RS et al. Surg Endosc 1999;13:689–94. 7. The EU Hernia Trialists Collaboration. Br J Surg 2000;87:​860–7. 8. Schaap HM et al. Surg Gynecol Obstet 1992;174:460–4. 9. Fitzgibbons RJ et al. JAMA 2006;295:​285–92. 10. Thompson JS et al. Am J Surg 2008;​195:89–93. 11. Fujita M et al. Arch Surg 2004;139(6):​596–600. 12. Feliu X et al. J Laparoendosc Adv Surg Tech A 2004;14:​362–7. 13. Richards SK et al. Hernia 2004;8:​144–8. 14. Schneider BE et al. Surg Laparosc 2003;4:​261–7. 15. Lal P et al. Surg Endosc 2003;17:850–6. 16. Gholghesaei M et al. Surg Endosc 2005;19:816–21. 17. Schmedt CG et al. Surg Endosc 2005;19:188–99. 18. Amid PK et al. Eur J Surg 1996;162:447–53. 19. Kark AE et al. J Am Coll Surg 1998;86:447–56. 20. Mahon D et al. Surg Endosc 2003;17:1386–90. 21. Dedemadi G et al. Surg Endosc 2006;20:​1099–104. 22. Eklund A et al. Surg Endosc 2007;21:634–40. 23. Neumayer L et al. N Engl J Med 2004;350:1819–27. 24. Jarhult J et al. Surg Laparosc Endosc Percutan Tech 1999;9:115–8. 25. Ramshaw B et al. Surg Endosc 2001;15:50–4. 26. Tantia O et al. Surg Endosc 2009;23:734–8. 27. Feliu X et al. Hernia 2004;8:​113–6. 28. Sayad P et al. J laparoendosc Adv Surg Tech A 1999;9:127–30. 29. Knook MTT et al. Surg Endosc 1999;13:507–11. 30. Ferzli G et al. Surg Endosc 2004;18:228–31. 31. Kapiris SA et al. Surg Endosc 2001;15:972–5. 32. McCormack K et al. Health Technol Assess 2005;9:14. 33. Bringman S et al. Ann Surg 2003;237:142–7. 34. Kuhry E et al. Surg Endosc 2007;21:161–6. 35. Wantz GE. Surg Clin North Am. 1993;​73(3):571–81. 36. van der Hem JA et al. Br J Surg 2001;88:884–6. 37. Ramshaw BJ et al. Am Surg 1996;62:69–72. 38. Thill V et al. Acta Chir Belg 2008;108:405–8. 39. Bingener J et al. Surg Endosc 2003;17:1781–3. 40. Simons MP et al. Hernia. 2009;13:343–403.

102 Laparoscopic repair of sports hernia L. MICHAEL BRUNT

INTRODUCTION Groin injuries are a common problem in sports, and in recent years increased attention has been directed toward the condition popularly known as a “sports hernia.” The term sports hernia is a misnomer in the sense that this condition is not a true herniation. As a result, alternative terms have been recommended that better reflect the underlying nature of this problem; these include athletic pubalgia, inguinal disruption, and abdominal core injury. Although surgery for athletes with sports hernia has become commonplace only over the last 15 years, this entity was recognized in the early 1980s as one that could prematurely end an athlete’s career. For physicians who are asked to evaluate an athlete for possible sports hernia, it is important to understand the various causes of athletic groin pain and to have a systematic approach to the diagnosis and management of these individuals.1 In this chapter, the author’s approach to the diagnostic evaluation and management of athletic groin pain is discussed, including both laparoscopic and open approaches.

BACKGROUND Groin injuries are most common in sports in which there are frequent repetitive movements at high speed, such as cutting, turning, sprinting, and kicking motions. Sports that are particularly vulnerable to these types of injuries include soccer, football, and ice hockey The reported incidence has ranged from 5% to 28% in soccer players2 and 6% to 15% in elite ice hockey players.3,4 Unlike a lot of sportsrelated injuries, athletic groin injuries do not necessarily result from direct physical contact. Most of these injuries are soft tissue in nature, and the adductor muscle group is the most commonly injured site. Engrebretson and colleagues5 analyzed risk factors for groin injuries in a study of male soccer players in Norway. They

found that the incidence of injury was 0.6 per 1,000 player hours. Multivariate analysis showed that a previous history of an acute groin injury or weak adductor muscles on clinical evaluation were associated with an increased risk of groin injury. Another study by Tyler et al.6 looked at hip strength and flexibility in one National Hockey League team prospectively. They found that the adductor-to-abductor strength ratio was greatly decreased on the side of the injury. Most importantly, a program of adductor strengthening reduced the incidence from 3.2 per 1,000 game exposures to 0.71.

DIFFERENTIAL DIAGNOSIS The evaluation and management of athletic groin injuries can be challenging for many reasons: The regional anatomy is complex, there are numerous potential causes, and they can be difficult to diagnose and treat accurately. Fortunately, most athletic groin injuries resolve with conservative management and infrequently require surgical intervention. The differential diagnosis of athletic groin injuries is broad and includes muscular strains that may involve the rectus abdominal, obliques, iliopsoas, hip flexors, and adductor muscle groups. Pelvis-related injuries such as osteitis pubis and stress fractures also present as groin or pubic pain, and hip injuries, including labral tears, femoroacetabular impingement, and even hip arthritis, are also in the differential. True inguinal hernia is an infrequent cause of groin pain in the athlete but may occasionally be present either as a symptomatic or an incidental finding. Finally, one must consider the potential for nonathletic causes of groin pain such as gynecologic problems in young women and gastrointestinal, urologic, and other sources. The regional anatomy of the groin is among the most complex biomechanically in the entire musculoskeletal system. A representation of the anatomy is shown in Figure 102.1 schematically. It is important that physicians and athletic trainers

Diagnosis and examination  621 (a) External oblique muscle (cut) Internal oblique muscle (cut) Transversus abdominis muscle Iliopsoas muscle Sartorius muscle Adductor longus muscle Ilioinguinal nerve Rectus femoris muscle Gracilis muscle

(b) Rectus abdominis muscle

Pubic symphysis

adductor strains are very common in sports. Acute adductor injuries often are associated with a history of a sudden injury or even a pop or pull in the groin. These usually resolve with conservative management, even if there is a complete disruption or detachment of the adductor longus from the pubis. Treatment should consist of rest, ice, compression, nonsteroidal anti-inflammatory agents for pain control, and thermal modalities such as ultrasound and e-stimulation. Once the acute symptoms have settled, progressive range of motion exercise, balance training, and a graduated strengthening program followed by return to sports-specific function activities should be undertaken. The amount of time that a player may miss with an adductor injury may range from a few days to 5–6 weeks depending on the extent of the injury. Sports hernia represents a subset of athletic groin injuries in which there is chronic exertional inguinal or lower abdominal pain that fails to resolve with conservative management. The pain typically occurs during the extremes of exertion and is absent at rest or with normal light activities. Athletes often complain of pain with sudden starts, cutting or turning movements, and kicking motions. Because the players lose some of their ability to suddenly accelerate, they can be challenged to continue to compete at the elite level. Additional symptoms may include pain with coughing or sneezing or getting in and out of bed or a car. It is not unusual to have associated adductor symptoms, which can occur in up to 50% of athletes. The onset is often insidious and without a clear-cut precipitating event.

DIAGNOSIS AND EXAMINATION Adductor longus muscle

Figure 102.1  Anatomy of the pelvic region musculature: (a) standard view and (b) sagittal view. Note how the rectus and adductor aponeurosis wrap around the pubis on the sagittal view; this is often the site of tears in athletic pubalgia-type injuries. (Reproduced with permission from Brunt LM. Sports Hernia: In: Jones DB (ed) Masters Techniques in Hernia Surgery. Lippincott, Wilkins, Williams; 2013:219–29.35)

who care for athletes understand the basic anatomy of the musculoskeletal system around the pelvis in order to accurately differentiate and diagnosis the various injuries. The evaluation should begin with a detailed history and physical examination. Important aspects of the history include the circumstances around the onset of symptoms, location of the pain, and whether it radiates. Does the pain get better with rest? What activities precipitate symptoms? Were there potentially predisposing factors, such as a prior injury or a recent change in training regimen? As previously noted,

The classic finding on physical exam in an athlete with a sports hernia is tenderness at the distal lateral rectus/medial inguinal canal junction. There may also be a dilated external inguinal ring and a palpable gap or defect over the inguinal floor without an associated bulging or protrusion. Pain with a resisted sit-up or resisted trunk rotation is also commonly observed. There may also be pain on the abdominal side of the pubis with resisted straight leg raising or hip flexion and resisted adduction. Meyers7 has described 17 different clinical entities of athletic pubalgia, of which approximately 90% consist of either a pure abdominal injury, a pure adductor injury, or a combination of the two. Various mechanisms have been proposed to explain the pathophysiology and pain, and these include, principally, (1) the presence of an injury to the rectus tendon or aponeurosis injury or to the rectus/adductor aponeurosis complex, which can be seen on magnetic resonance imaging (MRI)8 or (2) weakness of the posterior abdominal wall and inguinal floor or “inguinal disruption”9 (Figure 102.2). Some authors have also postulated a component of inguinal or genital neuropathy as a source of the pain, but that mechanism is not widely accepted. In most centers, the preferred imaging modality is a high-resolution pelvic MRI, which should include axial, coronal, and oblique sequences.10,11 Findings on MRI

622  Laparoscopic repair of sports hernia (a)




Figure 102.2  Operative view of inguinal floor in abdom-

inal core sports injury. (a) Open view of posterior inguinal disruption. (b) Laparoscopic view of posterior inguinal disruption, right side (arrows). (IE, inferior epigastrics; M, midline; P, pubis.) Arrows point to the area of disruption of the posterior inguinal floor.

associated with sports hernia include tears of the combined rectus-adductor aponeurosis or isolated rectus or adductor tears of varying degrees (Figures 102.3 and 102.4), parasymphyseal edema, or a secondary cleft (Figure 102.5). MRI can also be useful for the evaluation of associated hip pathology. Computed tomography is not generally indicated for the evaluation of athletic groin pain, because it fails to show the musculotendinous details and is mainly limited to patients with suspected stress fractures. Some groups use dynamic ultrasound to look for bulging in the posterior inguinal floor.12 This modality is highly operator dependent and does not allow assessment of the other bony and soft tissue structures (e.g., adductors) around the pelvis.

Figure 102.3  Pelvic MRI images of left rectus tear.

Shown are (a) axial and (b) sagittal views. The area of separation appears as a white line on the images (circled in axial view, arrow in sagittal view).

INDICATIONS FOR SURGICAL MANAGEMENT Indications for surgery are symptoms that limit athletic performance, failure of a period of conservative therapy,

Figure 102.4  MRI of left adductor tear (arrow). The tear extends into the symphysis with evidence of a cleft.

Surgical approaches  623

The return to sport rates at 12 months were 97% for operative management and 50% for conservative management. Additionally, after 6 months, 7 of the 30 athletes in the conservative group crossed over and underwent surgery. These studies strongly support the role of surgical intervention in appropriately selected patients.


Figure 102.5  Pelvic MRI that shows right parasymphyseal edema (right arrow) and a tear extending into the left side (arrow).

usually a minimum of 6–8 weeks, and the exclusion of other diagnoses that would explain the athlete’s groin pain.1 Most commonly the other associated pathology that needs to be considered is hip related (labral tear and impingement), and this may coexist with sports hernia pubalgia. Two prospective randomized trials have evaluated surgical management versus conservative treatment for this condition.13,14 Both of these studies have shown higher rates of return to sport in an unrestricted and pain-free fashion than conservative management. In the more recent study, Pajaannen and colleagues14 randomized 60 patients to operative conservative management. At 3 months, 90% of patients in the operative group had returned to sport compared to only 27% in the conservatively managed group.

Various surgical approaches have been advocated for this condition and are listed in Table 102.1. Briefly, the primary pelvic floor as described by Meyers15 consists of a primary sutured repair of the inguinal floor and distal rectus and in selected athletes is done in conjunction with an adductor release. Muschawek and Berger16 described a minimal repair technique in which only the damaged portion of the inguinal floor is opened. The floor is then resutured with a continuous running suture with overlapping layers somewhat analogous to the Shouldice approach. An open anterior mesh repair has been advocated by many groups and has been the preferred approach of the author for this condition.17–20 The goal of this repair is to provide support and stability across the posterior inguinal floor and lower rectus insertion. A laparoscopic posterior mesh repair has been used increasingly for sports hernia repair, and several groups have reported excellent results with this approach. More recently, a laparoscopic posterior mesh repair accompanied by release of the inguinal ligament has been advocated by Lloyd.21 Laparoscopic repair of sports hernia was first reported in 1997 and can be accomplished by either a transabdominal preperitoneal (TAPP) or total extraperitoneal (TEP) approach.22,23 Most reported series have used the TEP approach, which is also the author’s preferred laparoscopic method. The operation is basically the same as a standard TEP inguinal hernia repair. Briefly, access is carried out with a 2 cm infraumbilical incision, and the posterior rectus sheath is accessed on the side of the planned repair. The preperitoneal space is then developed with a balloon dissector under direct laparoscopic visualization. The space is dissected out to expose the entire posterior inguinal floor on the side of injury (or both sides for

Table 102.1  Published results of laparoscopic repair of sports hernia Author/year


Ingoldby Srinivasan26 Evans27 Paajanen28 Kluin29 Genitsaris30 van Veen31 Ziprin32 Lloyd21 Bernhardt33 Rossidis34

14 15 287 41 14 131 55 17 48 47 54



Return to sport (%)

Mean follow-up


93 87 95 95 93 99 91 94 92 ? 100

– 46 months 3–48 months 48 months 3 months 60 months 3 months 23 weeks

TAPP and TEP TAPP TEP TAPP TAPP + inguinal ligament release TAPP TEP + adductor tenotomy

? 18 months

624  Laparoscopic repair of sports hernia

Figure 102.6  Laparoscopic view of dissected inguinal

floor. Shown are the midline (M), posterior rectus muscles (R), direct spaces (D), and symphysis pubis (SP).

bilateral injuries) from the midline along Cooper’s ligament to lateral to the indirect space (Figure 102.6). The peritoneum is dissected for 5–6 cm proximal to the internal ring to prevent the future development of an indirect hernia. A lightweight mesh is then placed to cover the entire inguinal floor and distal rectus extending from the midline to lateral to the internal ring (Figure 102.7). Absorbable fixation is used to secure the mesh with a tacking device. The most common finding at laparoscopy, as with the open approach, is weakness of the posterior inguinal floor or direct space, but tears at the rectus insertion and/or thinning of the rectus may be seen in some athletes (Figure 102.8). Wikiel and Eid24 recently reported on laparoscopic

Figure 102.8  Laparoscopic view that shows small tears (arrows) that are seen in the distal rectus left side.

findings in 40 athletes and noted small bilateral indirect defects in 85% of their athletes. A direct hernia was present in only one case, and there were five athletes (12.5%) who had femoral hernias. These findings are not consistent with what has been reported by other groups; while the reasons for this are unclear, one possible explanation is that it may have been due to a high percentage of recreational athletes (72.5%) in their series. The authors utilized an open approach for most athletes with sports hernia pubalgia.1,25 This procedure is done under local anesthesia with sedation and is carried out via a standard inguinal incision. There is often marked attenuation in the external oblique aponeurosis (Figure 102.9), an aspect that is not addressed by the laparoscopic repair, although the importance of this finding in the pathophysiology of athletic groin pain is unclear. The inguinal floor is repaired using a lightweight mesh placed in a tension-free fashion. The mesh is sutured to the transversalis aponeurosis and

Figure 102.7  Bilateral tension-free mesh repair of

disrupted inguinal floors, total extraperitoneal approach. The mesh overlaps in the midline and is secured with an absorbable tacking device.

Figure 102.9  Attenuated external oblique aponeurosis (arrows) as seen in an open repair.

Surgical outcomes  625

Figure 102.10  Open mesh repair of right inguinal floor. rectus sheath medially and to the inguinal ligament laterally (Figure 102.10). The mesh is split and the two limbs are brought around the cord and sutured to the inguinal ligament above the internal ring in the Lichtenstein fashion so that the mesh will lie evenly in the floor and not because there is pathology at the internal ring. An effort is made to cover the mesh by suturing the internal oblique muscle over to the inguinal ligament with an absorbable suture so that the spermatic cord will not be in direct contact with the mesh. The ilioinguinal nerve is resected selectively in cases in which it appears partially entrapped in a slit in the external oblique or if its position is such that it may be in extensive contact with the mesh in order to prevent postoperative neuralgia.

SURGICAL OUTCOMES The largest reported series of open primary repair was reported by Meyers in 2008.7 He operated on over 5,200 athletes from 1986 to 2008 with successful return to sport in approximately 95%. Muschawek16 described outcomes of the minimal repair technique in 128 athletes. Successful return to sport at 4 weeks was achieved in 83.7% of athletes, but long-term results have not been reported. Experience with open anterior mesh repairs has been described by several groups with return to sport in over 90%. Brown et al.19 reported outcomes in 98 professional or elite-level hockey players over an 18-year period. They used a polytetrafluoroethylene (PTFE) patch placed underneath the external oblique aponeurosis and resected the ilioinguinal nerve in all cases. Recurrent symptoms or injuries were observed in 3 athletes, and overall 97 of 98 successfully returned to sport. The author has performed repairs for sports hernia in over 200 athletes over the last 10-plus years, and an open tension-free mesh repair was utilized in 87% of cases.20 Return to full athletic activity has been achieved in 92% of athletes at a mean follow-up interval of 11.4 months.

The reported experience with and outcomes for a laparoscopic approach to sports hernia repair are listed in Table 102.1.21,23,26–34 In the only comparison of laparoscopic and open approaches done to date, Ingoldby analyzed outcomes in 28 athletes.23 Fourteen athletes had open repairs (3 primary sutured repairs and 11 Lichtenstein tension-free mesh), and 14 were done laparoscopically (TAPP). Both approaches reported successful return to sport in a high percentage of cases, but the laparoscopic approach was associated with a somewhat quicker return to activity at 4 weeks postsurgery (64.2% versus 92.9%). Two athletes in the laparoscopic group had neuralgia symptoms that resolved after 2 months. One case of recurrent symptoms was observed in each group. Most reported laparoscopic series are relatively small and include under 50 patients and are from European centers. In the largest laparoscopic series reported to date, Evans27 reported outcomes in 287 athletes who underwent laparoscopic mesh repair using the TAPP approach. Of note is that a bilateral repair was done in 161 cases (56%), of whom 31% were asymptomatic on the contralateral groin. The reasons for bilateral repair in the asymptomatic patients were unclear. Of 192 patients in whom data were available, 80% were playing sport by 3 weeks and 90% at 4 weeks. In long-term follow-up, there were 8 recurrences that required laparoscopic reoperation. Genitsaris and colleagues30 operated on 131 patients who failed 2–8 months of conservative management. A bilateral TAPP repair was carried out in all cases because of the finding of a posterior wall defect on the contralateral side, even though 33 patients had only unilateral symptoms. All athletes returned to sport at 3 weeks after surgery, and there was only one failure (0.76%) during follow-up. A combined laparoscopic (TEP) floor repair and adductor tenotomy was performed by Rossidis et al.34 in a series of 54 athletes. The majority of athletes played American football, and an MRI showed a rectus stripping injury with associated adductor longus origin strain in 26%. The tenotomy was performed via a separate incision made over the upper adductor longus and 1 cm below the tendinous insertion on the pubis. A standardized rehabilitation protocol was followed by the athletes, and return to sport was achieved at a mean of 24 days. An alternative laparoscopic approach has been employed by Lloyd21 who has postulated that tension in the ligament is a primary source of pain in this condition. In this procedure, a laparoscopic TAPP procedure is carried out, and the inguinal ligament is released medially near its insertion on the pubic tubercle. The area is then reinforced with a polypropylene mesh in a standard fashion. In the early experience with this technique, return to sport was successful in 92% of athletes treated with this technique at a mean of 28 days. Further studies are needed to confirm the results of this approach before it can be recommended. The British Hernia Society held a consensus conference in 2014 that addressed several questions regarding nomenclature, diagnosis, imaging, and treatment of sports hernia.9 The consensus panel comprised surgeons who did only open, only laparoscopic, and one who did both. In regard to the question

626  Laparoscopic repair of sports hernia

of which operative approach should be used, there was no clear consensus on whether an open or laparoscopic approach should be used. However, the laparoscopic repair had a somewhat quicker return to activity and sport, although no controlled comparisons have been done. It was emphasized that an individual surgeon’s expertise is often the primary variable in dictating the type of repair that is undertaken.

POSTOPERATIVE MANAGEMENT AND RETURN TO SPORT An important component of the treatment and recovery from surgery for sports hernia is physical therapy and postoperative rehabilitation. The author has worked with a professional athletic trainer to develop a rehabilitation protocol that is used as the template for recovery in all athletes.25 This approach consists of a stepwise program that comprises abdominal core strengthening as well as an emphasis on strength, flexibility, and balance of the thigh musculature and lower extremity. The first 5 days consist of relative rest and walking. A structured program then begins that consists of more extended walking progressing sequentially to light jogging, stationary biking, and core and lower body exercises. At 2 weeks, or as soon as it is comfortable, scar massage and mobilization may commence. The athlete is encouraged to begin low-level sports-specific activity (dribbling a soccer ball, skating, running, or catching a football) at 2–3 weeks and increase the speed and intensity from that point forward according to symptoms. With the minimal repair technique, Muschawek has reported an accelerated path for return to sport in athletes that allows resumption of training within 3–4 days and has resulted in a return to play as early as 3–4 weeks after the procedure.16 Regardless of the approach, a tension-free mesh repair should also allow early training and progression according to comfort level. In many cases, repairs are often done in the off-season, and a more conservative timetable for return to play is generally utilized. It is important to note that return to play may take longer in athletes who have significant adductor or other associated injuries.

REFERENCES 1. Minnich JM et al. Am J Sports Med 2011;39:​1341–9. 2. Ekstrand J et al. Scand J Med Sci Sports 1999;9:98–103.

3. Pettersson R et al. Br J Sp Med 1993;27:251–4. 4. Stuart MJ et al. Am J Sports Med 1995;23:458–61. 5. Engebretson AH et al. Am J Sports Med 2010;38:2051–7. 6. Tyler TF et al. Amer J Sports Med 2001;29:124–8. 7. Meyers WC et al. Ann Surg 2008;248:656–65. 8. Meyers WC et al. Oper Tech Sports Med 2007;15:165–77. 9. Sheen AJ et al. Br J Sports Med 2014;48:1079–87. 10. Zoga AC et al. Radiology 2008;247:​797–807. 11. Rubin DA. Imaging of athletic groin pain. In: Diduch DR et al. (eds.) Sports Hernia and Athletic Pubalgia, New York, NY: Springer; 2014:87–105. 12. Muschawek U et al. Sports Health 2010;2:216–21. 13. Ekstrand J et al. Eur J Sports Traumatol Rel Res 2001;23:141–5. 14. Pajannen H et al. Surgery 2011;150:99–107. 15. Meyers W et al. Am J Sports Med 2000;28:2–8. 16. Muschawek U et al. Hernia 2010;14:27–33. 17. Simonet WT et al. Int J Sports Med 1995;126:126–8. 18. Irshad K et al. Surgery 2001;​130:759–66. 19. Brown R et al. Clin J Sports Med 2008;​2008:221–6. 20. Brunt LM. Surgical treatment of sports hernia: Open mesh approach. In: Diduch D et al. (eds.) Sports Hernia and Athletic Pubalgia: Diagnosis and Treatment. New York, NY: Springer; 2014:133–42. 21. Lloyd DM et al. Surg Laparosc Endosc Percutan Tech 2008;18(4):363–8. 22. Azurin DJ et al. J Laparoendosc Adv Surg Tech 1997;​7:7–12. 23. Ingoldby C. Br J Surg 1997;84:213–5. 24. Wikiel KJ et al. Surg Endosc 2015;29:1695–9. 25. Brunt LM et al. My approach to athletic pubalgia. In: Byrd TW (ed.) Operative Hip Arthroscopy. 3rd ed., New York, NY: Springer; 2013:55–65. 26. Srinivasan A et al. J Laparoendosc Adv Surg Tech 2002;12(2):101–6. 27. Evans DS. Ann R Coll Surg Engl 2002;84:​393–8. 28. Paajanen HIS et al. Surg Laparosc Endosc Percutan Tech 2004;14:215–8. 29. Kluin J et al. Amer J Sports Med 2004;32:944–9. 30. Genitsaris M et al. Am J Sports Med 2004;32:1238–42. 31. van Veen RN et al. Surg Endosc 2007;21:189–93. 32. Ziprin P et al. J Laparoendosc Adv Surg Tech 2008;18:669–72. 33. Bernhardt GA et al. Surg Endosc 2014;28:439–46. 34. Rossidis G et al. Surg Endosc 2015;29:381–6. 35. Brunt LM. Sports hernia. In: Jones DB (ed) Masters Techniques in Hernia Surgery. Lippincott, Wilkins, Williams;2013:219–29.


INTRODUCTION The sketches of Leonardo da Vinci showed a humanoid robot design, which might be related to his famous anatomical study of the human body in the Vitruvian Man sketches. The ideas of da Vinci inspired many across centuries, even medical device companies, as the current surgical robot is named after him. Currently, the most commonly used surgical robot follows a master-slave relationship, with full control by the master surgeon at the console. In the 1990s, laparoscopy revolutionized surgery and created a new division in general surgery called minimally invasive surgery (MIS) as a subspecialty. As a result, it challenged surgeons across the globe to acquire this new technology to benefit their patients. Almost a decade later, Intuitive was able to develop a U.S. Food and Drug Administration (FDA)–approved robotic system based on the foundation of early works funded by the U.S. Department of Defense on telerobotic surgery, as well as technologies from International Business Machines (IBM), the Massachusetts Institute of Technology (MIT), and Stanford Research Institute (SRI). Since then, robotic technology continues to evolve in the market while other companies prepare to enter this arena. As of the end of 2012, more than 2,500 da Vinci Surgical Systems were being used in over 2,000 hospitals worldwide. Intuitive has the lion’s share of the market by holding the exclusive field-of-use license for more than 1,000 patents. Recently, Ethicon announced a new collaboration with Google to explore how the latest innovations in computer science and advanced imaging and sensors could be integrated into new robotic surgical systems.

LAPAROSCOPIC ROBOTICS IN GENERAL SURGERY The evolution of robotic surgery as previously described was an initiative of the U.S. Department of Defense. The robot

was intended to assist severely wounded soldiers in the battlefield to prevent casualties. The first robotic platform was intended for open surgery; it had two large cameras, and it was not focused on MIS. It was the visionary Fred Moll (Intuitive Surgical, Inc.) who formulated the hypothesis of the robot to solve the limitations seen in laparoscopic surgery, such as the lack of articulation of its instruments, inadequate precision, and nonintuitive motion due to the length of laparoscopic tools. Therefore, the new robotic platform intended for MIS was developed following three basic principles that still persist today: (1) a master/slave, software-driven system that provided intuitive control of a suite of seven degrees-offreedom laparoscopic instruments; (2) a stereoscopic vision system displayed in an immersive format; and (3) a system architecture composed of redundant sensors to provide maximum safety in operation. In March 1997, Intuitive Surgical tested the first prototype in humans and subsequently obtained FDA approval in July 2000.1

THE STANDARD DA VINCI SYSTEM The robotic system consists of the surgical console, a vison cart (tower), and the robot. The console consists of the binocular three-dimensional (3D) visualization system, a padded armrest, and the “masters.” It also has pedals for camera control, resetting master controllers, and for the use of energy devices. The first robot was released with only three arms, one for the camera and two for the robotic instruments. Limitations noticed on this platform were seen in procedures that required operations in more than one quadrant in the abdominal cavity, such as colorectal surgery. In the first generation (Standard), the arms could not self-adjust around the bed to allow the surgeon access to more than one quadrant of the abdominal cavity—it required repositioning of the surgical cart during various stages of the operation.

628  Laparoscopic robotics

In December 2002, the Standard version with four arms was released. This allowed the surgeon to have an additional robotic arm to retract structures. This additional arm, like the three previous, could easily be repositioned by the surgeon at the console, which in turn, decreased surgical time. Moving the robot was difficult and time consuming due to its size and weight. To address this issue, Intuitive released a Si that consisted of a motorized patient cart and efficient mounts for faster patient docking. With the fourth arm integrated, deployment was more rapid and less cumbersome. The role of robotics was very limited in cases requiring multiquadrant surgery. Many times these complex surgical procedures (colorectal surgery) required hybrid procedures combined with standard laparoscopic surgery.2

DA VINCI SI The da Vinci Si was approved by the FDA in February 2009. This model includes dual-console capability to support training and collaboration during surgery. The advantages provided by this device were longer instruments and the ability to reach two quadrants of the abdomen without the need to redock the robot (Figure 103.1). Furthermore, the development of EndoWrist robotic staplers, the bipolar wristed vessel, and the introduction of the Firefly technology (indocyanine green [ICG]) made this platform the most advanced in MIS. In December 2011, the single-site platform for the da Vinci Si obtained approval by the FDA to perform single-incision cholecystectomy. The single-site platform for the da Vinci Si was designed to offer the adequate triangulation required in MIS.

DA VINCI XI As the robotic technology continues to evolve, the recently designed da Vinci Xi platform enables placement of the surgical cart at any position around the human body, enabling access to four anatomical quadrants. The endoscope can be

OCG injected into blood stream

mounted on every robotic arm giving the surgeon more flexibility, its instruments can reach farther than the previous platforms, and the ports can be placed closer without affecting triangulation or conflicts. Currently, the single-site platform has not yet been released to the market and is in the FDA approval process. However, a new concept of single-site robotic surgery is simultaneously being developed by Intuitive, the da Vinci SP. This single-site platform designed to work on the Xi includes four wristed instruments (including the camera).

ADVANCED ROBOTIC TOOLS Firefly (indocyanine green) Fluorescence-guided surgery utilizing the ICG vital dye at a dose of 0.1–0.5 mg/kg (should not exceed 2 mg/kg) is currently used for fluorescent intraoperative cholangiography, bowel perfusion assessment, and lymph node mapping. It is broadly used in urology and gynecology (Figure 103.2).

Vessel sealer The EndoWrist vessel sealer is an advanced bipolar instrument used to coagulate and divide vessels up to 7 mm in diameter. It is wristed and versatile to work within very limited spaces, such as in foregut surgery, bariatric surgery, and splenectomy or low anterior resection.

EndoWrist robotic stapler The robotic stapler that is fully controlled from the console has Smart Clamp technology that provides feedback to the surgeon regarding the thickness of the tissue to be stapled compared to staple height in the robotic stapler load. If the sensors on the stapler detect that the tissue is too thick for the load applied, it will not fire.

Excitatory laser light source (8.3 nm)


Signal from fluorescing ICG (830 nm) Albumin protein in blood

Figure 103.1  A dual console allows two surgeons to share control of the surgical robot simultaneously.

Vision cart

Cost 629

Figure 103.2  FireFly technology is capable of emitting laser light that is close to infrared light with the flexibility to switch using dedicated commands at the console between white light and near-infrared (NIR) light view in real time, thus enabling surgeons to perform fluorescence-guided surgery utilizing the indocyanine green (ICG) dye.

Advanced Robotic Ultrasound Technology from BK Medical provides a curved linear probe and guarantees a unique real-time 3D visualization of the target anatomy.

CLINICAL Robotic surgery has progressively played an increasing role in every subspecialty in general surgery, including endocrine, such as thyroidectomy, colorectal, bariatric, and foregut, and solid organ, such as adrenalectomy, hepatobiliary, pancreatic, and hernia. Overall, the impression is that this technology is enabling surgeons to offer the minimally invasive approach to patients with challenging surgical scenarios that make conventional laparoscopic surgery cumbersome or impossible (Figure 103.3). As robotics continues to expand across other specialties, more collaboration is noted among general surgeons,

Figure 103.3  Robotic simulation exercise in order to achieve the necessary robotic skills.

urologists, and gynecologists when intraoperative consultations occur.3

LIMITATIONS IN LAPAROSCOPIC ROBOTICS IN GENERAL SURGERY Despite the fact that robotic technology could enable surgeons to overcome the existing limitations in laparoscopic surgery and expand the MIS procedures offered to patients, it comes with some limitations. The major current limitations described in robotic surgery are related to increased costs, prolonged surgical times, and learning curves. Since robotic surgery has been continuously evolving, these limitations should be constantly reviewed.

COST Robotic technology faces several challenges, including steep learning curves and extensive practice and training. Physician training is a major limiting step that comes at a significant price (time spent away from practice, time spent on simulation, time spent on cadaver, proctoring, learning curve, and finally team training to achieve efficiency). Perhaps the greatest challenge is the significant fixed cost with robotic surgery, with additional costs ­a rising from maintenance contracts and disposable robotic instruments. Rosemurgy et al. performed a study to compare the cost of care and reimbursement of robotic versus laparoscopic cholecystectomy. They found that robotic cholecystectomy took longer with higher charges ($8,182.57 greater) than laparoscopic cholecystectomy (p 5 years) should prompt a search for a pathologic lead point.9

Regardless of the underlying cause and location, the majority of intussusceptions have a similar presentation. Classic symptoms of abdominal pain, emesis, and rectal bleeding in a child of the appropriate age are almost diagnostic of intussusception. Stools are typically described as “currant jelly.” Unfortunately, these only occur in 25%–50% of patients.5 Other presenting findings vary from minor symptoms such as fever, diarrhea, and constipation to life-threatening peritonitis and septic shock. Laboratory values are mainly used to assess the severity of the patient’s illness. Imaging remains the mainstay of diagnosis in intussusception. Plain abdominal radiographs are generally nonspecific, although some may show an obstructive picture or soft tissue density in the right upper quadrant. Ultrasound (US) is the most common modality for diagnosis of intussusception in pediatric centers. In experienced hands, US has sensitivity and specificity approaching 98%.10 Classically a “target sign” is identified. US can also assess blood flow to the intussusceptum, identify any intramural gas, and demonstrate a pathologic lead point. Computed tomography and magnetic resonance imaging have little utility in diagnosis of intussusception but may be helpful in the search for a pathologic lead point.

Operative technique In the absence of hemodynamic instability or peritonitis, the first treatment of intussusception is a contrast enema, either under continuous fluoroscopy or ultrasound guidance. Traditionally performed with barium or Gastrografin, the majority of centers now perform pneumatic contrast enemas. Success rates for radiologic reduction have approached 80%–95% in the recent literature.5 Risk factors for failure of radiologic reduction include young (5 years), longer duration of symptoms (>72 hours), or severe rectal bleeding. These factors should not preclude an attempt at reduction in an appropriately resuscitated child. Repeated attempts at reduction are indicated in patients with recurrence of intussusception after successful radiologic reduction or after partial but not complete reduction at the initial attempt. The child must remain in stable condition without signs of intestinal compromise or perforation. Operative intervention is reserved for children with hemodynamic instability, peritonitis, or failure of radiologic reduction. Reduction can be approached through either an open or laparoscopic approach. The laparoscopic setup is similar to an appendectomy or Meckel diverticulectomy with three 5 mm trocars (Figure 115.3). Antibiotics to cover enteric organisms should be administered. Abdominal exploration is started by identifying intussusceptum, typically in the right lower quadrant. Using gentle traction on the intussusceptum while maintaining pressure in the intussuscipiens, the intussusception is reduced. After reduction, the bowel should be

References 695

examined from the cecum proximally looking to identify any pathologic lead point and assess viability. If the presence of ischemia or necrosis is identified, a small bowel resection should be performed, either intra- or extracorporeally.

Postoperative care Postoperatively, these patients tend to recover bowel function rather rapidly, especially if a bowel resection was not performed. Diets can be advanced within 24 hours. Hospital discharge usually occurs within 1–2 days. For patients undergoing a small bowel resection, intestinal function return may be more delayed. Laparoscopic reduction of intussusception has been shown to have a significant decrease in hospital length of stay without an increase in complications.11

REFERENCES 1. Pandya S et al. Surg Clin North Am 2012;92(3):527–39, vii–viii. 2. Hernanz-Schulman M. Pediatr Radiol 2009;39(Suppl 2): S134–9. 3. Adibe OO et al. J Pediatr Surg 2014;49(1):129–32, discussion 132. 4. Oomen MW et al. Surg Endosc 2012;26(8):​2104–10. 5. Pepper VK et al. Surg Clin North Am 2012;92(3):505–26, vii. 6. Kotecha M et al. Pediatr Radiol 2012;42(1):95–103. 7. Chan KW et al. Surg Endosc 2008;22(6):1509–12. 8. Park JJ et al. Ann Surg 2005;241(3):529–33. 9. Lehnert T et al. Int J Colorectal Dis 2009;24(10):1187–92. 10. Hryhorczuk AL et al. Pediatr Radiol 2009;39(10):1075–9. 11. Kia KF et al. J Pediatr Surg, 2005;40(1):281–4.



Image guided surgery

Edvard Munch, On the Operating Table, 1902–03. Oil on canvas, 43 × 58 1/2 inches. Munch Museum, Oslo. (Artwork in the public domain; image © Munch Museum.)

This work was completed during a particularly tumultuous time in the life of Edvard Munch, the famed painter of The Scream (1893). Several years after completing his iconic work, in 1898, Munch entered into a dramatic love affair with the daughter of a wealthy wine merchant in Kristiania (today Oslo) named Tulla Larsen. Their passionate union is detailed in a series of intimate portraits by Munch and their extensive correspondence details travels to Berlin and

Paris, as well as an extended separation because Munch contracted an illness and went to a sanatorium. When Tulla announced their engagement without consulting Munch, he called off the relationship, prompting Tulla to go to even more extreme measures to win her lover’s attention. This culminated in 1902 with her failed suicide attempt and, in September of that year, a pistol shot that damaged Munch’s middle finger. Although the circumstances of the shooting

Image guided surgery  697

remain a mystery, scholars are fairly certain that it was accidentally self-inflicted—the result of a heated argument. The following day, Munch underwent surgery to remove the bullet in his hand at the Rikshospitalet (Oslo National Hospital). The Operating Table is based on this experience, which also included an X-ray, a recent discovery by the German physicist Wilhelm Röntgen (who won the Nobel Prize for his invention in 1901). Munch is said to have been fascinated by the X-ray’s ability to visualize grains of wood, which he later used as inspiration for his art. In this painting, however, Munch has depicted himself nude on the operating

table, surrounded by a small group of faceless surgeons and a nurse who carries a bowl of what appears to be the artist’s blood. Seen from an oblique angle, the artist’s body shows no signs of trauma despite the blood-stained sheet beneath him. Nonetheless, the minor wound seems to have attracted a large crowd of onlookers in the operating theater. By depicting an audience in the painting, the artist also implicates us, the viewers of the painting, as witnesses of the procedure. Medical themes appear frequently in Munch’s work, perhaps owing to the fact that his father was a military surgeon and his mother and sister both died of tuberculosis when he was young.

116 Surgical procedures performed in radiology suites KINGA A. POWERS AND KELLEY WHITMER

INTRODUCTION Visualizing the subject field inherently defines successful surgical procedures. “Good exposure is the key to good surgery” is advice that John Bookwalter, upon inventing the Bookwalter retractor, recollected from his mentor, Cornelius Sedgwick, in the late 1970s. The concept of exposure has evolved along with technological advances in surgery. The classic image of Rembrandt’s seventeenthcentury painting The Anatomy Lesson of Dr. Nicolaes Tulp portraying a filleted surgical field wide enough for crowds of onlookers to visualize each step of the operation is in stark contrast to the minimally invasive, laparoscopic approach used by many surgeons today: surgery via a telescopic lens projected onto multiple high-definition monitors suspended in the operating room. As an alternate mode of enhancing exposure, it has become nearly ubiquitous to use X-ray, ultrasound, or fluoroscopy in at least some corner of a surgeon’s practice. Diagnostic imaging has concomitantly expanded into its own therapeutic field of interventional radiology. The rapidly flowing superhighways of surgery and radiology have veered from running parallel to converging, and have already demonstrated several instances of merging into a single path as evidenced by vascular surgery’s adoption of the endovascular approach and orthopedic surgery’s reliance on fluoroscopy.

SURGERY IN THE RADIOLOGY SUITE Many minimally invasive procedures are performed in interventional radiology suites equipped with fluoroscopic, computed tomography (CT), and ultrasound imaging modalities. These procedures are often performed by trained interventional radiologists or surgeons on patients under conscious sedation or simply with local anesthesia.

Critically ill patients who are not able to tolerate a general anesthetic may benefit from these less-invasive procedures; however, appropriate monitoring devices and personnel must be available to provide required supportive therapy during the procedure. Contingency plans must include considering accessibility to an operating room, surgical instruments, and staff should the minimally invasive ­procedure require an urgent conversion to an open surgical intervention.

MULTIDIRECTIONAL FLUOROSCOPY: ONE PLANE OR BIPLANE Fluoroscopic images are continuous two-dimensional (2D) X-ray projections through the body, and they appear as a movie of overlapping gray shadows of three-dimensional (3D) anatomy on a screen. A mobile, multidirectional fluoroscopy unit, otherwise known as a C-arm, can be brought into a conventional operating room. Several variations of fluoroscopic imaging exist, such as CT-fluoroscopy and cone-beam CT (CBCT) systems that can project highresolution 3D images of organs and can be used intraoperatively.1 Fluoroscopic guidance facilitates percutaneous procedures, such as angiography, nephrolithotomy, biliary drainage, biopsy of tissues such as lung nodules or bone lesions, or accessing subcutaneous radiopaque foreign bodies. With biplane fluoroscopy, two units are used set at 90° to one another, and they can acquire simultaneous imaging in orthogonal planes. Used in cerebral and coronary diagnostic angiography and interventions, this has been reported to reduce the total contrast load and possibly radiation dose to patients compared to single-plane imaging.2 Angiography, an X-ray examination of the arteries and veins for diagnosis and treatment purposes, is a commonly performed procedure. Angiography was enabled to be performed percutaneously by the 1953 invention of Sven

Multidirectional fluoroscopy: One plane or biplane  699

Table 116.1  Angiographic vascular procedures Improving the lumen Balloon angioplasty

Embolic protection devices


Stent graft

Mechanical thrombectomy Thrombolysis and ­pharmacomechanical thrombolysis

Debulking atheroma

A complex technology that widens narrowed blood vessels, invented by Andreas Gruentzig in 1977. The balloon technology includes enhanced angioplasty balloons that not only dilate vessels but can also cut fibrotic lesions by using small longitudinal blades on the balloon surface or a metallic cage. Liquid nitrogen can also be used to inflate balloons for a different effect. In addition, balloons can be used as delivery agents for drugs or gene therapy vectors Devices that when inserted into the lumen of a vessel can diminish particulate embolization in such procedures as coronary saphenous vein bypass or carotid endarterectomy. There are three basic types: distal filters, distal occlusion balloons, and proximal occlusion balloons with or without flow reversal A small flexible tube made of a metal mesh that is used as an intravascular scaffold for the vessel lumen. Stents are either balloon-expandable (deployed by inflating an angioplasty balloon) or self-expanding (deployed by releasing a constraining mechanism). They are used to open blocked or narrowed vessels and can also be drug-eluting and combine the scaffolding properties with delivery of drugs that prevent stenosis Also known as an endograft, a stent graft is a metal stent combined with a fabric material that provides a new lumen to divert blood flow. It can be inserted in a ruptured or ballooning section of an artery, prop a vessel open in occlusive disease, or redirect blood flow as in the TIPS (transjugular intrahepatic portosystemic shunt) procedure. In acute arteriovenous fistulas or pseudoaneurysms, a stent graft can be used to seal over a hole in the wall of the vessel and divert blood flow Introducing a catheter-based device capable of pulverizing a thrombus without a thrombolytic agent, for example, using fluid jets, brushes, baskets, lasers, and ultrasound Relieves blockage by dissolving blood clots with a drip infusion or pulse-spray of thrombolytic drugs at the site of the clot in such clinical conditions as acute arterial occlusions threatening viability of an end organ, thrombotic occlusion of dialysis graft, acute thrombotic stroke, extensive deep venous thrombosis, or a massive pulmonary embolism. A mechanical thrombectomy combined with a thrombolytic agent is termed pharmacomechanical thrombolysis Technique of percutaneously removing the plaque from an artery, an alternative to surgical endarterectomy, by using a variety of biting, boring, or blasting catheter devices that are made of small blades, drills, and lasers that enable making a path no larger than the diameter of the device itself

Decreasing blood flow Embolization

Endoluminal thermal or radioactive ablation Pharmacologic chemoembolization and drug delivery

Delivery of an embolization agent such as a thrombotic gel, IVALON (a particulate embolic material), microspheres made from acrylics, hydrogels, resins, polymers, glass, foam, or steel coil or plug through a catheter to stop the blood flow to leaking blood vessels, tumors, abnormal communications between blood vessels, and abnormal blood vessels in abnormal locations. Embolization of arteriovenous malformations or life-threatening bleeding can be achieved by injecting a substance that blocks the supply of blood to the affected blood vessels. Uterine artery embolization is used to stop life-threatening postpartum bleeding or can be used to treat fibroid tumors—uterine fibroid embolization. Varicose vein treatment is also a common surgical procedure in radiology suites, where the saphenous vein is sealed through the use of a laser or radiofrequency Used for obliterating the greater and lesser saphenous veins in patients with symptomatic venous insufficiency using a heat source such as a laser or a radiofrequency probe. Radioactive microspheres are used for embolization of primary and metastatic hepatic arterial lesions Delivery of drugs or chemotherapeutic agents into an organ or tumor through a catheter when combined with an embolic agent is termed chemoembolization. This technique is currently being used in treating liver lesions, endocrine malignancies, and metastasis. Various liquid sclerosing or vasoconstricting agents can be used, including dehydrated alcohol

Taking things out of or through vessels Intravascular foreign body retrieval Transvascular biopsy

Use of snares, wire baskets, forceps, and grasping cones or entangling coils can be introduced through a catheter to entrap and remove a foreign object Any lesion that has the potential for bleeding may be amenable to transvascular biopsy resulting in bleeding into a blood vessel. Examples are liver or renal lesions in coagulopathic patients and intravascular lesions (Continued)

700  Surgical procedures performed in radiology suites

Table 116.1 (Continued )  Angiographic vascular procedures Introducing drugs or devices Vena cava filter Vertebroplasty Pain management injections

Implanting a cage-like device to break up blood clots and prevent them from reaching the heart or the lungs to prevent a pulmonary embolism Delivery of “bone cement” into the vertebra to alleviate chronic pain Guided injection of anesthetic and steroid into a joint, bursa, or epidural space for management of acute or, more commonly, chronic pain

Ivar Seldinger, who used a catheter to enter the blood vessel through a skin puncture and introduced devices over a guidewire into the blood vessels, including injection of a contrast agent to make the artery or vein visible on the X-ray. With this pivotal technique, the need for open surgical exposure of blood vessels for angiography has been curtailed, and thus has begun the movement of surgical procedures from the operating room to the radiology suites. Today, virtually all minimally invasive interventional radiology procedures are performed with a variant of Seldinger’s original technique. With angiography, the contrast injection is recorded and projected by digital subtraction angiography (DSA). The surrounding structures can be digitally subtracted from the displayed images to record only arterial passage of contrast. Today’s technology allows for 3D reconstruction of angiographic images and aids in visualization of complex anatomy during surgical procedures. To further allow 3D reconstruction, an adjunct intravascular ultrasound (IVUS) is an available technology. An ultrasound probe is placed in a vascular lumen and allows visualization of intraluminal processes and planning of interventions. Angiographic interventions can be grouped into those that widen, improve, occlude, or deliver a substance to the lumen of blood vessels. Table 116.1 presents an overview of the angiographic percutaneous surgical procedures performed in radiology suites today. Fluoroscopic images are excellent at delineating contrast between bone, soft tissue organs of differing densities (heart and lungs), or foreign bodies, such as a catheter. Contrast agents can be used to aid in soft tissue differentiation during fluoroscopy. Radiology suite interventions that utilize fluoroscopy with injected contrast include biliary drainage and stenting, where a stent is visualized to open blocked ducts, and contrast material can be injected to obtain a cholangiogram and visualize drainage of bile. Percutaneous transhepatic cholangiography (PTC) with fluoroscopic guidance can be used as an adjunct to the endoscopic procedures (endoscopic retrograde cholangiopancreatography) as a technique to evaluate and stent the biliary tree. A variety of other gastrointestinal interventional procedures are performed using fluoroscopic guidance, such as gastrostomy or jejunostomy tube placement or various gastrointestinal tract stenting (esophageal, gastric outlet, and duodenal or colorectal) or access (Roux-loop access to enter excluded bile ducts for repeated interventions). Those procedures are often performed in endoscopy suites; however, they can

also be achieved using fluoroscopic guidance in radiology suites or in the operating room. Similarly, urinary tract obstruction can be treated with fluoroscopically guided nephrostomy tube placement, ureteric stent placement, or percutaneous nephrolithotomy (PCNL) to percutaneously access the kidney and dilate a tract that permits stone removal via a nephroscope.

COMPUTED TOMOGRAPHY OR COMPUTED TOMOGRAPHY FLUOROSCOPY Since the introduction of CT-guided nerve blocks and drainages by John R. Haaga3 over 30 years ago, interventional CT-guided procedures have become routine tools for percutaneous surgical interventions done in radiology suites. When ultrasound or fluoroscopic images do not allow imaging visualization, for example, in the lung, the mediastinum, bony areas, or areas of abdomen obscured by gas, CT is used to guide biopsies, drainages, and injections of various medications, including anesthetic and steroid into joints or the epidural space for management of acute or chronic pain. In addition, CT guidance allows access for tumor ablation techniques. Percutaneous drainage of an abscess is a very common procedure performed in radiology suites. The minimally invasive approach allows a wider patient selection in terms of comorbidities and has been recommended by the American College of Radiology since 2000 as a suitable alternative to surgical drainage of infected intra-abdominal collections in selected patients.4 CT-guided drainage can be performed in a variety of ways depending on the indication, including anterior and lateral abdominal wall, transenteric, transvaginal, transgluteal, and transrectal routes. Although most drainages are done to evacuate abscesses, other liquid-filled anatomy can be accessed through this approach, including bilomas, hematomas, seromas, urinomas, cysts, pseudocysts, pleural effusions/empyemas, the renal pelvis, and the urinary bladder. With traditional CT-guided interventions, the needle passage cannot be viewed in real time, and the patient must be brought in and out of the scanner for each needle pass. In general, the procedures require diagnostic CT scans first to establish a reference grid and to guide the puncture site of the needle. Subsequently, the patient needs to be able to be positioned supine, prone, or in lateral decubitus position for the duration of the procedure. Another disadvantage is

Resuscitation with angiography, ­percutaneous techniques, and operative repair  701

the radiation exposure to patient and operator, especially in complex CT-guided interventions such as radiofrequency ablation.5 Newer technologies allow for CT “cine” imaging and dynamic visualization. Computed tomography fluoroscopy (CTF) provides real-time fluoroscopic cross-sectional view of anatomy. The main disadvantage of CTF is the increased exposure to radiation for the patient and operator. During planning prior to the CTF or a CT-guided intervention, the doses applied need to be calculated and maximums established in advance. Intraoperative CT or CTF use is still limited; however, preoperative localization techniques with coil or wire placement can assist with minimally invasive surgery. For example, CT-placed localizing coils can aid video-assisted thoracoscopy surgery of small lung nodules or partial nephrectomy of small renal cell carcinomas or suspect renal lesions.6

ULTRASOUND Ultrasound (US) uses sonic waves that are reflected back by tissue as energy. Reconstructed images effectively visualize morphology, tissue stiffness, and blood flow in the anatomy examined. Ultrasound can be used for percutaneous access or intraoperatively with surgical procedures. Ultrasound is used to guide superficial biopsies or access the renal collecting system for percutaneous nephrostomy. Ultrasound is also used to assist in access for other procedures requiring catheter access to a vein or artery, which will subsequently be primarily performed utilizing multidirectional fluoroscopic guidance. New 3D transducers have become available and can be used percutaneously and also inserted into the body (transesophageal, transrectal, intravascular, or intracardiac probes). In addition, fusion of US and preoperative CT or magnetic resonance imaging (MRI) images or models, and fusion of real-time US images with direct human vision have been developed.7

MAGNETIC RESONANCE IMAGING Since its development in the 1970s, MRI has been used as an imaging tool for diagnosis and later for intervention. Initially, MRI-guided procedures were limited to aspiration and biopsies. Today the MRI-guided interventions include periradicular therapy, drainages, vascular interventions, and ablative therapies for tumors. MRI is based on energy captured from the excitation of various tissues’ hydrogen atoms with a series of magnetic fields. There is no ionizing radiation. Other important advantages include superior visualization of the organ anatomy and vasculature without instilled contrast, and multiplanar imaging with 3D capability. Furthermore, flow, diffusion, perfusion, and temperature can be measured using this modality.8 One limitation of MRI-guided procedures is their requirement for a unique environment

that considers safety concerns raised by the high magnetic fields. Patient monitoring equipment and instruments must be MR-compatible, and standard operating room equipment cannot be utilized. Intraoperative MRI suites are built as MR-compatible multiroom facilities with integration of other devices, such as fluoroscopy into XMR (combined X-ray and MR imaging) suites for cardiac interventions.

MIXED-REALITY ENVIRONMENTS Multimodal imaging or augmenting the image display by combining data from various modalities like CT and MRI or fluoroscopy and CT into a single image is a rapidly advancing field of radiology.7,9 A drive to enhance the physical human capabilities of surgeons, including the introduction of enhanced digital intelligence to surgeon tools, is evident in the development of operating room environments where the traditional radiology, endoscopy, and surgery techniques can be used in concert. The drive to enhance human intelligence and the senses of touch, vision, hearing, and perhaps to some degree taste and smell is beginning to change the way surgeons make decisions and how they execute their function. Current robotic-assisted surgery (RAS) technology is a very good example of this transformation, especially in the disciplines of urology and gynecology, where operations have been completely transformed. The emergence of mixed environments that allow for information connectivity, combine imaging technologies, and the use of “smart” technologies with enhanced surgical tools make the surgeon akin to a conductor directing an orchestra for the purpose of producing a beautiful musical piece—in this case, a perfectly performed operation with added value to the patient. Real-time assistive guidance with virtual 3D imaging and image fusion to reconstruct and display pathological and normal tissue are examples of currently available advances in surgery.10 Augmented reality (AR) techniques are emerging, which are designed to enhance and augment the visualization of anatomy, especially hidden anatomy, for surgeons operating with minimally invasive techniques.7

RESUSCITATION WITH ANGIOGRAPHY, ­PERCUTANEOUS TECHNIQUES, AND OPERATIVE REPAIR Untreated hemorrhage leads to exsanguination and death in the setting of trauma. Open approaches eliminate the natural tamponade effect of surrounding tissues and can increase hemorrhage. For this reason, hemorrhage is now treated by endovascular techniques in many cases. These procedures are normally performed by an interventional radiologist or vascular surgeon in a suite dedicated to endovascular treatment. Treatment may necessitate transfer of a potentially unstable trauma victim from the trauma center to the

702  Surgical procedures performed in radiology suites

interventional radiology department, and then often to a traditional operating room for additional treatment. These transfers cost valuable time and ultimately may lead to worse outcomes or death of trauma patients. Also, endovascular suites may not be equipped to readily handle monitoring or active treatment of other life-threatening injuries during the endovascular intervention. This is being addressed through several ways summarized by the acronym, RAPTOR— resuscitation with angiography, percutaneous techniques, and operative repair.11 First, surgeons are now being cross-trained by interventional radiologists during their residencies to increase their skills with endovascular techniques. Trauma patients are typically first evaluated by a trauma team who must be well versed in what technique will best treat a particular injury, be it catheter-directed embolization, endovascular repair and stent grafting, or open repair. Additionally, trauma centers are addressing the problematic transfers by equipping hybrid treatment operating rooms equipped for endovascular techniques and open repair.12 These hybrid operating rooms may be equipped with large monitors that can display the patient’s initial diagnostic CT exam, a vascular “road map” created by digital subtraction angiography, and the real-time fluoroscopic images from the endovascular ­treatment being administered. Following endovascular intervention, or at times perhaps during endovascular treatment of an injury, other injuries can be treated as needed by open or other minimally invasive techniques.

Obviously, the biggest limitation to this approach is the expense of building and equipping a hybrid treatment ­operating room and staffing this facility with appropriate specialists. An additional limitation includes surgeon training. Also, if multiple trauma victims arrive at a trauma c­ enter simultaneously, a situation that is unfortunately very common, a center with only one hybrid treatment operating room will need to appropriately triage these patients to make the best use of the available facility and staff.12


1. Wallace MJ et al. J Vasc Interv Radiol 2008;19(6):799–813. 2. Sadick V et al. Br J Radiol 2010;83:379–94. 3. Haaga JR. Eur Radiol 2005;15(Suppl 4):d116–20. 4. Duszak JR et al. Radiology 2000;215 (Suppl):1067–75. 5. Kloeckner R et al. Eur J Radiol 2013;82(12):2253–7. 6. Mahnken AH et al. CT- and MR-Guided Interventions in Radiology. Berlin, Heidelberg: Springer; 2009. 7. Linte CA et al. Comput Med Imaging Graph 2013;37(2):83–97. 8. Blanco RT et al. Eur J Radiol 2005;56(2):130–42. 9. Perrin DP et al. Curr Probl Surg 2009;46(9):730–66. 10. Himidan S et al. Semin Pediatr Surg 2015;24(3):145–9. 11. Kirkpatrick AW et al. Injury 2014;45:1413–21. 12. Fehr A et al. J Trauma Acute Care Surg 2016;80(3):457–60.


INTRODUCTION Reduced depth perception and reduced tactile feedback are the main challenges introduced by the minimally invasive surgical approach. The operative field displayed on a monitor induces a loss of proprioception, which to compensate for requires extensive training. Intraoperative manual palpation can provide crucial anatomical information, which laparoscopic instruments are unable to reproduce. Computer science is producing technologies allowing for an easier adaptation to the modified depth of perception and is providing surrogate experiences of physical palpation through an artificial road map of the surgical anatomy: the concepts of virtual reality (VR) and augmented reality (AR).1 VR and AR are the fundamental components of the emerging concept of computer-assisted surgery (CAS).2 VR medical software can extract a three-dimensional (3D) virtual clone of the patient from medical imaging (computed tomography [CT] scan or magnetic resonance imaging [MRI]). This patient-specific virtual model enhances the ability to explore the surgical anatomy and can be used literally to perform a virtual surgical exploration3 and plan digitally the most suitable approach. The superposition of the preoperative digital 3D model onto intraoperative real images gives AR, and it can provide visualization of delicate or unapparent structures of interest and crucial anatomical relationships, by a modular virtual transparency. Pioneer successful applications of AR guidance have been in neurosurgery and maxillofacial surgery.4 Image guidance in these surgical disciplines is made easy by the presence of osseous landmarks, which are motionless and highly contrasted. As a consequence, the virtual model results are highly congruent with the real patient, while in digestive surgery AR is greatly limited by respiratory movements and by organ manipulation and deformation. However, irrespective of the clinical application, the fundamental steps to obtain AR are the same. The process to obtain AR includes the following

steps: (1) generation of a virtual patient-specific model; (2) visualization of the model in the operative field; and (3) registration, which corresponds to the accurate overlaying of the 3D model onto the real-time images. In this chapter, we briefly describe the most relevant aspects of those steps.

STEP 1: GENERATION OF VIRTUAL PATIENT’S SPECIFIC THREE-DIMENSIONAL MODEL The key for CAS is the patient-specific virtual model. Through interactive navigation, the operator can use the 3D models for virtual surgical exploration, which can enhance the detection of critical anatomical data.3 Furthermore, the surgical approach can be safely simulated before the procedure on the real patient, and finally, the model can be displayed in real time in the operating room to guide the procedure. There are two different approaches to obtain a virtual 3D model from DICOM (Digital Imaging and Communication in Medicine) data: direct volume rendering (DVR) and surface rendering (SR) (Figure 117.1). DVR methods generate images of a 3D volumetric data set without delineating structures. Each gray level of the primitive DICOM image can be associated with a color and a degree of transparency through a transfer function. During rendering, a light ray going through each voxel of the 3D image is simulated, and the optical properties are cumulated along each viewing ray to form an image of the data. DVR is available on standard radiologic workstations and does not require preprocessing. DVR is also available on personal computers through open-source software, e.g., OsiriX on MacOS.5 Our group has developed open-source software VR RENDER,1 which runs on all operating systems (Windows, MacOS, and Linux). DVR may enhance the understanding of anatomy, but DVR models are not adapted to computer-assisted surgery since the 3D volume is computed integrally and the different organs cannot be “virtually manipulated” separately. To fulfill the requirements for

704  Augmented reality (a)



Figure 117.1  3D virtual patient-specific modeling: (a) direct volume rendering (DVR), (b) surface rendering (SR), and (c) fusion of both DVR and SR from a DICOM image.

Figure 117.2  VR-Med software allowing simultaneous display and merging of different imaging modalities. CT-MRI image fusion

of arteries (red arrows) segmented from the CT arterial phase; veins (blue arrows) from the CT venous phase; Wirsung and common bile duct (green arrows) from the cholangio-MRI in a single 3D virtual patient modeling.

computer-assisted surgery, 3D models should be obtained through SR. SR requires a preprocessing of organ segmentation, which can be manual, semiautomatic, or fully automatic. Based on this delineation, a colored geometrical mesh is generated automatically, and SR allows visualization of the different organs with or without transparency. SR allows modular “manipulation” of single organs, and for this reason can be used for virtual navigation, tool positioning, volumetric analysis, and organ resection planning through software such as VP-Planning. Another improvement is brought by the Visible Patient service (www.visiblepatient.com), which allows for a combination of image display and registration. For example, CT scan arterial and venous phases can be displayed simultaneously with a cholangio-MRI from the same patient, and the 3D model can be merged to have all the data of vascular and biliary tree in the same image. This fusion can be of particular interest in hepatobiliary cases (cholangiocarcinoma or pancreatic cancer), where improved planning might radically influence the surgical strategy (Figure 117.2). Such 3D modeling has been used by our surgical team on more than 2,000 clinical cases for the thoracoabdominal area during the last 10 years. Recently, we could demonstrate the accuracy of the 3D Virtual Surgical Planning software (Figure 117.3) in determining the total liver and future remnant liver volumes in a series of 43 patients undergoing major hepatectomies.6

STEP 2: DISPLAY OF THE MODEL IN OPERATIVE ROOM SETTING The next step is to display the 3D virtual model in the operative field and superimpose it onto real-time images to obtain AR during the therapeutic act. There are mainly three options.

Direct projection A beamer is positioned above the patient, and the virtual model is projected onto the patient’s skin. The visual effect is remarkable, offering a virtual transparency of the patient. We have used this method to optimize port positioning, particularly in case of robotic surgery.7 Similarly, Sugimoto et al.8 used projector-based and video-based AR navigation by overlaying DVR 3D models obtained with OsiriX 3D viewer (Pixmeo, Geneva, Switzerland) on the patient’s skin and on screen to guide the placement of operative ports in laparoscopic gastric and colorectal surgeries. However, in projector-based AR, there are different perspectives, and the head positions of all of the operators should be tracked to increase accuracy, which is quite complex.

Step 3: registration of the three-dimensional model  705 (a)


Figure 117.3  Automatic resection volume computing, virtual surgical tool positioning, and virtual planning: (a) virtual hepatic

multiresection planning with remnant liver computation on the 3D model and (b) laparoscopic tool positioning and virtual surgical resection simulation.

See-through optical display See-through display is a fascinating AR modality. A semitransparent mirror allows the operator to integrate AR data while directly looking at the patient.9 Alternative see-through modality includes a videography screen with microlenses providing a 3D effect and enhanced depth perception.10 Additionally, see-through eyewear for multimedia or military applications (e.g., Google Glass, Optinvent ORA-1, Vuzix, or Laster Technologies smart vision system) can also be used to display AR. However, AR based on informative glasses needs precise tracking of pupil movements, and the current technology still does not ensure the degree of accuracy needed for surgery. Okamoto et al.11 evaluated a video see-through system in three hepatobiliary cases in which the synthetic SR images reconstructed by preoperative CT scan were superimposed on real organs. Significant accuracy errors and lack of depth feedback were reported with this configuration.

Video camera display In video camera display, the virtual 3D model is overlaid with images from the operative field, which are acquired by endoscopic or external cameras, and merged. AR is displayed directly on the screen. For an external view of a patient’s internal structures, AR can be obtained through static or head-mounted cameras. The headmounted cameras have the advantage of enabling AR in correspondence with the surgeon’s sight. However, its use is limited by the needs of head position tracking and by some uncomfortable feeling for the user. In the setting of minimally invasive surgery, it is straightforward to display AR information directly on the endoscopic image as we have illustrated with adrenal surgery,12 liver 7 and pancreatic tumor resections,13,14 and minimally invasive parathyroidectomy. 3,15

STEP 3: REGISTRATION OF THE THREEDIMENSIONAL MODEL Registration is the process of accurately overlaying the 3D virtual model onto the patient’s real anatomy, which is of primary importance for any AR process to be reliable. Registration is most commonly performed interactively, involving some degree of human manipulation. A straightforward interactive registration method consists of visualizing the preoperative 3D model on the operative monitor and manually resizing and orienting the model according to some visible landmarks (e.g., bone structures such as the iliac crest or eventually some radiopaque markers used during acquisition of both preoperative and intraoperative images).7,12 Alternatively, the positions of landmarks can be predetermined using preoperative imaging, and during the procedure a navigation pointer again outlines the landmarks,16 and then the model is semiautomatically repositioned. When it comes to automatic registration, the main challenge of AR in soft tissue surgeries includes organ deformation or displacement by surgical manipulation or during breathing. Automatic registration is an area of ongoing experimental research and requires a lot of improvement. The key process to obtain fully automatic registration is in the ability to proceed with a real-time intraoperative update of the 3D model, or to predict the motion range with acceptable approximation. Furthermore, camera and tool calibration using fiducials and tracking systems, generally based on optical systems integrating infrared cameras and/ or electromagnetic (EM) systems, are also required to compute positioning during surgery. The main approach is to directly acquire a 3D image of the surgical field and to update the imaging at any time during surgery. This can be done using 3D ultrasound,17 as recently demonstrated by Nam et al. for liver surgery applications. Alternatively, we have proposed use of an intraoperative low-dose 3D x-ray imaging system (Artis zeego by Siemens Healthcare) to compute the new liver

706  Augmented reality (a)



Figure 117.4  Automatic AR obtained with DynaCT image: (a) registration of a laparoscopic and a DynaCT image allowing to (b) localize and overlay precisely the tumor location (in green: adenoma chemically induced in a porcine model), even after a large liver lobe displacement (c).

shape and position and provide an up to 1 mm accurate AR view during surgical manipulation18 (Figure 117.4). Furthermore, to compensate for real-time deformation due to organ movement and manipulations, our group is actively working on a different approach consisting of a real-time simulation of organ deformation during the operative procedure. Proof of this concept has been initially realized for abdominal organ deformation due to breathing movement with a 1 mm accuracy real-time AR.19 Application to laparoscopic surgery will require the addition of biomechanical properties to the geometrical model of organs in order to predict their behavior under a given condition. 20 Patient-specific biomechanical properties could be provided preoperatively by elastographic imaging system, with magnetic resonance elastography being the preferred option.

CONCLUSIONS AR guidance in minimally invasive surgery is still in its infancy and poses significant challenges. However, the developments so far are encouraging. A lot is still required to provide accurate and automatic AR guidance enabling safer and easier minimally invasive surgical procedures.


1. Nicolau S et al. Surg Oncol 2011;20:189–201. 2. Marescaux J et al. J Pediatr Surg 2015;50:30–6. 3. D’Agostino J et al. N Eng J Med 2012;367:1072–3. 4. Wagner A et al. J Craniomaxillofac Surg 1995;23:271–3. 5. Volonte F et al. J Hepatobiliary Pancreat Sci 2011;18:506–9. 6. Begin A et al. Surg Endosc 2014;28:3408–12. 7. Pessaux P et al. Langenbeck Arch Surg 2015;400:381–5. 8. Sugimoto M et al. J Hepatobiliary Pancreat Sci 2010;17: 629–36. 9. Fichtinger G et al. Comput Aided Surg 2005;10:241–55. 10. Liao H et al. IEEE Trans Biomed Eng 2010;57:1476–86. 11. Okamoto T et al. J Hepatobiliary Pancreat Sci 2013;20: 249–53. 12. Marescaux J et al. JAMA 2004;292:2214–5. 13. Mutter D et al. Expert Rev Gastroenterol Hepatol 2010;4: 613–21. 14. Pessaux P et al. Surg Endosc 2014;28:2493–8. 15. D’Agostino J et al. World J Surg 2013;37:1618–25. 16. Marvik R et al. Surg Endosc 2004;18:1242–8. 17. Nam WH et al. Phys Med Biol 2012;57:69–91. 18. Bernhardt S et al. Med Image Anal 2016 May;30:130–43. 19. Hostettler A et al. Prog Biophys Mol Biol 2010;103:169–84. 20. Umale S et al. J Biomech 2011;44:1678–83.



Essay on issues in minimally invasive surgery

Hanaoka Seishū, Breast cancer surgery, ca. 1800–35. Published in Illustrated Book on External Treatments for Unusual Diseases (Kishitsu geryō zukan) (Japan: Tangetsu, 18—?), 61. US National Library of Medicine, Bethesda, MD. (Image courtesy US National Library of Medicine.)

708  Essay on issues in minimally invasive surgery

What was it like to perform surgery before the use of medical imaging devices? Before the invention of technology that allowed doctors to see inside of the body, surgeons often relied on written description and medical illustrations to “see” common maladies and their treatments, in addition to learning firsthand from experienced teachers. In e­ ighteenth-century China and Japan, physicians wanting to perform surgery often used manuals to learn how to produce their own surgical instruments and perform surgical techniques. The Japanese surgeon Hanaoka Seishū (1760–1835) prepared such a book showing patients with transparent or invisible skin, so that others could view a variety of afflictions, including tumors, goiters, and burns. This beautifully rendered image depicts Hanaoka removing a tumor from the breast of a 60-year-old woman named Kan Aiya on October 13, 1804. She was the first patient to undergo surgery using Mafutsusan, an anesthetic made from the datura flower, which is widely recognized as the first surgical procedure to be performed under anesthesia (despite later Western developments based on ether). Hanaoka performed many such surgeries and taught his

students how to perform them as well. The book shows the tools used in the procedure—a pair of scissors and a scalpel—and how they were used in the lumpectomy. After making a three-inch vertical incision above the tumor, Hanaoka felt around for the tumor with his left hand while incising it with the right, as seen in this image. The book then presents the excised tumor, complete with cross-sectional views. This manuscript was likely prepared between 1804, when the surgery was completed, and 1835, when Hanaoka died. It was illustrated by a Chinese artist named Tangetsu, who is identified with a red stamp on the back cover. The quality of the illustrations suggests that the book was created in honor of Hanaoka’s many accomplishments, and given that his patient notes have been lost, this book is a valuable record of his cases. Annotated guide to Hanaoka Seishu’s Surgical Casebook, National Library of Medicine, accessed 27 July 2018, https:// ceb.nlm.nih.gov/proj/ttp/flash/hanaoka/hanaoka.html.

118 The challenges and solutions of performing minimally invasive surgery in underdeveloped environments RAYMOND R. PRICE AND ADEWALE O. ADISA

INTRODUCTION Aseptic technique, anesthesia, and minimally invasive surgery (endoscopic and laparoscopic), three patient-friendly innovations, revolutionized surgery during the twentieth century.10 Yet the benefits of minimally invasive surgery (MIS) still elude much of the developing world. Outpatient laparoscopic cholecystectomy with the ability to return to work in 4–7 days has become the standard of care in highincome countries (HICs). Unfortunately, patients in lowincome countries (LICs) continue to be subjected to larger incisions, increased pain, and longer recovery—or in many instances—continued suffering for lack of any available curative treatments. Preconceived notions about the role for surgical care— and more specifically MIS and endoscopy—in low- and middle-income countries (LMICs) have severely handicapped appropriate expansion in resource-constrained areas of the world. Many public health experts suggest that surgical care is too expensive to implement in LMICs when competing with other types of interventions to improve health. Some argue that developing laparoscopy in LMICs places additional strain on an already tenuous medical system where there are limited physical (electricity, running water, hospital infrastructure, and equipment) and human resources (absolute numbers, inadequate training, and significant learning curves for proficiency in MIS). Many voices from the developing world provide markedly different poignant counterarguments promoting the development of more robust surgical care including MIS in LMICs. The MIS pioneer from India, Dr. Tehemton Erach Udwadia, stated, “I believe surgery is a humanitarian science, and if it is to be that, then the cutting edge of surgical progress must be made available and affordable to all people in all places.”10 Dr. Leslie Akporiaye, Medical Director of the Shawsand Medical

Center in Delta State, Nigeria, where he is developing laparoscopic surgical capability, remarked, “As we now live in a global society, it would be unconscionable for Nigerians to be denied the medical advantages of new technology.” And from the austere environment of the high steppes of Mongolia, where 33% of the population continue living a nomadic lifestyle, Dr. Orgoi Sergelen, Chief of Surgery at the Mongolian National University of Medical Sciences (MNUMS), who led the countrywide expansion of laparoscopic cholecystectomy, emphatically stated, “Laparoscopic surgery is more important for developing countries than high-income countries.” Increasingly, the global community, understanding new possibilities for improved quality surgical care, is recognizing the benefits to the general population and to the local economies through development of minimally invasive and endoscopic surgery despite the challenges faced in resourcepoor environments. The barrier to surgical care, including MIS in all its forms, may not necessarily be related to funding (or the lack thereof) but more to the lack of vision for innovative methods for implementation. If surgical care, as stated by Jim Kim, President of the World Bank, is truly an “indivisible, indispensible part of healthcare,” and since MIS and endoscopy can help millions of people lead healthier and more productive lives, then maybe one of the new frontiers for improved global health should include the worldwide expansion of MIS in resource-restricted environments.

CHALLENGES Poverty Poverty causes the greatest suffering on earth; it is the main reason why MIS and endoscopy are mostly unavailable in LMICs, causing patients to suffer from more painful, and often

710  The challenges and solutions of performing minimally invasive surgery in underdeveloped environments

longer, incapacitating procedures, and present with later stages of surgically treatable conditions. In many countries, MIS is limited primarily to private hospitals, possibly widening the surgical gap between the rich and the poor. Understanding the challenges facing the expansion of MIS and endoscopy worldwide can help identify appropriate solutions.

Burden of disease Surgery has traditionally been neglected as an integral component of public health for improving the overall health of communities.4 The most recent report on the burden of disease indicates that an epidemiological transition of disease is occurring where chronic conditions, many surgically treatable, are now more common than the traditional infectious causes. In fact, 5 billion (not the previously reported 2 billion) people lack access to safe, affordable surgical and anesthesia care when needed.15 To address such a large burden of previously unrecognized diseases within the context of limited global resources, initiatives that provide high yield results, that can reach the entire population, and that are low cost receive the greatest endorsement. Without adequate evaluation of the cost-benefit analysis of MIS in LMICs, many have assumed that MIS and endoscopy do not have a role in global public health. The World Bank’s Disease Control Priorities in Developing Countries 2nd edition (DCP2) identified four distinct areas where surgery could play a role for improving global public health: Trauma, Obstetrical Emergencies, Acute Surgical Emergencies, and some Non-Acute Surgical Conditions. 3 Building on this body of evidence, the Disease Control Priorities 3rd edition (DCP3) appropriately highlighted that essential surgical procedures rank among the most cost effective of all health interventions.5,6 Their list of 44 essential surgical procedures does not include laparoscopy or many other MIS procedures. The DCP3 and the World Health Assembly resolution for including essential surgery as part of universal health care recommends financing universal coverage of essential surgery first on the path to universal health coverage (Figure 118.1). Leaving MIS out of the definition of “essential surgery” has the potential to significantly limit the expansion of MIS over the new 2015–2030 sustainable development goals (SDGs) agreed upon by the world’s nations if MIS continues to be viewed as a high-cost procedure and limited to a select portion of the population.

Lack of infrastructure Many of the early advances in endoscopy and MIS came from innovators who lived in surroundings very comparable to the developing world today. Before video laparoscopy, the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), with financial assistance from the Agency for International Development

Figure 118.1 

The dimensions of universal coverage of essential surgery. (Mock CN et al. Essential surgery: Key messages of this volume from Disease Control Priorities, World Bank, 2015; Vol. 1, p.14. http://dcp-3.org/sites/default/files/chapters/DCP3_ Essential%20 Surgery_Ch1.pdf)

(AID), expanded basic laparoscopy for use in gynecological diagnosis and fertility management throughout Africa, Asia, South America, and the Middle East from 1973 to 1983. They had 51 training centers in 34 different countries where they trained 2,901 physicians. A follow-up survey of the equipment installed found 90% continued usage.16 However, MIS and endoscopy gradually evolved to include more expensive equipment as the demand for video laparoscopy, and better laparoscopes, cameras, monitors, insufflators, and energy devices skyrocketed. The unstable electrical grids thwarted widespread introduction of modern video laparoscopy in LMICs. Ninety-five percent of technological equipment in LMICs has been donated from visiting surgical teams; much of the equipment has often not been designed to contribute toward long-lasting system improvements (LCoGS). A significant amount of the equipment was used or refurbished older equipment. Fifty percent of the equipment ceased functioning due to a myriad of reasons, including lack of spare parts, excess sophistication, or local personnel who did not know how to use it.17 Any form of maintenance agreements usually did not accompany most of the donated equipment. Attempts to introduce MIS into resource-limited environments have been plagued by this phenomenon of dumping old equipment, causing many to question the sustainability of laparoscopy in LMICs. Even Mother Teresa stated, “I do not need your surplus. I do not want you to give me your leftovers. Our poor do not need your condescending attitude nor your pity.” The World Health Organization developed a similar statement addressing appropriate technology in LMICs, “It is not only a waste of precious resources to move useless and unsafe equipment from one place to another, it also undermines the good will and trust that those involved are trying to build.”18

Solutions 711

Limited human resources In many parts of the world, general doctors provide the majority of surgical care. The few certified surgeons and anesthesiologists in LMICs are found mostly in urban areas; rural areas may find only one surgeon for 2 million people. Surgical residencies are often short and do not include any specific training in MIS or endoscopy. Postgraduate continuing surgical education is usually unavailable or provided by short-term surgical missions for procedures that have a documented steep learning curve. Formal certification by governing bodies is in its early developmental stages. Some countries are actively training nonphysician providers to perform surgical procedures (abscess drainage, hernia repair, and cesarean section) to improve access to at least basic surgical care needs.7 This limited surgical capability makes surgery a challenge, not only for MIS, but also for even the most basic procedures.2 When expertise is developed in MIS, there is a natural process to migrate to areas that provide adequate equipment and supplies to perform MIS, leading to the “brain drain” of well-trained providers from rural areas to more urban areas or even to other countries. This lack of surgical workforce and resources causes some to question whether MIS surgery is safe to develop in LMICs or if LMICs are even capable of providing care for the complications that could occur.2

Inadequate health care financing Money alone does not necessarily lead to improved health care. While the United States spends more of its gross domestic product on health care than any other country, it ranks only 50th among 221 nations for life expectancy.19 Nevertheless, a country’s health care financing directly correlates to the volume of surgical procedures performed. The number of surgical procedures performed per 100,000 populations is extremely small for countries that spend less than US$100/person/year compared to countries that spend more than US$1,000/person/year13 (Figure 118.2). Any type of health care, including MIS, which carries a steep price tag, will continue to provide a significant challenge to sustainable development in low-income countries. Other financial barriers to developing MIS in LMICs include local politics, tribalism, corruption, cash economies, local social philosophies, and government instability.

Figure 118.2  Worldwide distribution of surgical procedures (234.2 million surgical procedures worldwide). (Data from Weiser TG et al. Lancet 2008;372[9633]:139–44. Copyright © 2015 Intermountain Healthcare. Used with permission.)

discoveries driving the expansion of MIS and endoscopy in LMICs and secondarily improving health care overall. Rather than being viewed as a burden to health care  in  LMICs, MIS and endoscopy might actually be a facilitator or enabler for strengthening health care systems (Figure 118.3). Realization of MIS and endoscopy in LMICs will be sustainable when the local desire combines with local leadership to find the most appropriate inclusion within their

New financing mechanisms Poverty reduction

Human resource professional development

Minimally invasive surgery endoscopy Decrease “brain drain” migration

SOLUTIONS Many have previously assumed that the challenges facing the expansion of MIS and endoscopy in LMICs are insurmountable. However, harnessing the time and energy previously dedicated to analyzing and predicting why MIS and endoscopy are nearly impossible in resource-restricted settings and focusing innovation toward identifying and implementing solutions to overcome these barriers might lead to new

Infrastructure improvements

Supports universal health care

Burden of disease treated

Affordable, high-quality innovations

Figure 118.3  Health systems strengthening through MIS and endoscopy.

712  The challenges and solutions of performing minimally invasive surgery in underdeveloped environments

health care system. Partnerships from HICs can play a role in addressing the potential barriers, but a local champion for long-lasting change plays a central role for long-term sustainable development.

Poverty Investing in MIS and endoscopy in LMICs may actually be a vehicle that promotes economic growth while improving the lives of a larger population. The benefit of faster recovery and earlier return to work might be more critical in the more tenuous LMICs setting, where an illness treated through MIS techniques could potentially prevent a precipitous drop in the family’s economic status, for example, from a middle-income level to a low-income level. Investing in surgical services can strengthen health care systems by providing improved earning potential through a myriad of job opportunities: Surgeon, anesthetist, nurse, scrub technician, janitor, administrator, bioengineer, and computer support are just a few of these. Quality surgery leads to the development of further expertise locally, including blood banking, pathology, and laboratory testing, which also require a better trained workforce. The overall result decreases the unemployment rate, leading to decreased poverty. However, a recent literature review showed a complete lack of published material addressing the impact of surgery on surgical systems.9 The potential impact of surgery on poverty is an uncharted and important area for research that could help define the role of MIS and endoscopy in LMICs.

Burden of disease The burden of surgically treatable diseases varies by geographic regions of the world. Gallbladder disease was the

second most common cause of inpatient morbidity in Mongolia, while it is much less common in many SubSaharan African nations. Beginning in 2005 in Mongolia, the Health Sciences University of Mongolia (HSUM), renamed recently the Mongolian National University Of Medical Sciences, along with the Dr. W.C. Swanson Family Foundation (SFF), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a countrywide campaign to expand laparoscopic cholecystectomy. This public health approach to addressing gallbladder disease in Mongolia targeted a regionally prevalent cause of morbidity with an MIS approach for the entire population. This 10-year project has seen a dramatic change in the method and geographic availability of cholecystectomy from 2% of the gallbladders removed laparoscopically in 2005, and only in the capital city, to over 65% treated regionally in the rural areas of Mongolia, in addition to increased locations in the capital city, by 2013. By 2011, the primary method for gallbladder removal transitioned from the traditional, more invasive open surgical method to laparoscopic removal. The principles leading to this successful program include understanding the needs in Mongolia, integrating modern surgical development with basic surgical techniques and principles, developing local infrastructure, enabling independent surgical growth and ingenuity, and adapting the training, infrastructure, and business models to the local environment (Table 118.1).8,12 When there is a large prevalence and incidence of a certain disease in a given population (as in Mongolia), and MIS provides a dramatic improvement in patient outcomes, a case could be made that laparoscopic cholecystectomy for gallbladder disease should be included within the fourth distinct area as defined by the DCP2—Non-Acute Surgical Conditions— for improving global public health (Figure 118.4). Where modern diagnostic capability with computed tomography and magnetic resonance imaging scanning is

Table 118.1  Principles for successful development of laparoscopic surgery in Mongolia

1. Identifying and understanding the need a. Burden of disease b. Professional development c. Building community trust 2. Integrating modern surgical development with basic surgical techniques and principles a. Developing the didactic curriculum integrating laparoscopy with basic emergency and essential surgical training b. Organize high-volume practical training component c. Multidisciplinary team training (surgeon, anesthetist, nurse, scub technician, biotechnician, administrator) d. Develop evaluation and research capability (quality improvement) 3. Infrastructure development a. Local equipment and supplies b. Sustainable local supply line and repair capabilities 4. Enabling independent growth and ingenuity within local communities a. Bilateral (United States and local country) laparoscopic training teams b. Incorporating laparoscopic skills labs: training the local educators c. Encouraging the development of a multi-institutional training program 5. Adapting to resource-poor environment

Solutions 713 Surgery as a public health strategy 1. Trauma 2. Obstetrical emergencies 3. Acute surgical emergencies 4. Non-acute surgical conditions




Otitis media


Regionally prevalent and disabling conditions

Non-acute surgical conditions

Laparoscopic cholecystectomy for gallbladder disease

Figure 118.4  Laparoscopy as a public health strategy for gallbladder disease in Mongolia. limited, laparoscopy for tumor diagnosis along with endoscopic evaluation for earlier detection might find a role for treating regionally prevalent and disabling conditions in Sub-Saharan Africa. MIS for obstetrics and female sterilization has already begun establishing its role for global public health in LMICs. The preventive role of MIS and endoscopy, such as colonoscopic polypectomies to prevent colon cancer or a colposcopy and excision to prevent cervical cancer, are well documented. Further research into the ability of MIS and endoscopy to address the burden of disease as well as advocacy for MIS and endoscopy on the global stage is greatly needed.

Lack of infrastructure Expanding surgical care in resource-poor areas, including MIS and endoscopy, is necessarily focusing innovation and technology on sustainability, including affordability, like never before. Dr. Udwadia realized early on that, “Science has no national boundaries and discounts the qualities of ingenuity and innovation which are the thrust of surgery in the developing world.”11 World sentiment for equity and cost-affordable health care has led businesses, educational institutions, international funding organizations, and others to rededicate their efforts to discover innovative, extremely affordable solutions for surgical care. Already, high-definition (HD) quality laparoscopes that are disposable but can be sterilized 25 times can be made for US$75 are being sold with lower-cost laparoscopic light sources and cameras in India. Some HIC universities have partnered with low-income countries to design extremely affordable products that have developed into companies

supporting MIS and endoscopy. A student group from Stanford University developed a low-cost portable ventilator for US$300 suitable for infants and adults, called “One Breath.” This won the Popular Science award in 2010. The University of Utah has projects that have led to the development of an extremely low-cost disposable HD laparoscope and insufflation machines used for laparosocpy. The Copenhagen Consensus,1 a meeting of leading economists (including four Nobel Prize laureates) promoted a case for the development of a broad range of surgical services beyond basic surgical services that could be highly beneficial to poor people. With the rapid development of low-cost highquality equipment designed to work in energy-poor environments, MIS and endoscopy are likely to enter the realm of cost-effective delivery methods and revolutionize health care for LMICs as they have done in HICs. Appropriate costeffective supply chains and long-term maintenance agreements need to accompany these products in LMICs. Local capacity building is key for sustainable development. Models of laparoscopic missions where teams bring all the laparoscopic equipment, operate for a week or two independently, and then lock everything up until they return the following year creates more harm than good. These models undermine the trust that people place in their local surgeons, and the surgical capability disappears once good-willed donations supporting these trips wane.

Limited human resources Physicians and nurses in LMICs want to deliver “effective preventive and curative health services to the full population,

714  The challenges and solutions of performing minimally invasive surgery in underdeveloped environments

equitably and efficiently, while protecting individuals from catastrophic health care costs,” similar to those in HICs.17 Combining infrastructure development for MIS and endoscopy with education creates an environment where health care providers at all levels develop increased job satisfaction. Investing in a well-trained surgical workforce that has the tools to deliver MIS has the potential to decrease the loss of health care providers to migration to more urban areas, or even other countries, helping to maintain the professional expertise locally. Patients develop increased trust in their surgeons when they see their family members and friends recover so quickly. MIS provides surgeons with a needed source for professional advancement and pride in the care they can deliver. Addressing the surgical treatable burden of disease in LMICs requires investing in training an adequate welltrained workforce. A combination of designing appropriate postgraduate training as well as including MIS and endoscopic training into residency programs can help strengthen the health care system. The Lancet Commission on Global Surgery has recommended that Ministries of Health should develop surgical workforce plans to achieve surgical workforce densities of 20–40/100,000 with adequate rural and urban distribution by 2030. For MIS to deliver its full potential to improve patient lives and improve economies, training in MIS and endoscopy must be included in this worldwide initiative based on the regional difference in the burden of disease.

Inadequate health care financing Overcoming many countries, low investment in health requires marketing the dramatic value proposition that MIS and endoscopy provide for local economies. The quicker recovery, rapid return to work, less pain, decreased scarring, and earlier diagnosis and treatment all lend evidence that surgical services in LMICs save lives and promote economic growth. Scaling up surgical services including MIS must be viewed as an investment, not a cost. It took many years of expanding laparoscopic surgery throughout Mongolia with very little investment from the Mongolian government. In 2014, outcomes research, patient and doctor interviews with local media, and widespread public demand led to the Ministry of Health agreeing to financially support laparoscopic cholecystectomy countrywide. It is often unrecognized that acceptable, affordable surgical care requires advocacy on behalf of patients and communities. Government officials can play an important role for developing MIS and endoscopy through legislation, execution of policy, and allocation of resources for action.14 Financing MIS in LMICs includes a variety of potential sources, including private and public funding. A study by the International Finance Corporation (IFC) in 2009 noted over 60% of health care in Sub-Saharan Africa was privately funded. In fact, the private sector was often the only option for delivery of health services in remote rural regions and

poor urban slums. The 4 billion people at the lower end of the income distribution still make a formidable source for private health care enterprise that with demand could propel MIS development in LMICs. The IFC recommended improving the environment for private health care to flourish in LMICs by creating an equity investment vehicle, partnering with local financial institutions, providing advisory services to build capacity within local financial intermediaries, helping expand the education of health care workers, and encouraging the development of health insurance companies. The Lancet Commission on Global Surgery identified potential sources for public revenue to invest in scaling up surgical care in LMICs. These included increased mobilization of domestic resources (through general taxation and taxation of tobacco and alcohol), reallocation and efficiency gains (reducing or eliminating fuel subsidies), and contributions from external resources (both traditional development assistance for health [DAH] and innovative financing). As the equity revolution continues, whereby local communities demand access to high-quality surgical care including MIS, countries will begin to support more sustainable development of MIS and endoscopy. Adequately funding the local health care providers can play a role in maintaining expertise locally.

CONCLUSIONS While there are many challenges to MIS and endoscopy in resource-restricted areas of the world, many surgical, public health, business, and engineering innovators are challenging the prevailing thought that MIS and endoscopy are too expensive and are transforming health care for LMICs by discovering solutions to these challenges. Solutions will primarily come from leaders within these countries, at times with assistance in partnership with HIC institutions and organizations. Previously thought to be inaccessible to the billions of people in LMICs, timely and appropriate MIS and endoscopy are already building communities, expanding economies, saving lives, and engendering hope. Dr. Edgar Rodas, previous Minister of Health from Ecuador, provided great counsel to a group of medical students regarding difficult challenges, “Do not let the four walls of the operating room limit your view of the horizon of possibilities.”

REFERENCES 1. Copenhagen Consensus: Nobel Laureates: More Should Be Spent on Hunger, Health: Top Economists Identify the Smartest Investments for Policy-Makers and Philanthropists. 2012. Accessed date November 2, 2018. https://www.copenhagenconsensus.com/copenhagen-consensus-iii 2. Contini S et al. Ann Surg 2010;251(3):574; author reply 75. 3. Debas HT. Surgery. In: Jamison DT et al. (ed.) Disease Control Priorities in Developing Countries, 2nd ed. 2006:1245–59.

References 715 4. deVries C et al. Global Surgery and Public Health: A New Paradigm. Sudbury, MA: Jones and Bartlett Learning; 2012. 5. Jamison DT. Disease Control Priorities, 3rd edition: Improving health and reducing poverty. Lancet 2018;391:e11–4. 6. Mock CN et al. Essential surgery: Key messages from Disease Control Priorities, 3rd ed. Lancet 2015;385:2209–19. 7. Ozgediz D et al. Lancet 2008;371:627–28. 8. Price R et al. World J Surg 2013;37(7):1492–9. 9. Spiegel DA et al. World J Surg 2015;39:2132–9. 10. Udwadia TE. Surg Endosc 2011;15(4):337–43. 11. Udwadia TE et al. Int Surg 1995;80(4):371–5. 12. Vargas G et al. Int Surg 2012;97(4):363–71. 13. Weiser TG et al. Lancet 2008;372(9633):139–44. 14. Omaswa F et al. African health leaders: Making change and claiming the future. Oxford University Press, Oxford; 2014.

15. Meara JG et al. AJM Leather - Surgery and global health: A Lancet Commission. The Lance-Elsevier Limited, 2014. 16. Castadot RG et al. Int J Gynaecol Obstet. 1986;24(1):53–60. 17. World Health Organization. The world health report 2000: improving performance. Geneva: WHO; 2000. Available from http:/www.who.int/whr/en/ 18. World Health Organization. Local Production and Technology Transfer to Increase Access to Medical Devices Addressing the barriers and challenges in low- and middle-income countries. Geneva: WHO Press, 2012. Available from http:/www. who.int/medical_devices/1240EHT_final.pdf 19. National Research Council, Committee on Population. US health in international perspective: Shorter lives, poorer health. National Academies Press, 2013 April 12.

119 Essay: The future of robotics in minimally invasive surgery CRYSTAL KRAUSE, SONGITA CHOUDHURY, AND DMITRY OLEYNIKOV

INTRODUCTION As the trend in surgery moves toward less invasive procedures, there has been an increase in the use of laparoscopic and robotic surgery. While laparoscopic surgery has helped tremendously in reducing patients’ scarring, morbidity, complications, and hospitalization time, it has also limited surgeon dexterity, sensory feedback, and visualization. Computer-assisted surgical robotics has addressed many of these limitations of traditional laparoscopic surgery, such as reduced visual field, stabilization of tool vibrations, reduced number of incisions, and improved surgical ergonomics for the surgeon. While there have been rapid advances and improvements in robotic systems, large gaps in the technology still exist that need to be addressed, including enhancing haptic feedback, increasing safety mechanisms, and improving range of motion of instruments. The purpose of this chapter is to review the history of computer-assisted robotics in surgery, discuss some of the currently utilized surgical robots, and explore emerging surgical robotic technologies.

HISTORY OF SURGICAL ROBOTICS The first robots used in human surgery were adapted from industrial-use robots. The very first robotic surgery was a brain tumor biopsy performed with a PUMA (Programmable Universal Machine for Assembly; Stäubli, Switzerland) 200 robot (Figure 119.1) in 1985.1,2 This robot mainly served to hold a probe to improve the accuracy of brain tumor biopsies and treatments.2,3 The PROBOT (Prostatectomy ROBOT) was also based on the PUMA robot, was capable of autonomous surgery, and was used for

transurethral resection of the prostate. Further development of PROBOT was halted due to a lack of funding and acceptance of the autonomous nature of PROBOT by the surgical community.4–6 The Computer Assisted Surgical Planning and Robotics (CASPAR) robot was another autonomous, PUMA-based robot, but it was designed for total hip and knee arthroplasty and for anterior cruciate ligament (ACL) repair. CASPAR used three-dimensional (3D) computed tomography (CT) data of the tibia and femur for precise, preoperative planning. In surgery, osteal channels were created by the robot with high surgical precision, and surgery was completed using conventional techniques.7 CASPAR was first used in Germany in 2000 for robot-assisted knee arthroplasty, but use was discontinued in 2004, as studies showed that additional efforts associated with the robot use did not pay off in postoperative patient benefits.3,8 The ZEUS Robotic Surgical System (Computer Motion, Inc., Santa Barbara, California) was designed for use in minimally invasive general surgery. The ZEUS robot had motor-driven arms with actuating graspers that were directly linked to the surgical table and graspers that were inserted into the patient through a laparoscopic port. Internal viewing was accomplished via the AESOP robotic arm (also designed by Computer Motion, Inc.), which was a voice-activated, endoscope-holding arm. With the ZEUS System, the surgeon sat at an open interface, observing a digital screen to control the system and used a microphone to control the endoscope arm. The end effectors of the ZEUS had seven degrees-of-freedom (DOF), giving significant surgical dexterity. In 2001, the ZEUS System was U.S. Food and Drug Administration (FDA)–approved, and successfully performed the first long-range, transatlantic, telemanipulated surgery.9 In 2003, Intuitive Surgical acquired Computer Motion, Inc., and despite its promising

Current computer-assisted surgical systems  717

resection in orthopedic surgery. It was a semiactive robot, using CT data as input, and assisted in bone resection for unicompartmental knee arthroplasty (UKA). The Acrobot consisted of a high-speed cutter attached to a three-DOF robotic arm that sculpted away bone while actively preventing the surgeon from cutting bone outside the preoperatively defined area.11,12 Acrobot was first used clinically in 2001, and its accuracy was demonstrated in a clinical trial in 2004. However, Stanmore Implants was acquired by MAKO Surgical Corp. in 2013 as part of a settlement in intellectual property litigation, and further marketing of the Acrobot system in the United States was stopped.13


Figure 119.1  PUMA 200. A small robot originally designed for manufacturing assembly and other industrial applications [43].

beginning, the ZEUS System was taken off the market in favor of development of the da Vinci Robotic System.6,10 The Acrobot Sculptor (Active Constraint Robot; Stanmore Implants Worldwide Ltd.) was a robotic device designed to increase the accuracy and precision of bone

The da Vinci Surgical System was developed by Intuitive Surgical, Inc. (Sunnyvale, California) and is used in a wide variety of applications, including urologic, cardiac, thorascopic, and gynecological surgeries (Figure 119.2).14 The da Vinci system is the most used surgical robotic system in the world, with over 1.5 million procedures performed and 2,600 systems installed.14,15 The first da Vinci–assisted human surgery was performed in Germany in 1998.14 In 2000, the da Vinci became the first robotic surgery system approved by the FDA for general laparoscopic surgery. This system helps to overcome some of the limitations of a standard laparoscopic approach and allows precise dissection in a confined space.14 The advantages of the da Vinci compared to conventional laparoscopic surgery have spurred its use in laparoscopic radical prostatectomies, helping this platform gain widespread use and acceptance by the surgical

Figure 119.2  The da Vinci Robotic Surgical System consists of the surgeon console, the patient cart, which holds the articulated arms, and the imaging system. Shown in the figure is the surgeon console, with the surgeon looking into the console viewer, and the da Vinci Si patient cart with Single-Site instruments. (©2015 Intuitive Surgical, Inc.)

718  Essay: The future of robotics in minimally invasive surgery

community.16 da Vinci robot surgeries have been associated with a decreased length of stay, lower transfusion rate, and lower in-hospital death rate, but some studies have shown that robot-assisted surgeries are associated with increased cost when compared to laparoscopic and open surgeries.14 The main components of the da Vinci system are a master console and a floor-mounted slave. The slave consists of three to four robotic arms that are each capable of manipulating an instrument with three DOF. The master console is equipped with two cameras that together provide a 3D view of the surgical field.17 The slave is controlled via the master/slave manipulator through the use of finger cuff telemanipulators. The master console was created with the surgeon’s needs in mind, as it has adjustable finger loops on the telemanipulators, an adjustable intraocular distance, and padded head rest and arm bars.18 The instruments make this surgical system unique— they have seven DOF, mimicking the movements of the human wrist, and have tremor filtration.17 There are a few hurdles that have limited the advancement of this technology, including the cost of the robot and instruments, lack of haptic feedback, size of the system, and inability to quickly switch instruments during a procedure.17,19 ROBODOC (THINK Surgical, Inc., Fremont, California) is a bone resection device used in orthopedic surgery. While other early surgical robots were used mainly in an assistive capacity, the ROBODOC was designed as a semiautonomous system to increase the accuracy of femoral implants and reduce the incidence of perforation and fracture of the femur in revisional hip replacement surgeries.20 ROBODOC was developed jointly in 1990 by Integrated Surgical Systems and IBM. The ROBODOC design is based on a customized version of a Selective Compliance Assembly Robot Arm (SCARA) industrial robot.21 ROBODOC is a five-axis robot with haptic feedback sensors, making it possible to implement manual guidance, tactile search, and safety checking, and to adapt the cutter feed rate.22 Autonomous ROBODOC actions are programmed preoperatively with the Orthodoc Presurgical Planner (ORTHODOC) computer program.21 The surgeon places two guide pins on the patient’s femur, and a CT scan with guide pin locations is loaded into the ORTHODOC software, creating a 3D model of the bone.23 Surgical procedures are preprogrammed into ROBODOC, but each step must be manually approved throughout the procedure.21,23 There have been reports of complications with the ROBODOC, including aerosolization of bodily fluids and tissues, heat damage, and procedure stop due to bone motion during cutting.24–27 ROBODOC received FDA approval in 2008 and is also sold in Europe, Asia, and other regions.3 The Robotic Arm Interactive Orthopedic (RIO) System (MAKO Surgical Corp., Ft. Lauderdale, Florida) is another robot designed to assist in the placement of orthopedic devices in UKA. Studies comparing RIO procedures to conventional UKA found the RIO procedures had improved positioning and soft tissue balancing, decreased variance, and better alignment than conventional surgery.28,29 RIO is

a semiautonomous system controlled by the surgeon, and it has both auditory and haptic feedback. The RIO software also uses presurgical CT scans to confine the area to be cut, thus limiting variability and undesirable bone loss. The RIO was approved for use by the FDA in 2005, and as of 2013 had been used for over 23,000 surgeries worldwide.30,31 The major difference between the ROBODOC and the RIO systems is that the ROBODOC operates autonomously, and the RIO is surgeon guided. Both systems have been shown to improve the accuracy of implant placement.28,29

SURGICAL ROBOTICS IN DEVELOPMENT There are several robots designed for use in minimally invasive surgery in clinical trials, including the MiroSurge, EndoSAMURAI, and SurgiBOT. MiroSurge is under development by Deutsches Zentrum für Luft-und Raumfahrt (Cologne, Germany), and this system can be used for both minimally invasive as well as open procedures.32,33 The robot manipulators have seven DOF, have haptic feedback sensors, and are primarily teleoperated, but they can be manually positioned as well.33 Typically, three MIRO arms are used: two for guiding the instruments and one for the endoscopic camera.33 The surgical system is versatile because of the many locations to mount the arms and multiple modes of control.34 The EndoSAMURAI (Olympus, Tokyo, Japan) is a prototype endoscopic platform.35,36 The system is composed of a laparoscopic workstation and a more traditional endoscopic component.36 The endoscopic component can both irrigate the lens and provide air insufflation.35 The platform contains a traditional operating channel and two hollow, steerable arms, which have five DOF and are connected to the endoscope.36 The surgical instruments can be easily exchanged in the hollow arms, which allows for a variety of tasks to be completed, including hemostasis, coagulation, grasping, tissue cutting, retreating, and suturing.36 The ability to use commercially available endoscopic instruments also means operative costs can be reduced.35 EndoSAMURAI may be more successful in performing intraperitoneal procedures because the surgeon is able to manipulate the arms outside of the normal scope, increasing the triangulation of the instruments.35,36 While there are many advantages to this device, a few limitations should be addressed, such as arm length and the suboptimal orientation of the instruments relative to the optics.35 The SurgiBot (Transenterix, Durham, North Carolina) is a single-incision robotic surgery system consisting of flexible instruments controlled by the surgeon. 37 The advantages of the SurgiBot include strength of manipulation, improved 3D vision and ergonomics, and precision movement with scaling. Compared to the systems currently available, the SurgiBOT system is less expensive, allows for internal triangulation, and allows the surgeon to be next to the patient.38 This patient-side, minimally invasive device is unique because it may allow underserved populations to

References 719

utilize surgical robots without the large investment needed to acquire current devices.38 Miniature in vivo robots are a new area of surgical development. These robots are designed for insertion into the peritoneal cavity through a natural orifice or a single incision, providing a novel approach for addressing the constraints of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES). These devices can be used inside the peritoneum without the typical constraints of the access point. Miniature robots can provide the surgeon with a repositionable visualization platform using peritoneum-mounted or mobile camera robots. One single-incision robot currently under development at the University of Nebraska has been successfully used in porcine procedures, including cholecystectomy, colectomy, and tissue biopsy (Figure 119.3).16,38–40 This robot consists of two arms with six DOF and interchangeable end effectors, including monopolar and bipolar cautery, graspers, and needle drivers.41 This surgical robot is controlled by a prototype interface with video imaging, two controllers, and a foot pedal, with the movements of the surgeon’s hands on the interface being directly mirrored by the robot. This robot utilizes standard two-dimensional laparoscopic as well as a prototype 3D camera for imaging. Triangulation of the two robot arms is achieved with the imaging source centered between the robotic arms. The motors that power movement are located in the arm joints, which allows for a significant reduction in the size.42 In experimental testing using a live porcine model, this robot successfully completed a cecotomy in approximately 30 minutes. 39 This miniature robot has a much smaller footprint than currently available surgical devices and will potentially be more affordable, making it available to a wider range of facilities.

FUTURE DIRECTION OF SURGICAL ROBOTICS Early robots mainly functioned as positioning guides and were also designed to increase the precision of repetitive tasks, while current robots are in fact telemanipulation machines allowing the surgeon to guide instruments and motion that is mirrored from the control that the surgeon is using. This allows for a computer-aided approach to surgical manipulation and leaves open the possibility for automated function augmentation of visualization and other computer enhancements. While current technology is robust, there is little competition in the market for new devices and applications. This limits entry of devices into the market as well as creates barriers to novel technological approaches. Automation is one area where other industrial applications have significantly outpaced medical capabilities. It is clear that the goal of surgical robotics needs to be more patient centered and focus on patient safety and disruptive technology for common surgical problems. The monopoly that exists in surgical robotics must be disrupted so the high barrier to entry can be alleviated. One area of robotic application is the use of NOTES and SILS entry to perform complex gastrointestinal procedures. This technique remains a significant challenge because of physical constraints of sending a device deep into the abdominal cavity, sometimes through up to 30 feet of intestine, for surgical manipulation. Only technological advances can make this a true possibility. Continued developments in robotic technologies promise to provide an improved platform for intuitive visualization and dexterous tissue manipulation to complete procedures using these less invasive approaches. Robots of the future will likely be much more autonomous than the current machines, and almost certainly smaller, mass produced, and capable of tasks not possible with today’s technology. Future robots will need to enhance and enable surgical procedures that are presently too risky or are too highly variable, leading to significant problems for surgeons attempting these complex tasks. Just as the da Vinci robot ushered in the age of intracorporeal suturing, so will robots of the future bring new capabilities.

ACKNOWLEDGMENT The authors acknowledge support from the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.


Figure 119.3  Miniature in vivo surgical robot, singleincision robot prototype. (From Zhang X et al. Stud Health Technol Inform 2011;163:740–2.)

1. Doyle JJ. Sun Sentinel 1985. 2. Kwoh YS et al. IEEE Trans Biomed Eng 1988;35:153–60. 3. Gomes P. Robot Comput Integrated Manuf 2011;27:261–6. 4. Mei Q et al. Vis Biomed Comput 1996;1131:581–90. 5. Davies B. Proc Inst Mech Eng H 2000;214:129–40.

720  Essay: The future of robotics in minimally invasive surgery 6. Lanfranco AR et al. Ann Surg 2004;239:14–21. 7. Petermann J et al. Oper Tech Orthop 2000;10:50–5. 8. Stengel D et al. Knee Surg Sports Traumatol Arthrosc 2009;17:446–55. 9. Marescaux J et al. Nature 2001;413:379–80. 10. Pugin F et al. J Visc Surg 2011;148:e3–8. 11. Cobb J et al. J Bone Joint Surg Br 2006;88:188–97. 12. Masjedi M et al. Adv Orthop 2013;2013:194683. 13. MAKO Surgical Corp. and Stanmore Implants Worldwide Ltd. announce MAKO’s purchase of Stanmore Sculptor robotic guidance arm. (2013) NASDAQ Globe Newswire 2015. 14. Ng ATL et al. Hong Kong Med J 2014;20:241–50. 15. Broeders IA. Best Pract Res Clin Gastroenterol 2014;28:225–32. 16. Badaan SR et al. Chapter 59: Robotic systems: Past, present, and future. In: Hemal AK et al. (eds.) Robotics in Genotourinary Surgery. London, UK: Springer-Verlag; 2011:655–65. 17. Hanly EJ et al. Am J Surg 2004;188:19S–26S. 18. Simorov A et al. Surg Endosc 2012;26:2117–25. 19. Oleynikov D. Surg Clin North Am 2008;88:1121–30. 20. Yamamura M et al. Adv Orthop 2013;2013:347358–63. 21. Pransky J. Ind Robot 1997;24:231–3. 22. Kazanzides P. Robots for orthopaedic joint reconstruction. In: Faust RA (ed.) Robotics in Surgery: History, Current and Future Applications. Huntington, NY: Nova Science Publishers; 2007:61–94. 23. Sugano N. Clin Orthop Surg 2013;5:1–9. 24. Nogler M et al. Acta Orthop Scand 2001;72:595–9.

25. Nogler M et al. Clin Orthop Relat Res 2001;(387):225–31. 26. Schulz AP et al. Int J Med Robot 2007;3:301–6. 27. Chun YS et al. J Arthroplasty 2011;26:621–5. 28. Lonner JH et al. Clin Orthop Relat Res 2010;468:141–6. 29. Plate JF et al. Adv Orthop 2013;2013:1–6. 30. Cook A et al. Fact Sheet, MAKO Surgical Corp. (NASDAQ: MAKO). 2015, 2013. 31. Vitiello V et al. IEEE Rev Biomed Eng 2013;6:111–26. 32. Tobergte A et al. The sigma.7 haptic interface for MiroSurge: A bi-manual surgical console. 2011;3023–9. 33. Konietschke R et al. The DLR MiroSurge—A robotic system for surgery. Robotics and Automation, 2009 ICRA ’09 IEEE International Conference on. 2009, 1589–90. 34. Beasly RA J Robotics 2012;1–14. 35. Yeung BPM et al. Int J Surg 2012;10:345–54. 36. Fuchs KH et al. Surg Endosc 2012;26:2281–7. 37. SurgiBot Patient-side Robotic Surgery—TransEnterix, Inc. 2015. http://www.transenterix.com/technology/surgibot/. 38. Wortman TD et al. Surg Endosc 2012;26:727–31. 39. Wortman TD et al. IEEE Trans Biomed Eng 2013;60:926–9. 40. Wortman TD. Design, analysis, and testing of in vivo surgical robots, 2011. 41. Zhang X et al. Stud Health Technol Inform 2011;163:740–2. 42. Oleynikov D et al. Proc Inst Mech Eng Part C 2010;224:1487–94. 43. RP Automation PUMA 260A Robot Parts. 2015. http://www. rpautomation.com/Admin/PUMA260ARobotParts.aspx.

120 Essays on the future of endoscopic surgery: Redefining, future training, and credentialing pathways AURORA D. PRYOR

As anyone who is engaged in the practice of minimal access surgery is aware, we have seen a myriad of changes in the last decade. Many of these novel approaches are presented in this book. The barriers between surgeon and gastroenterologist have continued to blur, and patients have options for treatment with a variety of less invasive approaches. As these techniques continue to evolve, we need to ensure that our medical providers are delivering high-quality patient care. We need to ensure that training, credentialing, and transparency to patients remain at a high level as we transition from more traditional approaches. Training in general surgery has historically focused on big surgery and large incisions. As minimal access surgery has evolved, however, surgery is now done for a large number of procedures with small incisions or even transoral/endoscopic approaches. General surgeons continue to perform the vast majority of screening endoscopy cases in the country, and basic training must result in graduating surgeons competent to perform these procedures. In addition, training in upper gastrointestinal surgery now needs to include interventional endoscopy techniques for primary therapy as well as complication management techniques, such as dilation and stenting. This training may be nested within core general surgical training or evolve into a specialty curriculum as our training paradigm evolves. It is possible that the general surgeon of the future will focus only on common or emergent diseases, and specialists will address more complex pathologies. There are active discussions among the leadership in general surgery to change residency training to a general

core and then a mandated fellowship or advanced training module. It is possible that general surgery as an all-encompassing specialty will be phased out. If that is the case, then we will need to be certified as disease-specific practitioners: foregut surgeons, bariatric surgeons, colorectal surgeons, etc. We must ensure that training in each of these areas is robust enough that we can offer our patients a full breadth of care options for their underlying disease. We will also continue to see blurring between the lines of gastroenterology and surgery. Training and credentialing in new procedures for the practicing physician must also be considered. As physicians choose to adopt new techniques, they should be assessed for underlying minimal expectations in their current clinical capabilities, should undergo defined training specific for the new technique, possibly have proctoring for a new procedure, and at a minimum undergo review of initial outcomes. Credentials for a new procedure should also require surgeons to disclose the new or novel nature of the procedure to patients to ensure that they understand the surgeon’s capability with this technique. It is also important to track procedural performance to ensure optimal outcomes. Surgeons should also not maintain credentials for a procedure that they do not routinely perform. Peer review or observation may be a critical aspect of ongoing performance evaluation and should be included in recredentialing. Outcomes tracking and quality improvement programs should be required for all proceduralists in the future. Despite systems to ensure safe adoption of new technologies into practice, there will remain questions on

722  Essays on the future of endoscopic surgery: Redefining, future training, and credentialing pathways

applicability. What really constitutes a practice change that requires new training and credentialing? Do we need to disclose when we change suture types or try a newer version of a surgical stapler? Do we need training to switch vendors for our energy devices? Despite excellent safeguards and

planning, there will be innovations without clear adoption pathways. These technologies will require that we as physicians monitor each other and our outcomes to ensure that we use both traditional and novel interventions to achieve the optimum outcomes in patient care.


AAAs, see Abdominal aortic aneurysms AASLD, see American Association for the Study of Liver Diseases ABBA, see Axillo-bilateral breast approach Abdominal aortic aneurysms (AAAs), 659, 663, 665 approaches, 659, 660 laparoscopic repair of, 659–661 morbidity, 661 mortality, 661, 663 operative data, 662 outcomes, 664 tubes and grafts, 663 Abdominal wall hernia, 596; see also Laparoscopic hernia repair in children; Laparoscopic incisional and ventral hernia repair Abdominal wall muscles, 608 Abdominoperineal resection (APR), 168 ABIM, see American Board of Internal Medicine Ablation techniques, 254 Ablative treatment of liver tumors, 444; see also Microwave ablation; Radiofrequency ablation clinical outcomes and trials, 455–457 colorectal liver metastases, 457 electrode placement for ablation, 447 hepatocellular carcinoma, 457 intraoperative ultrasound guidance, 446–447 liver lesions, 457 liver tumor ablation principle, 452–453 microwave ablation, 449–452 microwave vs. radiofrequency ablation, 453–455 modalities for hepatic malignancies, 444 operative radiofrequency ablation, 447–448 radiofrequency ablation principles, 444–446 ABS, see American Board of Surgery; Artificial bowel sphincter AC, see Adenocarcinoma Acalculous cholecystitis, 409; see also Laparoscopic cholecystectomy Access in minimally invasive surgery, 238

abdominal wall layers, 240 complications, 241 direct or blind insertion, 239 evidence-based criteria for safe laparoscopic entry, 238 exiting abdomen, 242 Hasson or open technique, 239 injuries to viscera or solid organs, 241 insufflation by Veress needle at Palmer’s point, 241 obesity, 241–242 optical view technique, 239–240 radially expanding access, 240 robotic access, 241 SILS platform, 240 single-incision laparoscopic surgery, 240–241 thin patients, 242 transfacial suturing device, 242 trocar, 238, 240 Veress needle, 239 Accountable Care Organizations (ACOs), 198 Accreditation Council for Graduate Medical Education (ACGME), 3, 19, 193 ACE, see Assessment of Competency in Endoscopy ACG, see American College of Gastroenterology ACGME, see Accreditation Council for Graduate Medical Education Achalasia, 148, 305, 310; see also Peroral endoscopic myotomy; Roboticassisted laparoscopic Heller myotomy barium esophagram, 148 Chicago classification, 149 contemporary evaluation, 148 diagnosis, 305–306 goal of surgery, 314 history, 305 laparoscopic Heller myotomy, 307–309 nonsurgical management of, 306 subtypes, 148, 306 surgical management of, 306 symptoms, 305 treatment options, 149 ACL, see Anterior cruciate ligament

ACOs, see Accountable Care Organizations ACOSOG, see American College of Surgeons Oncology Group Acrobot Sculptor, 717; see also Robotics ACS, see American College of Surgeons ACS NSQIP, see American College of Surgeons National Surgical Quality Improvement Program Acuscopic surgery, 129 Acute fluid collection (AFC), 118; see also Endoscopic procedures of pancreas Acute hiatal hernia recurrence, 304 Acute life-threatening events (ALTEs), 687 Acute necrotic collection (ANC), 118 Acute pancreatitis, 118; see also Endoscopic procedures of pancreas Acute variceal hemorrhage, 80; see also Upper gastrointestinal bleeding Additional length (AL), 275 Adenocarcinoma (AC), 326, 514; see also Intestinal neoplasms Adenoma detection rate (ADR), 90 ADR, see Adenoma detection rate Adrenalectomy, 493; see also Laparoscopic adrenalectomy Adrenocortical cancer, 493; see also Laparoscopic adrenalectomy Advanced gastric cancer (AGC), 349; see also Laparoscopic gastrectomy AFC, see Acute fluid collection AGA, see American Gastroenterological Association AGC, see Advanced gastric cancer Agency for Healthcare Research and Quality (AHRQ), 204 Agency for International Development (AID), 710 AHRQ, see Agency for Healthcare Research and Quality AHSQC, see Americas Hernia Society Quality Collaborative AID, see Agency for International Development AIOD, see Aortoiliac occlusive disease AJCC, see American Joint Committee on Cancer AL, see Additional length

724 Index ALTEs, see Acute life-threatening events American Association for the Study of Liver Diseases (AASLD), 19 American Board of Internal Medicine (ABIM), 19 American Board of Surgery (ABS), 21, 22, 38, 192 American College of Gastroenterology (ACG), 19 American College of Surgeons (ACS), 192 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), 200, 591 American College of Surgeons Oncology Group (ACOSOG), 347 American Gastroenterological Association (AGA), 19 American Joint Committee on Cancer (AJCC), 328 American Society for Gastrointestinal Endoscopy (ASGE), 19, 46, 67, 403 American Society of Anesthesiologists (ASA), 31, 659 level of sedation, 26 American Society of Colon and Rectal Surgeons (ASCRS), 21, 193, 557 American Society of Metabolic and Bariatric Surgery (ASMBS), 21, 67, 193 Americas Hernia Society Quality Collaborative (AHSQC), 594 Ampullary mass, 37 Anal fistulae, 633 ANC, see Acute necrotic collection Anesthesia for laparoscopy, 233 cardiovascular effects of laparoscopy, 234 complications of laparoscopy, 235 elevated IAP, 234 neuromuscular blockade and laparoscopy, 234 perioperative pain management for laparoscopy, 235 physiologic changes during laparoscopy, 233 residual blockade, 234 respiratory mechanics and effects, 233–234 Anesthetic challenges in GI suites, 26 adverse events in sedation, 28–29 benzodiazepines, 27 hypnotic agents, 28 ketamine, 28 medications, 27 monitoring, 27 opioids, 27–28 procedures, 29 propofol, 28 reversal agents, 28 sedation, 26–27 sedation dosage information, 27 Angiographic vascular procedures, 699–700 Angiography, 698 Anorectal malformations, 678; see also Pediatric laparoscopy

Anoscopy, 110; see also Endoscopy, diagnostic lower Antenna coupling, 229 Anterior cruciate ligament (ACL), 716 Anterior gastric prolapse, 369; see also Laparoscopic adjustable gastric banding Anterior superior iliac spine (ASIS), 583, 609 Aortic vascular disease, 659, 660; see also Abdominal aortic aneurysms Aortoiliac occlusive disease (AIOD), 659; see also Abdominal aortic aneurysms APC, see Argon plasma coagulation APDS, see Association of Program Directors in Surgery Apollo OverStitch endoscopic suturing device, 69; see also Endoscopic bariatric therapies Apollo OverStitch Endoscopic Suturing System, 77 Appendiceal orifice, 89 Appendicitis, complicated, 519 APR, see Abdominoperineal resection AR, see Augmented reality Arantius ligament, 441; see also Glissonian approach Argon plasma coagulation (APC), 52, 81, 83, 230–231; see also Upper gastrointestinal bleeding Arteriovenous malformations (AVMs), 88 Artificial bowel sphincter (ABS), 558 ASA, see American Society of Anesthesiologists ASCRS, see American Society of Colon and Rectal Surgeons ASGE, see American Society for Gastrointestinal Endoscopy ASIS, see Anterior superior iliac spine ASMBS, see American Society of Metabolic and Bariatric Surgery Aspire Assist device, 69; see also Endoscopic bariatric therapies Aspirin, 333 Assessment of Competency in Endoscopy (ACE), 21 Assisted pancreatoduodenectomy, 475 Association of Program Directors in Surgery (APDS), 192 Augmented reality (AR), 181, 701, 703; see also Surgery in radiology suite automatic, 706 automatic resection volume compution, 705 direct projection, 704 model display in operative room setting, 704 patient’s specific 3D model, 703–704 process to obtain, 703 see-through optical display, 705 3D patient-specific modeling, 704–706 video camera display, 705 virtual planning, 705 virtual surgical tool positioning, 705

VR-Med software, 704 VR RENDER, 703 AVMs, see Arteriovenous malformations Axillo-bilateral breast approach (ABBA), 497; see also Endoscopic/remote-access endocrine surgery BABA, see Bilateral axillo-breast approach BAL, see Bronchoscopy with bronchialalveolar lavage Balloon angioplasty, 699 Balloon dilatation, 94; see also Lower endoscopy therapeutic dilation and stenting Band; see also Bariatric surgery complications; Upper gastrointestinal bleeding erosion, 384 ligation, 83 slippage, 384 Bard EndoCinch Suturing System, 68, 72; see also Endoscopic bariatric therapies; Revisional bariatric techniques Bariatric surgery, 245, 386; see also Laparoscopic reoperative bariatric surgery gastric banding, 245 Roux-en-Y gastric bypass, 245–246 sleeve gastrectomy, 245 Bariatric surgery complications, 381; see also Laparoscopic adjustable gastric banding; Laparoscopic Roux-en-Y gastric bypass; Laparoscopic sleeve gastrectomy anastomotic leak, 381–382 band erosion, 384 band slippage, 384 bypass-related complications, 381 cholelithiasis, 383–384 dysphagia, 384 hemorrhage, 383 postoperative bleeding, 382 sleeve gastrectomy complications, 383 small bowel obstruction, 382–383 staple line leak, 383 Barium esophagram (BE), 267; see also Esophageal function testing esophagram, 267–268 in evaluation of esophageal disease, 268 timed barium esophagram, 268, 269 video swallow, 267 Barrett esophagus, 35, 50 argon plasma coagulation, 52 Barrett metaplasia, 51 BARRx generator, 52 cryoablation, 52 diagnosis, 50–51 endoscopic ablation techniques, 51 endoscopic mucosal resection, 52–53 high-definition white light image, 50 multipolar electrocoagulation, 52 narrow-band imaging, 51

Index 725 photodynamic therapy, 51–52 radiofrequency ablation, 52 treatment of, 50–53 treatment rationale, 51 Barrett metaplasia, 51; see also Barrett esophagus BARRx generator, 52; see also Barrett esophagus BE, see Barium esophagram Benign gastrointestinal disease in children, 691 hypertrophic pyloric stenosis, 691–692 intussusception, 694–695 Meckel diverticulum, 693–694 Benign prostatic hyperplasia (BPH), 647 Benign tumors, 513; see also Intestinal neoplasms Benzodiazepines, 27 Bezoar, 400 BIB, see Bioenterics Intragastric Balloon Bilateral axillo-breast approach (BABA), 497, 500; see also Endoscopic/remoteaccess endocrine surgery completed subplatysmal flap, 501 flap creation and techniques, 500–501 incisions sites, trocar angle, and flap skin drawing, 500 indication and preparation, 500 nerve dissection, 501 patient positioning, 500 postoperative management and outcome, 501 procedure, 500 setup, 500 thyroid or parathyroid operation, 501 Biliary; see also Endoscopic retrograde cholangiopancreatography; Laparoscopic cholecystectomy; Pediatric laparoscopy atresia, 678–679 colic, 408 dilation, 127 stone disease, 125, 126, 408 Biliopancreatic diversion with duodenal switch (BPD-DS), 393 Biliopancreatic limb (BPL), 374 Bioenterics Intragastric Balloon (BIB), 67, 68, 400; see also Endoscopic bariatric therapies; Intragastric balloon Bipolar electrocautery, 82; see also Upper gastrointestinal bleeding Bladder surgery, 649; see also Robotics in urologic surgery BMI, see Body mass index Bochdalek hernia, 679 Body mass index (BMI), 67, 302, 358, 394, 548, 563; see also Obesity; Weight regain Bookwalter retractor, 698 Boot Camps, 192; see also Laparoscopic training Bowel perforation, 116; see also Endoscopy, diagnostic lower

Bozzini’s light guide, 129 BPD-DS, see Biliopancreatic diversion with duodenal switch BPH, see Benign prostatic hyperplasia BPL, see Biliopancreatic limb Bronchoscopy with bronchialalveolar lavage (BAL), 687 CA, see Carbohydrate antigen Calibrated length (CL), 275 Calibrating suture (CS), 277 Capacitive coupling, 229 Capnography, 28, 31 Carbohydrate antigen (CA), 466 Carcinoembryonic antigen (CEA), 84 Cardiac septal occlude, 78 Cardiospasm, 148 Carolinas Comfort Score (CCS), 588 CAS, see Computer-assisted surgery CASPAR, see Computer Assisted Surgical Planning and Robotics Cavitron Ultrasonic Surgical Aspirator (CUSA), 437 CBD, see Common bile duct CCF/Wexner-FIS, see Cleveland Clinic Florida/Wexner-Fecal Incontinence Score CCK, see Cholecystokinin CCS, see Carolinas Comfort Score CDC, see Centers for Disease Control and Prevention CEA, see Carcinoembryonic antigen Cecum, 114 Celiac artery compression syndrome, see Median arcuate ligament syndrome Celiac axis syndrome, see Median arcuate ligament syndrome Celiac plexus neurolysis (CPN), 42 Celiac trunk compression syndrome, see Median arcuate ligament syndrome Center of gravity (CG), 222 Centers for Disease Control and Prevention (CDC), 199 Centers for Medicare and Medicaid Services (CMS), 199 Central processing units (CPUs), 191 Cephalosporin, 140 Cervical endoscopic thyroidectomies, 497; see also Endoscopic/remote-access endocrine surgery CG, see Center of gravity CHA, see Common hepatic artery Chinese Laparoscopic Gastrointestinal Surgery Study Group (CLASS), 351 Cholecystokinin (CCK), 409 Choledochal cyst, 678–679; see also Pediatric laparoscopy Choledocholithiasis, 424; see also Laparoscopic common bile duct exploration Choledochoscopy, 126; see also Endoscopic retrograde cholangiopancreatography

Circumferential radial margins (CRMs), 169 CL, see Calibrated length CLASS, see Chinese Laparoscopic Gastrointestinal Surgery Study Group CLASSIC trial, 546 CLEAN-NET, see Combinations of Laparoscopic and Endoscopic Approaches for Epithelial tumors using Non-Exposure Technique Cleveland Clinic Florida/Wexner-Fecal Incontinence Score (CCF/WexnerFIS), 557 CMS, see Centers for Medicare and Medicaid Services Cold biopsy, 115 Colectomy techniques, hand-assisted, 548 Collis gastroplasty, 290; see also Laparoscopic antireflux esophageal lengthening procedure Colon and rectal surgery (CRS), 22 Colonoscopy, 29, 110; see also Colonoscopy, diagnostic; Endoscopy, diagnostic lower indications for, 84, 111 Colonoscopy, diagnostic, 84; see also Endoscopy, diagnostic lower advanced planning, 85–86 advancement phase, 87 alternative screening options, 91 bowel preparation, 86 communication with patient, 85 complications, 90 documentation, 90 final check, 86 finding lumen, 87–88 indications for, 84–85 informed consent, 86 intubation of terminal ileum, 88 lesion detection, 89 location, determining, 89–90 patient position, 87 patient selection, 85 postprocedure care, 90 preparation for, 85 pre-procedure assessment, 86 quality measures, 90–91 risk of colonoscopy, 85 sedation, 86–87 surgery procedure, 87 therapeutic interventions during, 90 unruly colon, 88 withdrawal phase, 88–89 Colorectal liver metastasis (CRLM), 254, 457 Combinations of Laparoscopic and Endoscopic Approaches for Epithelial tumors using NonExposure Technique (CLEANNET), 65 Combined hiatal hernia, 294; see also Hiatal hernia

726 Index Common bile duct (CBD), 256, 410, 424; see also Laparoscopic cholecystectomy; Laparoscopic common bile duct exploration stone prediction, 410 stones, 410–411 Common hepatic artery (CHA), 469 Components separation method, 582 adjunctive measures to assist fascial approximation, 589–590 anterior approach, 582, 583 division of external oblique aponeurosis, 586 external oblique release, 586 intermuscular approach, 583–586 interoblique balloon dissection technique,  585 laparoscopic appearance of intermuscular space, 586 laparoscopic component separation, 583 muscular and fascial layers of abdominal wall, 583 open components separation, 582 open vs. laparoscopic component separation, 586–588 outcomes of hernia repairs, 587 placement of inguinal hernia balloon dissector, 584 port placement for robotic posterior component separation, 589 posterior component separation, 583, 588–589 replacing balloon dissector with balloon trocar, 585 separating external and internal oblique muscles, 586 Composite meshes, 592; see also Mesh Computed tomography (CT), 39, 85, 267, 327, 342, 353, 408, 517, 700–701; see also Surgery in radiology suite Computed tomography fluoroscopy (CTF), 701; see also Surgery in radiology suite Computer-assisted surgery (CAS), 703; see also Augmented reality Computer Assisted Surgical Planning and Robotics (CASPAR), 716; see also Robotics Computer-assisted surgical robotics, 716; see also Robotics Computer-assisted surgical systems, 717–718; see also Robotics Concatenation, 209 Cone-beam CT (CBCT), 698 Confluence of the crura, 364; see also Laparoscopic adjustable gastric banding Congenital diaphragmatic hernia, 679; see also Pediatric laparoscopy Contrast agents, 43 Copenhagen Consensus, 713 Cor-Knot System, 107 Cost implications in minimally invasive surgery, 3

case study, 4 cost data from RCTs, 5 cost-effectiveness estimates, 6 costs for minimally invasive therapy, 6 costs of laparoscopic vs. open colorectal surgery, 4–5 costs of robotic-assisted vs. laparoscopic vs. open colorectal surgery, 5–6 health technology assessment, 4 rationale, 3–4 Systems Based Practice, 3 therapy selection, 3 CP myotomy, see Cricopharyngeus myotomy CPN, see Celiac plexus neurolysis CPUs, see Central processing units Credentialing, 196; see also Laparoscopic training Cricopharyngeus myotomy (CP myotomy), 316 Cricothyrotomy, 190 Critical view of safety (CVS), 413; see also Laparoscopic cholecystectomy cystic duct and artery, 413 elevated gallbladder from cystic plate, 414 initial dissection of hepatocystic triangle, 414 requirements for achieving, 413 scoring, 415 CRLM, see Colorectal liver metastasis CRMs, see Circumferential radial margins Crohn disease, 514–515, 535; see also Laparoscopic management of small bowel diseases common opening, 536 completed anastomosis, 537 ileocolic resection, 535–536 indications for surgery, 535 intracorporeal stapling of colon, 536 ligasure device, 536 postoperative management, 537 preoperative preparation, 535 proper plane of dissection, 536 CRS, see Colon and rectal surgery Cryoablation, 52 CS, see Calibrating suture CT, see Computed tomography CTF, see Computed tomography fluoroscopy CUSA, see Cavitron Ultrasonic Surgical Aspirator Cushing syndrome, 493 CVS, see Critical view of safety DAH, see Development assistance for health Da Vinci robot, 646; see also Robotics in urologic surgery Da Vinci Robotic Surgical System, 539, 717–718; see also Robotics Da Vinci Si, 628; see also Laparoscopic robotics Da Vinci Xi, 628; see also Laparoscopic robotics DCI, see Distal contractile integral Debulking atheroma, 699 Degree of freedom (DOF), 190, 716

DES, see Distal esophageal spasm Development assistance for health (DAH), 714 DI, see Distensibility index Diagnostic laparoscopy (DL), 249, 464 acute pain, 249–250 bedside laparoscopy for critically ill, 250–251 benign cancer, 249 esophageal cancer, 251 gastric cancer, 251–252 malignant cancer, 251 palliation, 464 pancreatic cancer, 252 trauma, 250 DICOM, see Digital Imaging and Communication in Medicine Dielectric constant, 449 Diffuse esophageal spasm, 152 Digestive surgery, 7 Digital Imaging and Communication in Medicine (DICOM), 703; see also Augmented reality Digital subtraction angiography (DSA), 700 99mTc-diisopropyl-iminodiacetic acid (DISIDA), 409 DILALA, see Diverticulitis laparoscopic lavage Direct coupling during polypectomy, 231 Direct laser metal sintering (DLMS), 259; see also Three-dimensional printing Direct volume rendering (DVR), 703; see also Augmented reality DISIDA, see 99mTc-diisopropyliminodiacetic acid DISPACT, see DIStal PAnCreaTectomy Distal contractile integral (DCI), 270, 306 Distal esophageal spasm (DES), 270 DIStal PAnCreaTectomy (DISPACT), 484 Distensibility index (DI), 273 Diverticulitis, 521; see also Laparoscopic surgery for diverticulitis Diverticulitis laparoscopic lavage (DILALA), 523; see also Laparoscopic surgery for diverticulitis DL, see Diagnostic laparoscopy DLMS, see Direct laser metal sintering DOF, see Degree of freedom Dor fundoplication, 283–284; see also Laparoscopic partial fundoplication Double triangle rule, 609 DSA, see Digital subtraction angiography Dumping syndrome, 376 Dunbar syndrome, see Median arcuate ligament syndrome Duodenal atresia, 679; see also Pediatric laparoscopy DVR, see Direct volume rendering Dysphagia, 384; see also Bariatric surgery complications; Reoperative fundoplication postfundoplication, 301

Index 727 EAS, see External anal sphincter EBL, see Estimated blood loss EBUS-TBNA, see Endobronchial US-guided transbronchial needle aspiration Echoendoscopes, 41; see also Endoscopic ultrasound Eckardt Clinical Score, 152 EFTR, see Endoscopic full-thickness resection EGD, see Esophagogastroduodenoscopy EGJ, see Esophagogastric junction EHL, see Electrohydraulic lithotripsy Electrohydraulic lithotripsy (EHL), 126 Electromagnetic systems (EM systems), 705 Electromagnetic wave (EM wave), 449 Electrosurgery, 228 Electrosurgical unit (ESU), 228, 445 Elipse balloon system, 404; see also Intragastric balloon Embolic protection devices, 699 Embolization, 699 EMR, see Endoscopic mucosal resection EM systems, see Electromagnetic systems EM wave, see Electromagnetic wave Encapsulated bacteria, 481 EndoBarrier, 69, 70; see also Endoscopic bariatric therapies Endobronchial US-guided transbronchial needle aspiration (EBUS-TBNA), 40 Endoclips, 82–83; see also Upper gastrointestinal bleeding Endoluminal thermal or radioactive ablation, 699 Endorectal ultrasound (ERUS), 105 EndoSAMURAI, 718; see also Robotics Endoscope, 18 Endoscopic balloon dilation, 94 Endoscopic bariatric therapies, 67, 70; see also Revisional bariatric techniques aspiration strategies, 69 EndoBarrier, 70 future directions, 69–70 intragastric balloons, 67–68 malabsorptive strategies, 69 pyloroduodenal occlusive devices, 69 suturing strategies, 68–69 Endoscopic full-thickness resection (EFTR), 60, 62 hybrid endoscopic-laparoscopic fullthickness resection, 63–66 OTSC Clip application, 64 pure endoscopic approach, 62–63 Endoscopic fundoplication, 58 Endoscopic mucosal resection (EMR), 52–53, 60, 103 with assistance of variceal band ligator, 61 with cap-fitted endoscopy, 61 vs. endoscopic submucosal dissection, 62 strip biopsy technique, 61 Endoscopic procedures of pancreas, 118, 124 access of pseudocysts and necrosis, 121 indications and timing for intervention, 119–120

pseudocyst management, 119 step-up approach, 120–124 walled-off necrosis management, 119 Endoscopic/remote-access endocrine surgery, 497 bilateral axillo-breast approach, 500–501 cervical endoscopic thyroidectomies, 497 facelift thyroidectomy approach, 499–500 history of, 497–498 principles and technique, 498 transaxillary approach, 498–499 transoral approach, 501–502 Endoscopic retrograde cholangiopancreatography (ERCP), 18, 32, 119, 125, 384, 410, 424, 480 balloon extraction of bile duct stones, 127 benign disease management, 125 biliary stone disease, 125, 126 choledochoscopy, 126 complications and prevention, 128 contraindications, 127–128 covered SEMS placement for obstructive malignant lesion, 127 diagnostic techniques, 125 dilation, 127 indications, 125 limitations and future direction, 128 malignant disease management, 125 preparation, 125 sphincterotomy, 126 stenting, 126–127 stent placed for benign biliary disease, 127 stone retrieval, 126 surgically altered anatomy, 128 therapeutic techniques, 126 tissue sampling, 125–126 Endoscopic sleeve gastroplasty (ESG), 68 Endoscopic submucosal dissection (ESD), 60, 103 components, 62 early esophageal adenocarcinoma, 63 endoscopic mucosal resection vs., 62 needle knives used for, 62 Endoscopic surgery future of, 721–722 resection, 60, 66 Endoscopic suturing, 76–77; see also Revisional bariatric techniques devices, 72 stapling devices, 55 Endoscopic transvaginal appendectomy, laparoscopic vs., 160; see also Transvaginal appendectomy Endoscopic ultrasonography fine needle aspiration (EUS-FNA), 480 Endoscopic ultrasound (EUS), 39, 121, 327, 341, 408; see also Therapeutic endoscopic ultrasound biliary drainage, 43 contrast-enhanced, 43 equipment, 41 esophageal cancer, 40

evaluation of pancreatic cysts, 40 evaluation of subepithelial lesions of UGI tract, 39 future of, 43 gastric cancer, 40 imaging of gastrointestinal tract, 39 linear echoendoscope, 41 lung cancer, 40 obesity treatment, 43 pancreatic cancer, 40 probe, 41 radial echoendoscope, 41 role of, 39 staging cancer, 39 Endoscopic ultrasound, therapeutic, see Therapeutic endoscopic ultrasound Endoscopic vacuum therapy (EVT), 77 sponge attached to nasogastric tube, 77 sponge deployed for wound healing, 78 Endoscopy, 45, 231; see also Gastrointestinal endoscopy advanced, 19 Endoscopy, diagnostic lower, 110; see also Colonoscopy, diagnostic; Lower endoscopy therapeutic dilation and stenting alternatives to, 117 anoscopy role, 110 cecum, 114 colonoscopy role, 110 complications, 116–117 contraindications, 110–111 endoscopic retroflexion view, 115 hepatic flexure, 113 indications, 110, 111 insertion technique, 112 marking malignant lesions, 116 patient preparation, 111–112 pedunculated polyp amenable to snare polypectomy, 115 room setup and equipment considerations, 112 scope manipulation, 112–114 sigmoidoscopy role, 110 splenic flexure, 113 terminal ileum, 114 tissue sampling techniques, 115–116 withdrawal of colonoscope, 114–115 Endoscopy, diagnostic upper gastrointestinal, 30, 37, 38; see also Gastrointestinal endoscopy ampullary mass, 37 Barrett esophagus, 35 complications, 37 diagnostic evaluation, 32 duodenum evaluation, 33, 35 education, 37–38 equipment, 31 esophageal neoplasm, 36 esophagitis, 35 esophagus evaluation, 32–33, 34 gastric antral vascular ectasia, 36

728 Index Endoscopy, diagnostic upper gastrointestinal (Continued) gastric varices, 37 gastrointestinal stromal tumor, 36 hiatal hernia, 36 indications and contraindications, 31 indications/contraindications, 30 normal findings, 34–35 passing endoscope, 32 pathology on, 35–37 patient positioning, 32 preoperative preparation, 30–31 specimen collection, 33–34 stomach evaluation, 33, 34, 35 ulcer, 37 withdrawal of endoscope, 33 Endovascular aneurysm repair (EVAR), 659; see also Abdominal aortic aneurysms EndoWrist robotic stapler, 628–629; see also Laparoscopic robotics End Results System, 199; see also Surgical quality measurement Energy devices, 228 Energy sources, 228 adverse events, 229 antenna coupling, 229 argon beam plasma coagulator, 230–231 best practice to prevent electrosurgical injuries, 230 capacitive coupling, 229 common energy devices, 228 current diversion in MIS, 229–230 direct coupling during polypectomy, 231 electrosurgery, 228 endoscopy, 231 injuries related to active electrode, 230 ultrasonic energy, 228–229 Enhanced Recovery After Surgery (ERAS), 8, 200, 235 Enhanced recovery programs (ERP), 7, 14 aim, 7–8 bariatric and foregut surgery, 12 colorectal surgery, 10, 12 combining laparoscopic surgery with, 10 components of, 8–10 daily care plan for bowel surgery, 9–10 for elective colorectal surgery, 13–14 elements for gastrointestinal surgery, 8 HPB surgery, 12, 14 LAFA study, 10 RCT outcomes of laparoscopic vs. open colorectal surgery, 11 sample for laparoscopic bowel surgery, 14 SMART program, 14 EOA, see External oblique aponeurosis EoE, see Eosinophilic esophagitis EORTC, see European Organization for Research and Treatment of Cancer Eosinophilic esophagitis (EoE), 268 Epigastric hernias, 600; see also Laparoscopic incisional and ventral hernia repair

Epinephrine, 81–82; see also Upper gastrointestinal bleeding Epiphrenic diverticulum, 316; see also Esophageal diverticula ePTFE, see Expanded polytetrafluoroethylene ERAS, see Enhanced Recovery After Surgery ERCP, see Endoscopic retrograde cholangiopancreatography Ergonomic minimally invasive surgical/ endoscopy suite, 222 considerations for future development, 225 enhancing ergonomics of surgeon, 224 evidence-supported stance and posture, 224–225 evolution of MIS operating room, 223 image quality and visual comfort scale, 226 improving work space and function, 223–224 laparoscopic instrument, 225–226 microbreaks, 225 minimally invasive assistant surgeon, 225 optimized ergonomics through enhanced workflow, 223 optimizing patient position and safety, 224 robotic surgery, 226 target effect, 225 women in minimally invasive surgery, 225 Ergonomics, 222 ERP, see Enhanced recovery programs ERUS, see Endorectal ultrasound ESD, see Endoscopic submucosal dissection ESG, see Endoscopic sleeve gastroplasty ESGE, see European Society of Gastrointestinal Endoscopy ESMO, see European Society of Medical Oncology Esophageal cancer, 40, 326; see also Minimally invasive Ivor Lewis esophagectomy Esophageal dilation, 45; see also Esophageal stenting Balloon dilator with insufflator, 46 dilation, 45 Maloney and Hurst tipped push dilators, 46 Savary dilator, 46 through scope balloon dilator, 47 technique, 46–47 types of dilators, 45–46 Esophageal diverticula, 316 complications, 320 diagnosis and preoperative assessment, 317 epidemiology, 317 epiphrenic diverticulum on barium swallow, 316 operative technique, 317 outcomes after minimally invasive surgery, 318–319 postoperative care, 317, 320 presentation, 317 zenker diverticulum, 316 Esophageal function testing, 267 ambulatory pH monitoring, 270–271

barium esophagram, 267–268 functional lumen imaging probe studies, 272 high-resolution impedance manometry study, 272 high-resolution manometry, 268–270 impedance planimetry, 273 interpretation of results, 270 multichannel-intraluminal impedance, 271 upper endoscopy, 267 Esophageal myotomy, 637; see also Thoracoscopic surgery Esophageal neoplasm, 36 Esophageal perforation, 47; see also Esophageal stenting Esophageal stenosis, 45 Esophageal stenting, 47–48; see also Esophageal dilation deployed stent, 49 fully covered and partially covered stents, 48 outcomes, 49 stent on deployment device, 48 stent placement secured with clips, 76 technique, 48 Esophageal ultrasound (EUS), 39; see also Endoscopic ultrasound Esophageal ultrasound-guided biliary drainage (EUS-BD), 43 Esophageal ultrasound-guided ethanol lavage with paclitaxel injection (EUSELPI), 42 Esophageal ultrasound-guided fine needle injection (EUS-FNI), 40 Esophagitis, 35 Esophagogastric junction (EGJ), 268 Esophagogastroduodenoscopy (EGD), 20, 31, 55, 267, 293, 305, 409 Esophagus Sizing Tool, 287; see also External magnetic antireflux ring placement EsophyX, 56–58 Estimated blood loss (EBL), 460 ESU, see Electrosurgical unit ETEP approach, see Extended totally extraperitoneal approach Ether Dome, 16 European Organization for Research and Treatment of Cancer (EORTC), 347 European Society of Gastrointestinal Endoscopy (ESGE), 23 European Society of Medical Oncology (ESMO), 339 EUS, see Endoscopic ultrasound; Esophageal ultrasound EUS-BD, see Esophageal ultrasound-guided biliary drainage EUS-ELPI, see Esophageal ultrasound-guided ethanol lavage with paclitaxel injection EUS-FNA, see Endoscopic ultrasonography fine needle aspiration EUS-FNI, see Esophageal ultrasound-guided fine needle injection EVAR, see Endovascular aneurysm repair

Index 729 EVT, see Endoscopic vacuum therapy EWL, see Excess weight loss Excess weight loss (EWL), 67 Expanded polytetrafluoroethylene (ePTFE), 583 Exposure, concept of, 698 Extended totally extra-peritoneal approach (ETEP approach), 569 External anal sphincter (EAS), 557 External magnetic antireflux ring placement, 286 Esophagus Sizing Tool, 287 LINX device, 288 LINX Reflux Management System, 286 outcomes, 288 retroesophageal window, 287 technique for placement, 286–288 Ti-Knot device, 287 External oblique aponeurosis (EOA), 582 Eye tracking systems, 186; see also Objective metrics in simulation Facelift thyroidectomy approach, 499; see also Endoscopic/remote-access endocrine surgery flap creation and techniques, 499–500 indication and preparation, 499 patient positioning, 499 postoperative management and outcome, 500 procedure, 499 thyroid or parathyroid operation, 500 Familial adenomatous polyposis (FAP), 163 Fanelli laparoscopic endobiliary stent kit, 411 Fanelli wire-guided cholangiogram catheter set, 420 FAP, see Familial adenomatous polyposis FC, see Fellowship Council FDA, see U.S. Food and Drug Administration 18FDG, see 18F-fluorodeoxyglucose FDG PET-CT, see Fluorodeoxyglucosepositron emission tomography CT FDM, see Fusion deposition modeling FEC, see Flexible Endoscopy Curriculum Fecal immunochemical testing (FIT), 91 Fecal incontinence (FI), 557 Fecal incontinence severity index (FISI), 108 Fecal incontinence therapies, 557 injectable bulking agents, 558, 561–562 radiofrequency energy delivery, 557–558 sacral nerve stimulation, 562–565 surgical strategy and surgical repair, 557 Feeding tube placement, 353 gastrostomy tubes, 353–354 jejunostomy tubes, 354–355 laparoscopic gastric tubes, 354 postoperative considerations, 355 T-fastener device, 354 Fellowship Council (FC), 22 Femoral hernias, 684 Fentanyl, 27 FES, see Fundamentals of Endoscopic Surgery

FEV1, see Forced expiratory volume in 1 second FFF, see Fused filament fabrication 18F-fluorodeoxyglucose (18FDG), 342 FGBD, see Functional gallbladder disease FGIDs, see Functional gastrointestinal disorders FI, see Fecal incontinence Fine needle aspiration (FNA), 40, 341, 670 Finger indentation technique for gastrotomy localization, 142; see also Percutaneous endoscopic gastrostomy FIQL Index, see FI Quality of Life Index FI Quality of Life Index (FIQL Index), 558 FireFly, 628; see also Laparoscopic robotics FISI, see Fecal incontinence severity index Fistula, 391 Fistulous diverticular disease, 522; see also Laparoscopic surgery for diverticulitis FIT, see Fecal immunochemical testing Flank hernias, 600; see also Laparoscopic incisional and ventral hernia repair Flexible endoscopy; see also Gastrointestinal endoscopy ABS-FEC, 22 ACGME, 19, 20 ASGE, 20 colon and rectal surgery, 22 Fellowship Council, 22 GAGES tool, 22 Gastroenterology Core Curriculum, 19 general surgery, 21–22 medical training in, 19–21 minimum case numbers for general surgery residents, 21 requirements for medical and surgical training, 23 surgical endoscopist, 21–22 surgical training in, 21 Flexible endoscopy, 16 Flexible Endoscopy Curriculum (FEC), 21 FLIP, see Functional lumen imaging probe FLS, see Fundamentals of Laparoscopic Surgery Fluid collections in pancreatitis, 118 Flumazenil, 28 Fluorescence cholangiography, 422; see also Intraoperative biliary imaging Fluorodeoxyglucose-positron emission tomography CT (FDG PET-CT), 267 Fluoroscopic images, 698 FNA, see Fine needle aspiration Focused Professional Practice Evaluation (FPPE), 23 Forced expiratory volume in 1 second (FEV1), 233 FPPE, see Focused Professional Practice Evaluation FRC, see Functional residual capacity French position, 436, 506; see also Totally laparoscopic right hepatectomy

Full-thickness upper gastrointestinal disruption management, 74 Apollo OverStitch Endoscopic Suturing System, 77 cardiac septal occlude, 78 clips, 75 emerging techniques, 78 endoscopic management according to location, 75 endoscopic suturing, 76–77 endoscopic vacuum therapy, 77–78 esophageal stent placement secured with clips, 76 fistula closure by OTSC, 75 initial management, 74 limitations and complications of endoscopic closure, 78–79 luminal stenting, 76 over-the-scope clips, 75–76 postoperative care following endoscopic closure, 78 through-the-scope clips, 75 tissue sealants, 77 tools and techniques, 74–75 Functional adrenal tumors, 493; see also Laparoscopic adrenalectomy Functional gallbladder disease (FGBD), 409, 410; see also Laparoscopic cholecystectomy Functional gastrointestinal disorders (FGIDs), 409; see also Laparoscopic cholecystectomy Functional islet cell tumors, 480; see also Laparoscopic distal pancreatectomy Functional lumen imaging probe (FLIP), 273 Functional residual capacity (FRC), 359 Fundamentals of Endoscopic Surgery (FES), 22, 38, 193; see also Laparoscopic training development of, 194 goal of, 194 validity of, 194 Fundamentals of Laparoscopic Surgery (FLS), 181, 185, 189, 192, 238; see also Laparoscopic training peg transfer task, 194 training box with video screen, 193 Fundamental Use of Surgical Energy (FUSE), 190, 193, 195; see also Laparoscopic training FUSE, see Fundamental Use of Surgical Energy Fused filament fabrication (FFF), 259; see also Three-dimensional printing Fusion deposition modeling (FDM), 259, 260; see also Three-dimensional printing G-6-PDH, see Glucose-6-phosphatedehydrogenase GAGES, see Global Assessment of Gastrointestinal Endoscopic Skills

730 Index GAGES-C, see Global Assessment of Gastrointestinal Endoscopic Skills—Colonoscopy Gallbladder ejection fraction (GBEF), 410 Garren-Edwards Gastric Bubble (GEB), 67, 400; see also Endoscopic bariatric therapies Gastric antral vascular ectasia (GAVE), 36, 83 Gastric band, 366; see also Laparoscopic adjustable gastric banding Gastric banding, 245; see also Bariatric surgery Gastric cancer, 40; see also Laparoscopic gastrectomy laparoscopic surgical treatment of early, 349 Gastric carcinoids, 340–341; see also Nonadenomatous gastric tumors Gastric fundoplication, 281; see also Laparoscopic partial fundoplication Gastric LMS, 341; see also Nonadenomatous gastric tumors Gastric tumor resection, 342; see also Nonadenomatous gastric tumors adjuvant therapy following, 346–348 based on location, 344 based on tumor location and size, 344 endoscopic submucosal resection, 346 for gastric nonadenomatous tumors, 344 goals of, 343 indications for resection, 342–343 laparoendoscopic resection of gastroesophageal junction tumors, 344–345 laparoendoscopic transgastric resection of GIST, 345 laparoscopic and open resection, 345–346 margin status, 343 natural orifice transluminal endoscopic surgery resection, 346 operative approaches, 344 organ-sparing resection, 343 reconstructions following gastrectomy, 347 resection of GIST along lesser curve of stomach, 346 resection of pyloric antrum/canal gastrointestinal stromal tumor, 347 role for lymphadenectomy, 343 Gastric varices, 37 Gastroduodenal artery (GDA), 469, 476 Gastroduodenostomy, 351 Gastroenterology Core Curriculum, 19; see also Surgeon’s role in endoscopy Gastroesophageal junction (GEJ), 33, 55, 151, 278, 292, 310, 326, 688 Gastroesophageal reflux disease (GERD), 55, 58–59, 152, 245, 268, 281, 286, 359, 392, 687, 691 Babcock clamp, 688 completed wrap with stitches, 689 diagnosis of, 55 discussion, 689–690

endoluminal therapies for, 55 endoscopic fundoplication, 58 laparoscopic treatment of, 687 liver retractor, 688 placement of camera port, 688 procedure, 688–689 radiofrequency ablation, 55–56 room setup for pediatric laparoscopic fundoplication, 688 technique for placing gastrostomy button, 689 techniques, 55, 687–688 transoral fundoplication, 56–58 treatment of, 55 workup, 687 Gastrointestinal endoscopy; see also Endoscopy, diagnostic upper gastrointestinal; Flexible endoscopy checklist for initial privileging in GI endoscopy, 24 Gastroenterology Core Curriculum, 19 historical role of surgeons in flexible, 18–19 privileging in flexible, 23–25 SAGES, 23 training in, 19 Gastrointestinal leakage, 381–382, 383; see also Bariatric surgery complications Gastrointestinal perforation management, 74; see also Full-thickness upper gastrointestinal disruption management Gastrointestinal stromal tumor (GIST), 36, 339–340, 514, 637; see also Intestinal neoplasms; Nonadenomatous gastric tumors; Thoracoscopic surgery resection, 637–638 Gastrointestinal surgery (GI surgery), 18 Gastrointestinal tract (GI tract), 60 EUS imaging of, 39 Gastrointestinopancreatic neuroendocrine tumors, 504; see also Pancreatic neuroendocrine tumors Gastrojejunostomy, 351 Gastroscopy, 129 Gastrostomy closure (GC), 76 Gastrostomy tubes, 353–354; see also Feeding tube placement; Percutaneous endoscopic gastrostomy with jejunal extension, 145, 147 GAVE, see Gastric antral vascular ectasia GBEF, see Gallbladder ejection fraction GC, see Gastrostomy closure GDA, see Gastroduodenal artery GEB, see Garren-Edwards Gastric Bubble GEJ, see Gastroesophageal junction GelPOINT device, 468; see also Robotassisted pancreatoduodenectomy Gemcitabine, 43 Geomagic Touch devices, 190 GERD, see Gastroesophageal reflux disease

GERD-Health Related Quality of Life (GERD-HRQL), 56 GERD-HRQL, see GERD-Health Related Quality of Life GetWellSooner program, 215; see also Pre-event warm-up GILB, see Italian Lap-Band and BIB group GIST, see Gastrointestinal stromal tumor GI surgery, see Gastrointestinal surgery GI tract, see Gastrointestinal tract Glissonian approach, 440 anatomical landmarks used, 440, 441–442 bi-segmentectomy, 441, 443 control of Glissonian pedicle, 442–443 hemihepatectomy, 440–441, 442 intrahepatic, 443 for laparoscopic liver resections, 441, 442 liver, 440 mesohepatectomy, 443 principles, 440 trisectionectomy, 443 Global Assessment of Gastrointestinal Endoscopic Skills (GAGES), 22 Global Assessment of Gastrointestinal Endoscopic Skills—Colonoscopy (GAGES-C), 195 Global Operative Assessment of Laparoscopic Skills (GOALS), 195–196 Glucose-6-phosphate-dehydrogenase (G-6-PDH), 402 GOALS, see Global Operative Assessment of Laparoscopic Skills Google Glass, 181 GPUs, see Graphical processing units Graft biomatrices, 78 Graphical processing units (GPUs), 191 Groin injuries, 620; see also Sports hernia repair HALS, see Hand-assisted laparoscopic surgery Hand-assisted laparoscopic surgery (HALS), 548 bipolar vessel sealer, 552 complications, 555–556 contraindications, 548 dividing ileocolic vessels and ligating using bipolar vessel sealing device, 550 dividing lateral attachments, 553 dividing left-sided attachments of omentum, 554 dividing splenic flexure and remaining transverse mesocolon, 554 elevating IMA pedicle, 552 extraction, anastomosis, and closure, 554–555 incision under ileocolic pedicle, 550 indications, 548 isolating and dividing right-sided branches, 551 left colectomy, 551–554, 555 mobilization of left colon from medial to lateral, 553 patient positioning, 549 port placement, 549

Index 731 postoperative management, 555 preoperative planning, 549 results, 556 right and transverse colectomy, 551 right colectomy, 549–550 right-sided colon mobilized from medial to lateral, 550 surgery, 549 technique, 549 terminal ileal mesentery, 555 transverse colectomy, 550–551 Hanging spleen technique, 486; see also Laparoscopic splenectomy Harjola-Marable syndrome, see Median arcuate ligament syndrome Harmonic shears, 486 Hartmann procedure, 522–523 Hasson or open technique, 239, 512; see also Access in minimally invasive surgery; Laparoscopic management of small bowel diseases Hasson trocar, 487 HCC, see Hepatocellular carcinoma HD, see High-definition HDL, see High-density lipoprotein Head-mounted display (HMD), 190, 191 Health Insurance Portability and Accountability Act (HIPAA), 631 Health Sciences University of Mongolia (HSUM), 712 Helicobacter pylori (HP), 333, 401; see also Peptic ulcer disease Hemorrhage, 701 Hepatic flexure, 113 99mTc-hepatic iminodiacetic acid (HIDA), 409 Hepatobiliary and solid organ pathology, 246 adrenal gland, 246 liver, 246 pancreas and spleen, 246 Hepatocellular carcinoma (HCC), 457 Hepato-Pancreato-Biliary surgery (HPB surgery), 12, 14, 22 Hereditary nonpolyposis cancer syndrome (HNPCC), 84 Hernia; see also Sports hernia repair Bochdalek, 679 congenital diaphragmatic, 679 epigastric, 600 femoral, 684 flank, 600 Morgagni, 679 pediatric inguinal, 682 sports, 620 suprapubic, 600 traumatic abdominal wall, 684 ventral, 596, 600 Hernia repair, 582, 591, 595; see also Components separation method; Laparoscopic totally extraperitoneal hernia repair; Mesh; Robotic ventral hernia repair; Transabdominal preperitoneal inguinal hernia repair

biomaterial considerations in laparoscopic, 591, 595 biomaterial performance in laparoscopic, 593 central mesh failure, 594 intestine adhesions to resorbable barrier, 594 laparoscopic inguinal, 593–594 laparoscopic ventral, 592, 594 techniques, 608 TULP trial, 593 Herniotomy, 682 Hiatal hernia, 36, 292, 367; see also Laparoscopic adjustable gastric banding anatomy, 292 classifications, 293 complications and postoperative care, 295–296 diagnosis, 292–294 management, 294 mesh usage, 296–297 nomenclature, 292 operating room setup for laparoscopic, 295 with organoaxial volvulus, 294 outcomes, 296 significance, 292 surgical technique, 294–295 type I, 294 type II, 293, 294 type III, 294 Hiatal mesh, 302; see also Reoperative fundoplication HICs, see High-income countries HIDA, see 99mTc-hepatic iminodiacetic acid HIFU, see High Intensity Focused Ultrasound High-definition (HD), 168, 713 High-density lipoprotein (HDL), 360 High-income countries (HICs), 709 High Intensity Focused Ultrasound (HIFU), 444 High-power fields (HPF), 347 High-resolution esophageal pressure topography (HREPT), 306 High-resolution manometry (HRM), 148; see also Esophageal function testing contraindications to catheter-based studies, 270 esophageal pressure topography plot, 269 uses of, 268 HIPAA, see Health Insurance Portability and Accountability Act Hirschsprung disease, 678; see also Pediatric laparoscopy HMD, see Head-mounted display HNPCC, see Hereditary nonpolyposis cancer syndrome HP, see Helicobacter pylori HPB surgery, see Hepato-Pancreato-Biliary surgery HPF, see High-power fields HPS, see Hypertrophic pyloric stenosis HPSs, see Human patient simulators

HREPT, see High-resolution esophageal pressure topography HRM, see High-resolution manometry HSUM, see Health Sciences University of Mongolia Humanoid robot design, 627; see also Laparoscopic robotics Human patient simulators (HPSs), 188 Hybrid endoscopic-laparoscopic fullthickness resection, 63, 65–66 Hybrid flexible endoscopic approach, 159 Hybrid rigid laparoscopic approach, 159 Hybrid transanal TME, 168–170; see also Transanal total mesorectal excision Hybrid transvaginal appendectomy, 159; see also Transvaginal appendectomy vs. pure transvaginal approach, 160 Hybrid trocars, 229–230 Hypertrophic pyloric stenosis (HPS), 691; see also Benign gastrointestinal disease in children completed pyloromyotomy, 692 laparoscopic pyloromyotomy, 692 operative technique, 691–692 postoperative care and outcomes, 692 preoperative evaluation, 691 Hypnotic agents, 28 Hypotension, 29 IAP, see Intra-abdominal pressure IAS, see Incisionless Anastomosis System; Internal anal sphincter IBD, see Inflammatory bowel disease IBM, see International Business Machines ICC, see Interstitial cells of Cajal; Intra-class correlation coefficient ICER, see Incremental cost-effectiveness ratio ICG, see Indocyanine green ICU, see Intensive care unit IEHS, see International Endohernia Society IFC, see International Finance Corporation IGB, see Intragastric balloon Ileal pouch to anal anastomosis (IPAA), 175, 533, 556 Ileocecal valve, 89 IMA, see Inferior mesenteric artery Implantable devices, 228 IMTN, see International Multicenter Trial IMV, see Inferior mesenteric vein Incisional hernia, 582; see also Components separation method; Hernia repair Incisionless Anastomosis System (IAS), 69 Incisionless Operating Platform (IOP), 68, 72; see also Revisional bariatric techniques Incremental cost-effectiveness ratio (ICER), 4 Indocyanine green (ICG), 422, 628 Infected necrosis, 670 Inferior mesenteric artery (IMA), 170, 526, 541, 551 Inferior mesenteric vein (IMV), 526, 542

732 Index Inflammatory bowel disease (IBD), 85, 93, 171; see also Crohn disease; Ulcerative colitis treatment, 533 Informed decision-making, 198; see also Surgical quality measurement Inguinal hernia, 577; see also Hernia repair; Recurrent inguinal hernia repair; Robotic transabdominal preperitoneal approach hernioplasty, 617 repair, 569, 602 Injectable bulking agents, 558; see also Fecal incontinence therapies indications and short-term outcomes, 558 results of, 560 short-and long-term success of, 561 site and route of injections, 561 technical tips, 558, 561–562 Inkjet printing, 260; see also Threedimensional printing Institutional review board (IRB), 467 Insufficient weight loss, see Weight regain Integrated relaxation pressure (IRP), 270, 306 Intensive care unit (ICU), 659 Internal anal sphincter (IAS), 557 International Business Machines (IBM), 627 International Endohernia Society (IEHS), 577, 605 International Ergonomics Association, 222 International Finance Corporation (IFC), 714 International Multicenter Trial (IMTN), 156 International Pediatric Endosurgery Group (IPEG), 677 International Prostate Symptom Score (IPSS), 648 International Study Group of Pancreatic Fistula (ISGPF), 484 Interoblique balloon dissection technique, 585; see also Components separation method Intersphincteric resection (ISR), 169 Interstitial cells of Cajal (ICC), 339, 557 Interventional radiology suites, 698; see also Surgery in radiology suite Intestinal neoplasms, 513; see also Laparoscopic management of small bowel diseases adenocarcinoma, 514 benign tumors, 513 gastrointestinal stromal tumors, 514 neuroendocrine tumors, 513 non-Hodgkin lymphoma, 514 Intestinal rotation abnormalities, 679; see also Pediatric laparoscopy Intestinal strictures, 96; see also Lower endoscopy therapeutic dilation and stenting Intra-abdominal pressure (IAP), 233 Intra-class correlation coefficient (ICC), 196 Intraductal papillary mucinous neoplasms (IPMNs), 40, 480

Intragastric balloon (IGB), 67–68, 400, 405; see also Endoscopic bariatric therapies classification of, 401 contrast medium abdominal-RX of, 404 Elipse, 403, 404 history of, 400 last-generation, 403–404 Obalon balloon, 404–405 Orbera, 400–403 ReShape DUO integrated dual balloon system, 403 Intraluminal stents, 94–96; see also Lower endoscopy therapeutic dilation and stenting Intraoperative biliary imaging, 408, 419, 422; see also Laparoscopic cholecystectomy abnormal cholangiogram images, 421 alternative biliary imaging techniques, 421–422 Fanelli wire-guided cholangiogram catheter set, 420 fluorescence cholangiography, 422 laparoscopic fluorocholangiography, 419 laparoscopic ultrasound systems, 421–422 normal cholangiogram, 420 selective cholangiography, 419 technique and equipment, 419–421 Intraoperative cholangiography (IOC), 256, 408, 424; see also Intraoperative biliary imaging; Laparoscopic cholecystectomy Intraoperative ultrasound (IOUS), 253, 436; see also Totally laparoscopic right hepatectomy Intraperitoneal onlay mesh (IPOM), 608 Intravascular foreign body retrieval, 699 Intravascular ultrasound (IVUS), 700 Intravenous (IV), 374, 396, 467 Introducer technique, 143, 145; see also Percutaneous endoscopic gastrostomy Intussusception, 694; see also Benign gastrointestinal disease in children operative technique, 694–695 postoperative care, 695 preoperative evaluation, 694 IOC, see Intraoperative cholangiography IOP, see Incisionless Operating Platform IOUS, see Intraoperative ultrasound IPAA, see Ileal pouch to anal anastomosis IPEG, see International Pediatric Endosurgery Group IPMNs, see Intraductal papillary mucinous neoplasms IPOM, see Intraperitoneal onlay mesh IPSS, see International Prostate Symptom Score IRB, see Institutional review board IRP, see Integrated relaxation pressure ISGPF, see International Study Group of Pancreatic Fistula

ISR, see Intersphincteric resection Italian Lap-Band and BIB group (GILB), 402, 403 IV, see Intravenous IVUS, see Intravascular ultrasound JAAA, see Laparoscopic surgery of juxtarenal AAA Japan Clinical Oncology Group (JCOG), 352 Japanese Laparoscopic Surgery Study Group (JLSSG), 352 Japan Society for Endoscopic Surgery (JSES), 349 JCAHO, see Joint Commission on Accreditation of Healthcare Organizations JCOG, see Japan Clinical Oncology Group Jejunal extension tube (JET), 145 Jejunostomy tubes, 354–355; see also Feeding tube placement JET, see Jejunal extension tube JHPIEGO, see Johns Hopkins Program for International Education in Gynecology and Obstetrics JLSSG, see Japanese Laparoscopic Surgery Study Group Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), 710 Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 199, 205 JSES, see Japan Society for Endoscopic Surgery Ketamine, 28 Kidney surgery, 648; see also Robotics in urologic surgery partial nephrectomy, 648–649 robot-assisted radical nephrectomy, 648 Kinking, 391 KLASS, see Korean Laparoscopic Gastrointestinal Surgery Study Group Kocher maneuver, 469; see also Robotassisted pancreatoduodenectomy Korean Laparoscopic Gastrointestinal Surgery Study Group (KLASS), 352 LADG, see Laparoscopy-assisted distal gastrectomy LAFA study, 10 LAG, see Laparoscopic gastrectomy LAGB, see Laparoscopic adjustable gastric banding Lancet Commission on Global Surgery, 714 Laparo-endoscopic single-site surgery (LESS surgery), 6, 240, 244; see also LESS foregut surgery; Single port and reduced port access approaches to hepatobiliary and solid organ pathology, 246 for bariatric procedures, 245

Index 733 for colorectal surgery, 246–247 and concomitant operations, 247 Laparoendoscopic Single-Site Surgery Consortium for Assessment and Research (LESSCAR), 244 Laparoscopic 360° fundoplication, 274 Laparoscopic ablation of liver lesions, see Ablative treatment of liver tumors Laparoscopic adjustable gastric banding (LAGB), 245, 363, 387; see also Bariatric surgery complications access port placement, 366, 367 anatomy, 363–364 angle of His dissection, 364–365 anterior fundoplication, 366 anterior slippage, 369 band calibration, 368 band erosion, 368–369 band fluoroscopy, 369 band locked and gastric plication, 366 band slippage, 370 complications, 368 confluence of the crura, 364 gastric band, 366 gastric prolapse or “slippage”, 369–370 hiatal hernias, 367 history of, 363 instrumentation and setup, 364 operative technique, 364 outcomes and conclusion, 370–371 pars flaccida, 364, 365 patient management, 367–368 port and tubing problems, 370 port placement, 364 postoperative care, 366–367 pouch dilatation, 369, 370 titrating band and band choice, 368 Laparoscopic adrenalectomy, 493 contraindications, 493–494 equipment, 494 extraction of specimen, 495 future directions, 495 indications, 493, 494 left adrenalectomy, 495 patient positioning, 494 postoperative care, 495 right adrenalectomy, 494–495 risks of operation, 494 technical considerations, 494 Laparoscopic and endoscopic cooperative surgery (LECS), 63 procedure, 65 Laparoscopic antireflux esophageal lengthening procedure, 289 Collis controversy, 291 Collis gastroplasty, 290 Laparoscopic appendectomy, 516; see also Transvaginal appendectomy anatomy, 516 appendiceal anatomy, 517 complicated appendicitis, 519 epidemiology, 516

indications, 516–517 intraoperative anatomy, 518 MANTRELS, 517 postoperative care, 519–520 single-incision, 519 surgical techniques, 517–519 transvaginal vs. conventional, 160 trocar placement for, 518 Laparoscopic-assisted intraluminal gastric surgery, 130 blind insertion, 130 colonoscopy technical challenges, 131 colonoscopy technique, 130–131 direct-vision insertion, 130 endoscopy technique, 130 postoperative course, 131 Laparoscopic cholecystectomy (LC), 408, 419; see also Intraoperative biliary imaging abdominal access, 412 acute acalculous cholecystitis, 409 cholecystostomy tube placement, 418 common bile duct stones, 410–411 contraindications to, 411–412 critical view of safety, 413–415 Fanelli laparoscopic endobiliary stent kit, 411 functional gallbladder disease, 409–410 indications for surgery, 408 intraoperative cholangiography in 12 steps, 416 nonstone disease, 409 in obese patients, 415, 417 operative technique, 412 operative timing, 411 patient evaluation and preparation, 410 patient fitness for surgery, 411 patient positioning, 412 reduced port laparoscopic cholecystectomy, 418 retraction and exposure, 412–413 robot-assisted cholecystectomy, 418 seeking expert assistance, 418 severe biliary inflammation, 417–418 special circumstances, 415 specimen retrieval and incision closure, 415 stone disease, 408–409 subtotal cholecystectomy, 417–418 tensely distended gallbladder, 417 top-down approach, 417 Laparoscopic cholecystectomy, 154; see also Transvaginal cholecystectomy Laparoscopic colon resection, 521; see also Laparoscopic surgery for diverticulitis Laparoscopic common bile duct exploration (LCBDE), 424, 430–431 balloon dilation, 426 choledochoscope insertion, 426 choledochoscopic images, 428 choledochotomy closure, 430 choledochotomy creation, 429–430

completion cholangiogram and cystic duct ligation, 427–428 determination of optimal approach for, 425–426 dilating cystic duct, 428 indications and contraindications for, 426 indications for intraoperative imaging of CBD, 425 initiating transcystic, 426, 427 intraoperative cholangiogram images, 425 intraoperative imaging for choledocholithiasis, 425 length of stay and cost, 430 morbidity and mortality, 430 operative technique, 424 port placement and initial dissection, 425 postoperative management, 430 preoperative setup and planning, 424–425 procedure and equipment for transcholedochal, 429 procedure and equipment for transcystic, 427 results, 430 setting up choledochoscope, 428 stone extraction, 430 stone retrieval and extraction, 426–427, 429 transcholedochal, 428, 429 transcystic laparoscopic, 426 wire access, 426 Laparoscopic component separation (LCS), 583; see also Components separation method open vs. laparoscopic component separation, 586–588 Laparoscopic distal pancreatectomy (LDP), 480, 505; see also Pancreatic neuroendocrine tumors benefit of, 506 cystic pancreatic neoplasms, 480 hybrid approach for, 508 neuroendocrine tumors, 480–481 operating room setup, 483 operating room table and robot, 482 pancreatic ductal adenocarcinoma, 481 patient positioning, 481 port placement, 483 postoperative care and pancreatic fistulas, 484 preoperative workup, 480 resections, 481 robotic distal pancreatectomy, 482–484 selection criteria, 480 Laparoscopic distal pancreatectomy with en bloc splenectomy, 481 conversion to open distal pancreatectomy, 482 lesser sac exposure and splenic flexure mobilization, 481 pancreatic enucleation, 482 pancreatic mobilization, 481 pancreatic transection and division of splenic vein and artery, 481–482 specimen removal and drain placement, 482 spleen-preserving distal pancreatectomy, 482

734 Index Laparoscopic donor nephrectomy, 655 choice of side, 655 consent process, 655–656 operative technique, 656–658 patient positioning, 656 preoperative evaluation, 655 right nephrectomy, 658 Laparoscopic enteric access, 353; see also Feeding tube placement Laparoscopic femoral hernia repair in children, 684; see also Laparoscopic hernia repair in children Laparoscopic gastrectomy (LAG), 349 clinical trials of, 352 dissection of right gastroepiploic vein, 350 for gastric cancer, 349–350 lymph node dissection, 350–351 ongoing multicenter randomized prospective studies, 350 reconstruction after LATG, 351 techniques of anastomosis, 351 techniques with D2 lymph node dissection, 350–351 Laparoscopic gastric tubes, 354; see also Feeding tube placement Laparoscopic Heller myotomy, 307; see also Achalasia; Robotic-assisted laparoscopic Heller myotomy complications, 309 division of longitudinal muscle layer, 308 endoscopic evaluation of myotomy, 308 esophageal mucosa bulging through cut myotomy, 308 partial fundoplication, 309 port placement, 307 postoperative care, 309 preoperative considerations, 307 Laparoscopic hepatectomy; see also Glissonian approach Laparoscopic hernia repair in children, 682; see also Laparoscopic inguinal hernia repair in children abdominal wall hernia repair, 684 femoral hernia repair, 684 future directions, 684–686 inguinal hernia repair, 682–684 long-term results after, 684 utility of transinguinal or transabdominal laparoscopy, 684 Laparoscopic herniorrhaphy techniques, 602 Laparoscopic ileocolic resection, 535; see also Crohn disease Laparoscopic incisional and ventral hernia repair, 596 anatomic variants, 600 defect closure, 599 equipment and materials, 597 indications, 596 laparoscopic myofascial separation, 599–600 operative technique, 597–599 postoperative care, 599 preoperative planning, 596–597

principles of clinical quality improvement, 601 results of treatment, 600–601 robotic ventral/incisional hernia repair, 600 Laparoscopic inguinal hernia repair in children, 682; see also Laparoscopic hernia repair in children cautery injury in peritoneum, 683 completed, 684 complications, 684 fused right processus vaginalis, 683 lateral suture loop, 683 long-term results after, 684 medial suture loop, 684 patent left processus vaginalis with clinical hernia, 683 percutaneous hydrodissection, 683 postoperative care, 684 Laparoscopic inguinal herniorrhaphy, 682 Laparoscopic left hepatectomy, 432 Glissonian approach, 433 Hilar approach, 433 individual Hilar dissection, 433 mobilization of left liver, 432 parenchymal transection, hepatic duct, and vein dissection, 433 patient, surgeon, and trocar position, 432 port placement, 432 specimen retrieval, 433 Laparoscopic liver resection (LLR), 432; see also Laparoscopic left hepatectomy Laparoscopic major hepatectomy (LMH), 438; see also Totally laparoscopic right hepatectomy Laparoscopic management of small bowel diseases, 512 abdominal access, 512 Crohn disease, 514–515 Hassan technique, 512 intestinal neoplasms, 513–514 Meckel diverticulum, 514 small bowel obstruction, 512 Laparoscopic median arcuate ligament release, 666 anatomy, 666 compression of celiac artery, 668 diagnosis and treatment, 667 epidemiology, 666 history and physical exam, 666 median arcuate ligament, 667 mesenteric ultrasound of celiac artery, 667 outcomes, 668–669 pathophysiology, 666 procedure, 668 stenosis of celiac artery, 668 ultrasound velocities, 667 Laparoscopic nephrectomy, 651 blunt dissection, 653 dividing hilum, 653 dividing superior and lateral attachments, 653–654 Gerota’s fascia and retroperitoneum, 652

gonadal vein and ureter identification, 652–653 identification of ureter within retroperitoneum, 653 operative steps, 652 patient positioning and trocar placement, 651–652 placement of specimen into bag, 654 port positioning, 652 postoperative management and complications, 654 retroperitoneum exposure, 652 specimen removal and closure, 654 Laparoscopic Nissen fundoplication (LNF), 689 Laparoscopic pancreaticoduodenectomy (LPD), 472, 474, 507; see also Robotassisted pancreatoduodenectomy colon mobilization, 476 common bile duct division, 477 completed choledochojejunostomy, 478 dissection of uncinate process and superior mesenteric artery, 477–478 duodenojejunostomy, 479 gastroduodenal artery division, 476 hepaticojejunostomy, 478 Kocher maneuver and division of ligament of Treitz, 477 meta-analyses comparing open and MIS PD, 475 outcomes of, 474, 476 pancreatic duct exposure, 477 pancreaticojejunostomy, 478–479 pancreatic transection, 477 penrose around neck of pancreas, 477 posterior layer of choledochojejunostomy, 478 posterior layer of duct to mucosa anastomosis, 478 proximal bowel division, 476 reconstruction, 478 resection, 476 retropancreatic window, 477 specimen retrieval, 478 surgical technique, 476 trocar placement, 476 vascular reconstruction, 478 Laparoscopic pancreatic surgery (LPS), 505 Laparoscopic partial fundoplication, 281 clinical categories, 281 contraindications, 282 Dor fundoplication, 283–284 indications, 281–282 key operative steps, 282 outcomes, 284–285 patient positioning, 282 postoperative care, 284 preoperative evaluation, 282 surgical technique, 282 Toupet fundoplication, 282–283 types of, 281 Laparoscopic partial nephrectomy (LPN), 648; see also Robotics in urologic surgery

Index 735 Laparoscopic peritoneal lavage, 522–523; see also Laparoscopic surgery for diverticulitis Laparoscopic proctocolectomy, 533; see also Ulcerative colitis Laparoscopic pyloromyotomy, 678, 692; see also Hypertrophic pyloric stenosis; Pediatric laparoscopy Laparoscopic reoperative bariatric surgery, 386, 394–395; see also Weight regain adjustable gastric band, 391 considerations, 387, 393 emergency situations, 392–393 insufficient weight loss, 387–390 reintervention after adjustable gastric banding, 393 reintervention after gastroplasty, 393 reintervention after Roux-en-Y gastric bypass, 393–394 reintervention after sleeve gastrectomy, 394 Roux-en-Y gastric bypass, 391 severely altered gastrointestinal function, 391–392 sleeve gastrectomy, 391 surgical complications, 390–391 surgical treatment, 393 Laparoscopic repair of hernias, 591 Laparoscopic resection for colon carcinoma, 524 ileocolic vessel, 525 left, sigmoid colectomy, low anterior resection, 526–528 operative setup, 524, 525 patient position, 525 preoperative considerations, 524 right colectomy, 525–526, 527 surgeon position, 525 techniques, 524–525 trocar pattern, 525 Laparoscopic resection of endocrine pancreatic neoplasms, 504; see also Pancreatic neuroendocrine tumors Laparoscopic robotics, 627 advanced robotic tools, 628 challenges in, 631 clinical, 629, 630 cost, 629–630 da Vinci Si, 628 da Vinci Xi, 628 dual console, 628 EndoWrist robotic stapler, 628–629 FireFly, 628 future of, 631 future robotic single port technology, 631 limitations in general surgery, 629 robotic simulation exercise, 629 robotics in general surgery, 627 standard da Vinci system, 627–628 technical, 630 telesurgery and telementoring, 630 vessel sealer, 628

Laparoscopic Roux-en-Y gastric bypass (LRYGB), 372, 387; see also Bariatric surgery complications abdominal entry and trocar placement, 374 ante-colic vs. retro-colic, 372–373 complications, 375–376 concepts for performing, 372–374 gastrojejunostomy, 374–375 indications for surgery and preoperative preparation, 372 jejuno-jejunostomy, 374 length of Roux limb, 373–374 long-term outcomes, 376 long-term postoperative management, 376 operative technique, 374–375 Petersen space, 373 possible locations of internal hernia after, 373 postoperative care, 375–376 preoperative preparation, 374 Laparoscopic simple prostatectomy (LSP), 648; see also Robotics in urologic surgery Laparoscopic sleeve gastrectomy (LSG), 378, 387; see also Bariatric surgery complications complications and management, 379–380 patient selection, 378 result, 379 surgical technique, 379 Laparoscopic splenectomy, 485 anterior laparoscopic technique, 486 anterior technique, 487 anterior vs. posterior approach, 487 control of major vessel, 489 control of unnamed vessel, 489 division of hilar vessels and phrenic attachments, 487–488 division of pedicle with stapler using vascular load cartridge, 488 division of short gastric vessels and exposure of tail of pancreas, 487 division of splenic vessels, 488 exposure of inferior pole of spleen and division of inferior pole vessels, 487 extraction of spleen in bag, 488 hanging spleen technique, 486 hilar vessel bleeding, 489 management of complications, 489 open splenectomy/posterior laparoscopic technique, 486 operating room setup, 486 partial splenectomy, 489–490 port positions for, 487 positioning, 486 posterior technique, 488 postoperative care, 488–489 preoperative management, 485–486 splenic injury, 489 surgical anatomy, 485 trocar placement, 487 vascularization of spleen, 485

Laparoscopic staging for pancreatic malignancy, 464 contemporary evidence-based analysis, 465–466 data from systematic review, 465 diagnostic laparoscopy, 465 expert consensus guidelines, 466 overall recommendation, 466 patient characteristics for selective laparoscopy, 466 preoperative CT imaging, 464 preoperative MRI, 464 Laparoscopic surgery, 129 Laparoscopic surgery for diverticulitis, 521 in acute perforated sigmoid diverticulitis, 522–523 in elective sigmoid resection, 521 fistulous disease, 522 Hartmann procedure, 522–523 recurrent diverticulitis, 521–522 Sigma trial, 522 Laparoscopic surgery of juxtarenal AAA (JAAA), 660; see also Abdominal aortic aneurysms Laparoscopic surgical knot-tying technique (LKTT), 219 Laparoscopic totally extraperitoneal hernia repair, 569; see also Hernia repair completed dissection of posterior floor on right side, 570 complications, 572 dissection of extraperitoneal space, 570 partially reduced direct hernia, 570 positioned mesh, 571 posterior dissection of peritoneum, 571 technique, 569–572 Laparoscopic training, 192 clinical, 195–196 credentialing, 196 developments, 196 fellowship, 192–193 FLS program, 192 FLS training box with video screen, 193 fundamentals of endoscopic surgery, 194–195 fundamentals of laparoscopic surgery, 193–194 fundamental use of surgical energy, 195 medical school, 192 modalities, 193 peg transfer task of FLS manual skills, 194 practicing surgeons, 193 programs, 195 residency, 192 training modalities by level of education, 193 virtual reality simulation for laparoscopic cholecystectomy, 196 Laparoscopic transhiatal esophagectomy, 321 abdominal dissection, 321–323 abdominal port placement, 322 cervical dissection, 323–324 creation of gastric conduit, 323

736 Index Laparoscopic transhiatal esophagectomy (Continued) indications, 321 mediastinal dissection, 323 mobilization and encircling cervical esophagus, 324 postoperative care, 325 reconstruction, 324–325 setup and patient positioning, 321, 322 side-to-side stapled esophagogastrostomy, 324 transhiatal esophageal mobilization, 323 Laparoscopic treatment of inflammatory bowel disease, 533; see also Crohn disease; Ulcerative colitis Laparoscopic ultrasound (LUS), 253, 421–422, 424; see also Intraoperative biliary imaging during cholecystectomy, 255–257 for colorectal liver metastasis, 254 laparoscopic ablation of liver tumors, 254–255 operating room setting, 256 in pancreatic neuroendocrine tumors, 255 RFA of liver lesion, 255 for staging laparoscopy in pancreatic cancer, 253–254 transducers, 254 Laparoscopic ventral hernia repair, 592; see also Hernia repair Laparoscopic wedge resection (LWR), 349 Laparoscopy-assisted distal gastrectomy (LADG), 349; see also Laparoscopic gastrectomy Laparoscopy-assisted total gastrectomy (LATG), 349; see also Laparoscopic gastrectomy LARs, see Low anterior resections LATG, see Laparoscopy-assisted total gastrectomy LC, see Laparoscopic cholecystectomy LCBDE, see Laparoscopic common bile duct exploration LCS, see Laparoscopic component separation LDP, see Laparoscopic distal pancreatectomy Learning curve, 438 LECS, see Laparoscopic and endoscopic cooperative surgery Left hepatic artery (LHA), 433; see also Laparoscopic left hepatectomy Left hepatic vein (LHV), 432; see also Laparoscopic left hepatectomy Left portal vein (LPV), 433; see also Laparoscopic left hepatectomy Left upper quadrant (LUQ), 238 Leiomyoma of esophagus, 637–638; see also Thoracoscopic surgery Leiomyosarcoma (LMS), 339, 341; see also Nonadenomatous gastric tumors Length of stay (LOS), 8, 167, 474 LES, see Lower esophageal sphincter LESSCAR, see Laparoendoscopic SingleSite Surgery Consortium for Assessment and Research

LESS foregut surgery, 244; see also Laparoendoscopic single-site surgery LESS cholecystectomy, 244–245 LESS fundoplication, 245 LESS Heller myotomy, 245 LESS surgery, see Laparo-endoscopic singlesite surgery LHA, see Left hepatic artery LHV, see Left hepatic vein LICs, see Low-income countries Ligament of Treitz (LOT), 355; see also Feeding tube placement Linear echoendoscope, 41; see also Endoscopic ultrasound Linea semilunaris, 608 LINX device, 288; see also External magnetic antireflux ring placement LINX Reflux Management System, 286; see also External magnetic antireflux ring placement Liver surgery, 459; see also Robotic liver resection Liver transection, 440; see also Glissonian approach Living organ donation, 655 LKTT, see Laparoscopic surgical knot-tying technique LLR, see Laparoscopic liver resection LMH, see Laparoscopic major hepatectomy LMICs, see Low-and middle-income countries LMS, see Leiomyosarcoma LNF, see Laparoscopic Nissen fundoplication LOS, see Length of stay LOT, see Ligament of Treitz Low-and middle-income countries (LMICs), 709 Low anterior resections (LARs), 164, 542 Lower endoscopy therapeutic dilation and stenting, 93, 97; see also Endoscopy, diagnostic lower balloon dilatation, 94 deployed stent, 96 endoscopic balloon dilation, 94 guidewire passed across stricture, 95 insertion of TTS guidewire through obstruction, 94 intraluminal stents, 94–96 malignant strictures, 96 nonmalignant strictures, 96 obstructing lesion, 94 obstruction colonic lesion, 93 patient selection and indications, 93–94 results, 96 stents, 95 technique, 94 undeployed stent passed through stricture, 95 x-ray of stent, 96 Lower esophageal sphincter (LES), 55, 148, 267, 286, 305, 310 Low-income countries (LICs), 709

LPD, see Laparoscopic pancreaticoduodenectomy LPN, see Laparoscopic partial nephrectomy LPS, see Laparoscopic pancreatic surgery LPV, see Left portal vein LRYGB, see Laparoscopic Roux-en-Y gastric bypass LSG, see Laparoscopic sleeve gastrectomy LSP, see Laparoscopic simple prostatectomy Lung cancer, 40 LUQ, see Left upper quadrant LUS, see Laparoscopic ultrasound LWR, see Laparoscopic wedge resection Lymphoma, 340; see also Nonadenomatous gastric tumors Lynch syndrome, 84 MAC, see Monitored Anesthesia Care Magnetic resonance cholangiopancreatography (MRCP), 40, 125, 424 Magnetic resonance imaging (MRI), 39, 105, 217, 267, 286, 342, 408, 517, 621, 701; see also Surgery in radiology suite MALS, see Median arcuate ligament syndrome MALT, see Mucosa-associated lymphoid tissue MANOS, see Minilaparoscopy-Assisted Natural Orifice Surgery MANTRELS, 517 Marable syndrome, see Median arcuate ligament syndrome Marginal ulceration, 396; see also Thoracoscopic vagotomy burden of disease, 396 history, 396 indications for surgery, 397 initial workup and management, 396–397 risk factors, 396 surgical options, 397 Maryland Visual Comfort Scale (MVCS), 226 Massachusetts General Hospital (MGH), 16 Massachusetts Institute of Technology (MIT), 627 Master-slave robot, 646; see also Robotics in urologic surgery Mayo Colonoscopy Skills Assessment Tool (MCSAT), 20 MBSAQIP, see Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program MCNs, see Mucinous cystic neoplasms MCSAT, see Mayo Colonoscopy Skills Assessment Tool MD, see Meckel diverticulum MDCT, see Multidetector computed tomography Mechanical thrombectomy, 699 Meckel diverticulum (MD), 514, 691, 693; see also Benign gastrointestinal disease in children; Laparoscopic management of small bowel diseases

Index 737 laparoscopic Meckel diverticulectomy, 693 operative technique, 693–694 postoperative care, 694 preoperative evaluation, 693 Median arcuate ligament syndrome (MALS), 666, 667; see also Laparoscopic median arcuate ligament release Mediastinum, 634; see also Thoracoscopic surgery compartments of, 635 differential diagnosis for mediastinal mass, 635 mediastinal landmarks, 635 Medical paraphernalia, 407 Medigus Ultrasonic Surgical Endostapler (MUSE), 58 MEN, see Multiple endocrine neoplasia Mental training, 216 baseline comparison, 219 control group comparison, 220 evidence in surgical training, 218–220 FLS rubber tube model, 219 follow-up comparison, 220 mental practice evidence, 217–218 nodal points for hurdling, 217 nodal points used in hammer throwing, 217 sessions of, 217 simulation-based training, 216 skills acquisition, 216 systematic approach group comparison, 220 Mercedes-Benz star, 604 Mesh, 591, 595; see also Hernia repair biocompatibility and performance for hernia repair, 593 biomechanical characterization, 592–593 central mesh failure, 594 composite meshes, 592 mesh composition, 591–592 PCO Mesh, 592 physicomechanical properties of, 591 reinforced meshes, 591 single-polymer meshes, 591 small intestine adhesions to resorbable barrier, 594 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), 199 Metabolic syndrome, 360; see also Obesity Metrics, 184; see also Objective metrics in simulation MGH, see Massachusetts General Hospital MHV, see Middle hepatic vein MI, see Minimally invasive Microwave ablation (MWA), 444; see also Ablative treatment of liver tumors active and passive thermal zones with, 450 clinical application of liver tumor ablation, 452–453 clinical outcomes and trials for, 455–457 close to main portal confluence, 454 colorectal liver metastases, 457 complications of, 455

devascularization injury, 454 dielectric heating of water molecules, 450 electromagnetic field by MWA probe, 449 hepatocellular carcinoma, 457 influence of tissue characteristics on tissue effect, 450 intrahepatic fluid collection vs. intrahepatic abscess, 452 intraoperative ultrasound guidance, 446–447 liver lesions, 457 microwave ablation, 450–452 physical properties of, 456 principles, 449–450 vs. radiofrequency ablation, 453–455 shape and size manipulation, 452 transcutaneous MWA probes, 456 unintended vascular injury from, 455 Midazolam, 27 Middle hepatic vein (MHV), 433; see also Laparoscopic left hepatectomy MII, see Multichannel-intraluminal impedance Miniature in vivo robots, 719; see also Robotics Minilaparoscopy-Assisted Natural Orifice Surgery (MANOS), 134 Minimally invasive (MI), 648 approach to retroperitoneal collections in necrotizing pancreatitis, 670 Minimally invasive distal pancreatectomy, 505; see also Pancreatic neuroendocrine tumors French position, 506 postoperative care, 507 Minimally invasive Ivor Lewis esophagectomy, 326 complications, 330 esophagus carcinoma and esophagogastric junction, 328 laparoscopic stage, 327–329 oncologic workup and staging, 326–327 patient setup, 327 postoperative management, 329 preoperative oncologic workup, 327 preoperative planning, 326 results, 330 Siewart classification, 328 surgical technique, 327 thoracoscopic stage, 329 Minimally invasive laparoscopic surgery, 233; see also Anesthesia for laparoscopy Minimally invasive pancreaticoduodenectomy (MIS PD), 467, 474, 476; see also Laparoscopic pancreaticoduodenectomy; Robotassisted pancreatoduodenectomy meta-analyses comparing open and, 475 Minimally invasive surgery (MIS), 7, 19, 129, 184, 188, 222, 497, 627, 709; see also Objective metrics in simulation; Virtual reality simulation

burden of disease, 710, 712–713 challenges, 703, 709–711 dimensions of universal coverage of essential surgery, 710 goal of, 7 health systems strengthening, 711 impact on hepatopancreaticobiliary surgery, 474 inadequate health care financing, 711, 714 lack of infrastructure, 710, 713 laparoscopy as public health strategy for gallbladder disease, 713 limited human resources, 711, 713–714 negative consequences of, 7 poverty, 709–710, 712 principles for successful development of laparoscopic surgery, 712 robotics future in, 716 solutions in underdeveloped environments, 711–714 Minimally invasive video-assisted thyroidectomy (MIVAT), 497; see also Endoscopic/remote-access endocrine surgery MiroSurge, 718; see also Robotics MIS, see Minimally invasive surgery MIS PD, see Minimally invasive pancreaticoduodenectomy MIT, see Massachusetts Institute of Technology MIVAT, see Minimally invasive videoassisted thyroidectomy MNUMS, see Mongolian National University of Medical Sciences Modified barium swallow, see Video fluoroscopic swallow study Modified Blumgart technique, 470; see also Robot-assisted pancreatoduodenectomy Mongolian National University of Medical Sciences (MNUMS), 709 Monitored Anesthesia Care (MAC), 26, 86–87 Morbid obesity, 71; see also Endoscopic bariatric therapies; Revisional bariatric techniques Morgagni hernia, 679 Motion-based metrics, 185–186; see also Objective metrics in simulation MPEC, see Multipolar electrocoagulation MPLC, see Multiport laparoscopic cholecystectomy MRCP, see Magnetic resonance cholangiopancreatography MRI, see Magnetic resonance imaging Mucinous cystic neoplasms (MCNs), 40 Mucosa-associated lymphoid tissue (MALT), 514; see also Intestinal neoplasms Multichannel-intraluminal impedance (MII), 271; see also Esophageal function testing Multidetector computed tomography (MDCT), 253

738 Index Multi directional fluoroscopy, 698, 700; see also Surgery in radiology suite Multimodal imaging or augmenting, 701; see also Surgery in radiology suite Multiple endocrine neoplasia (MEN), 480 Multipolar electrocoagulation (MPEC), 52 Multiport laparoscopic cholecystectomy (MPLC), 154; see also Transvaginal cholecystectomy MUSE, see Medigus Ultrasonic Surgical Endostapler MVCS, see Maryland Visual Comfort Scale MWA, see Microwave ablation Naloxone, 28 Narrow band imaging (NBI), 89 Nasogastric tube (NGT), 321, 355; see also Feeding tube placement National Cancer Institute (NCI), 199 National Comprehensive Cancer Network (NCCN), 42, 60, 339 National Inpatient Sample (NIS), 521 National Institutes of Health (NIH), 378 National Surgical Quality Improvement Program (NSQIP), 203 Natural orifice specimen extraction (NOSE), 162 Natural orifice surgery, 162 hybrid transanal TME, 168–170 indications for transanal NOTES colectomy, 171–176 pure taTME, 170–171 transanal NOSE, 165–167 transanal NOTES colectomy, 167–168 transanal NOTES experience, 165 transanal total mesorectal excision, 168 transvaginal colectomy experience, 162–165 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR), 138 Natural orifice transluminal endoscopic surgery (NOTES), 6, 63, 71, 98, 134, 154, 157, 162, 516, 573, 719; see also Natural orifice surgery; Transanal Hybrid colon resection; Transvaginal NOTES access NBI, see Narrow band imaging NCCN, see National Comprehensive Cancer Network NCI, see National Cancer Institute NEC, see Necrotizing enterocolitis Necrotizing enterocolitis (NEC), 679; see also Pediatric laparoscopy Necrotizing pancreatitis, 670 Neostigmine, 234 NETs, see Neuroendocrine tumors Neuroendocrine tumors (NETs), 513; see also Intestinal neoplasms Neurogenic tumors, 635 Neuromuscular blockade, 234; see also Anesthesia for laparoscopy NGT, see Nasogastric tube NIH, see National Institutes of Health

NIS, see National Inpatient Sample NMDA, see N-methyl-D-aspartate N-methyl-D-aspartate (NMDA), 28 Nonadenomatous gastric tumors, 339; see also Gastric tumor resection benign and malignant, 342 diagnosis, 341–342 differential diagnosis and cells of origin, 340 gastric carcinoids, 340–341 gastrointestinal stromal tumor, 339–340 growth patterns of, 341 imaging studies, 342 leiomyosarcoma, 341 lymphoma, 340 malignant, 339 type I–III gastric carcinoids, 340 Non-Hodgkin lymphoma, 514; see also Intestinal neoplasms Nonmesh modified Bassini repair, 617; see also Recurrent inguinal hernia repair Nonmesh shouldice repair, 617 Nonspecific acute abdominal pain (NSAP), 249 Nonsteroidal anti-inflammatory drugs (NSAIDs), 7, 80, 235, 333, 396, 532 NOSCAR, see Natural Orifice Surgery Consortium for Assessment and Research NOSE, see Natural orifice specimen extraction NOTES, see Natural orifice transluminal endoscopic surgery NSAIDs, see Nonsteroidal anti-inflammatory drugs NSAP, see Nonspecific acute abdominal pain NSQIP, see National Surgical Quality Improvement Program Obalon balloon, 404–405; see also Intragastric balloon Obesity, 67, 71, 358; see also Endoscopic bariatric therapies; Revisional bariatric techniques cardiovascular disease, 358–359 classification of by BMI, 359 endocrinology, 359–360 epidemiology, 358 gastrointestinal disease, 359 infectious complications, 360 morbid obesity, 359 obesity paradox, 361 and postoperative morbidity, 360, 361 pulmonary disease, 359 -related comorbidities, 358 respiratory complications, 360 technical and intraoperative factors, 360 venous thromboembolic complications, 360 Objective metrics in simulation, 184, 187; see also Minimally invasive surgery features of, 185 importance of validity evidence, 184 measures of surgeon physiology, 186 motion-based metrics, 185–186

purpose of, 184 review of, 185 rubrics used to measure performance, 186 time and accuracy, 185 Objective Structured Assessment of Technical Skill (OSATS), 195–196 Obstruction colonic lesion, 93 Obstructive sleep apnea (OSA), 359 OCS, see Open components separation Odds ratio (OR), 104, 562 ODG, see Open distal gastrectomy ODP, see Open distal pancreatectomy OGT, see Orogastric tube ON, see Open nephrectomy OncoGel, 43 One Breath, 713 Ongoing Professional Practice Evaluations (OPPEs), 23 OP, see Open radical prostatectomy OPD, see Open pancreatoduodenectomy Open components separation (OCS), 582; see also Components separation method vs. laparoscopic component separation, 586–588 Open distal gastrectomy (ODG), 352 Open distal pancreatectomy (ODP), 480 Open nephrectomy (ON), 648; see also Robotics in urologic surgery Open pancreatoduodenectomy (OPD); see also Laparoscopic pancreaticoduodenectomy; Robotassisted pancreatoduodenectomy, 472, 474 Open radical cystectomy (ORC), 649; see also Robotics in urologic surgery Open radical prostatectomy (OP), 646 Open simple prostatectomy (OSP), 648 Operating room (OR), 222 Operative hernia repair, see Laparoscopic incisional and ventral hernia repair Opioids, 27–28 OPPEs, see Ongoing Professional Practice Evaluations Optical naturalism, 17 Optical view technique (OV technique), 239–240; see also Access in minimally invasive surgery Optiview, see Optical view technique OR, see Odds ratio; Operating room ORACLE, see Outcomes Reporting App for CLinician and Patient Engagement Orbera balloon, 68; see also Endoscopic bariatric therapies Orbera Intragastric Balloon System, 400; see also Intragastric balloon complications, 403 indications and contraindications for IGB treatment, 401 mechanism of action, 400–401 Orbera outcomes, 402–403 patient follow-up, 402

Index 739 placement and removal technique, 402 postplacement management, 402 preoperative workup, 401 ORC, see Open radical cystectomy Orogastric tube (OGT), 374 Orthodoc Presurgical Planner computer program, 718; see also Robotics OS, see Overall survival OSA, see Obstructive sleep apnea OSATS, see Objective Structured Assessment of Technical Skill Osmotic agents, 86 OSP, see Open simple prostatectomy OTSC, see Over-the-Scope Closure Device OTSCs, see Over-The-Scope Clips Outcome measure, 200; see also Surgical quality measurement Outcomes Reporting App for CLinician and Patient Engagement (ORACLE), 595 Overall survival (OS), 347 Over-The-Scope Clips (OTSCs), 64, 75–76 Over-the-Scope Closure Device (OTSC), 63 OV technique, see Optical view technique PAEs, see Preventable adverse events Pain management injections, 700 Palliation, 464 Pancreatic cancer, 40, 42, 464; see also Laparoscopic staging for pancreatic malignancy Pancreatic cystic lesions (PCLs), 40 Pancreatic fistula, 484 Pancreatic necrosis, 42 Pancreatic neuroendocrine tumors (PNETs), 255, 504; see also Laparoscopic distal pancreatectomy incidence and biologic specificity, 504 indications of surgical resections and oncologic goals, 504 laparoscopic resection of, 506 minimally invasive distal pancreatectomy, 505–507 minimally invasive pancreaticoduodenectomy, 507–509 minimally invasive surgery, 504–505 Pancreaticoduodenectomy (PD), 467; see also Robot-assisted pancreatoduodenectomy Pancreatic pseudocyst (PP), 42, 118 Paraesophageal hernia, 294; see also Hiatal hernia Parasternal mediastinotomy, 636–637; see also Thoracoscopic surgery Parietex Composite Mesh (PCO Mesh), 592; see also Mesh Pars flaccida, 364; see also Laparoscopic adjustable gastric banding dissection, 365 Patient care, 198–199; see also Surgical quality measurement Patient safety, 203 AHRQ Patient safety indicators

factors affecting, 204–205 future directions, 206 importance of innovation and minimally invasive surgery, 205 PSIs, 204 quality and, 203–204 Patient safety indicators (PSIs), 204 PCLs, see Pancreatic cystic lesions PCNL, see Percutaneous nephrolithotomy PCO Mesh, see Parietex Composite Mesh PCP, see Primary care physician PCS, see Posterior component separation PCST, see Posterior component separation technique PD, see Pancreaticoduodenectomy PDT, see Photodynamic therapy Pediatric inguinal hernias, 682 Pediatric laparoscopy, 677 anatomical considerations and intraoperative heuristics, 679 anorectal malformations, 678 bariatric surgery, 678 biliary atresia and choledochal cyst, 678–679 congenital diaphragmatic hernia, 679 consideration straining opportunities, 680 duodenal atresia, 679 evidence of best practice in, 680 fundoplication, 678 Hirschsprung disease, 678 improvements in surgical instrumentation, 679, 680 insufflation pressure and volume, 677 intestinal rotation abnormalities, 679 necrotizing enterocolitis, 679 physiological differences between pediatric and adult patients, 677 procedures common to adult and pediatric patients, 677 procedures unique to pediatric population, 678 pyloric stenosis, 678 surgical heuristics and prevention of pain, 680 PEG, see Percutaneous endoscopic gastrostomy PEJ, see Percutaneous endoscopic jejunostomy PEL, see Phrenoesophageal ligament Pelvic region musculature, 621; see also Sports hernia repair Pelvis-related injuries, 620; see also Sports hernia repair Peptic ulcer disease (PUD), 333, 396; see also Marginal ulceration; Perforated duodenal ulcer repair access and port placement, 334 approaches for management of, 333 history of peptic ulcer disease, 333 instruments, 334 operating room setup, 334 patient selection, 333–334 pitfalls, 338

positioning for PUD surgery, 335 preoperative preparation, 334 procedure, 335 techniques, 334 trocar locations for PUD surgery, 335 Percutaneous drainage of abscess, 700; see also Surgery in radiology suite Percutaneous endoscopic gastrostomy (PEG), 18, 130, 140, 353; see also Feeding tube placement complications, 143–145 finger indentation for gastrotomy localization, 142 future directions, 146 gastrostomy tube with jejunal extension, 145, 147 indications, 140 Introducer technique, 143, 145 modifications of method, 145–146 Pull technique, 140, 141 Push technique, 143, 144 Safe Tract technique, 140, 143 SLiC procedure, 143, 146 T-fastener method, 143, 147 transillumination technique, 142 Percutaneous endoscopic jejunostomy (PEJ), 146 Percutaneous nephrolithotomy (PCNL), 700 Percutaneous transhepatic cholangiography (PTC), 700 Perforated diverticulitis, 522; see also Laparoscopic surgery for diverticulitis Perforated duodenal ulcer repair, 335; see also Peptic ulcer disease anterior seromyotomy, 337 anterior stapled linear gastrectomy, 338 anterior vagal nerve management, 336–337 exposure of hiatus, 336 exposure to vagal nerve trunks, 336 Graham patch, 336 highly selective vagotomy, 337 posterior truncal vagotomy, 336 posterior vagotomy, 336 postoperative care, 338 PUD perforation omental patch, 335 PUD perforation suture repair, 335 Performance assessment rubrics, 186; see also Objective metrics in simulation Perioperative care, 7 Permittivity, see Dielectric constant Peroral endoscopic myotomy (POEM), 19, 148, 153, 270, 305 complications, 152 equipment needed for, 150 history, 149 longitudinal muscle fibers, 151 newer indications for, 152 postprocedure care, 151–152 preoperative considerations, 149 results, 152 submucosal plane, 150 technique, 149–150

740 Index PET, see Positron emission tomography Petersen space, 373; see also Laparoscopic Roux-en-Y gastric bypass Peterson defect, 383 Pfannenstiel incisional hernias, 580; see also Hernia repair PGY, see Postgraduate-year PH, see Prototype handle” Pharmacologic chemoembolization and drug delivery, 699 Photodynamic therapy (PDT), 51 Phrenoesophageal ligament (PEL), 292 PNETs, see Pancreatic neuroendocrine tumors Pneumothorax, 235 POEM, see Peroral endoscopic myotomy Polytetrafluoroethylene (PTFE), 625 PONV, see Postoperative nausea and vomiting POPF, see Postoperative pancreatic fistula Portal vein (PV), 468 POSE, see Primary Obesity Surgery Endolumenal Positron emission tomography (PET), 218, 327, 342 Posterior component separation (PCS), 583; see also Components separation method port placement for robotic, 589 Posterior component separation technique (PCST), 588–589, 614 Postgraduate-year (PGY), 219 Postoperative hemorrhage, 382; see also Bariatric surgery complications Postoperative nausea and vomiting (PONV), 235 Postoperative pancreatic fistula (POPF), 474 PP, see Pancreatic pseudocyst PPIs, see Proton pump inhibitors Pre-event warm-up, 212, 215 computer-based simulations, 213–214 GetWellSooner program, 215 mental warm-ups, 212, 213 robot warm-up tasks, 214 underground hand controllers, 215 video game warm-up by surgeon, 212 video game warm-up suite, 215 virtual simulators, 213 Preventable adverse events (PAEs), 204 Primary aldosteronism, 493 Primary care physician (PCP), 557 Primary Obesity Multicenter Incisionless Suturing Evaluation (PROMISE), 68 Primary Obesity Surgery Endolumenal (POSE), 68 Pringle maneuver, 437; see also Totally laparoscopic right hepatectomy PROBOT (Prostatectomy ROBOT), 716; see also Robotics Process measures, 199–200; see also Surgical quality measurement PROMISE, see Primary Obesity Multicenter Incisionless Suturing Evaluation

Propofol, 28 Prostate surgery, 646; see also Robotics in urologic surgery robot-assisted laparoscopic radical prostatectomy, 646–647 simple robotic prostatectomy, 647–648 Prosthetic materials, 591; see also Mesh Proton pump inhibitors (PPIs), 55, 80, 281, 286 Prototype handle (PH), 226 Pseudocyst, 42 PSIs, see Patient safety indicators PTC, see Percutaneous transhepatic cholangiography PTFE, see Polytetrafluoroethylene PUD, see Peptic ulcer disease Pull technique, 140, 141; see also Percutaneous endoscopic gastrostomy PUMA 200 robot (Programmable Universal Machine for Assembly), 716, 717; see also Robotics Pure flexible endoscopic approach, 158; see also Transvaginal appendectomy Pure rigid laparoscopic approach, 158 Pure taTME, 170–171; see also Transanal total mesorectal excision Pure transvaginal appendectomy, 158; see also Transvaginal appendectomy hybrid vs., 160 operative positioning for, 158 Push technique, 143, 144; see also Percutaneous endoscopic gastrostomy PV, see Portal vein Pyloric stenosis, 678; see also Pediatric laparoscopy Pyloroduodenal occlusive devices, 69; see also Endoscopic bariatric therapies QALYs, see Quality-adjusted life-years QOL, see Quality of life QOLRAD, see Quality of Life in Reflux and Dyspepsia Quality-adjusted life-years (QALYs), 4 Quality improvement, 198; see also Surgical quality measurement Quality of life (QOL), 588 Quality of Life in Reflux and Dyspepsia (QOLRAD), 56 Radial echoendoscope, 41; see also Endoscopic ultrasound Radially expanding access, 240; see also Access in minimally invasive surgery Radially expanding trocar, 240 Radical cystectomy, 649; see also Robotics in urologic surgery Radical nephrectomy, 651; see also Laparoscopic nephrectomy Radiofrequency (RF), 228, 557

Radiofrequency ablation (RFA), 40, 52, 55, 254, 444; see also Ablative treatment of liver tumors alternating electric field, 445 clinical application of liver tumor ablation, 452–453 clinical outcomes and trials for, 455–457 in colorectal liver metastases, 457 effect produced during, 448 electrical circuit of RFA system, 445 electrodes, 446 of esophageal mucosa, 18–19 evidence, 56 in hepatocellular carcinoma, 457 intraoperative ultrasound guidance, 446–447 microwave ablation vs., 453–455 operative, 447–448 optimal, 446 in other liver lesions, 457 physical properties of, 456 potential adverse events from, 449 principles, 444–446 spherical RF ablation, 448 technique and indications, 55–56 technological concept, 445 typical ESU for, 445 Radiofrequency energy delivery, 557, 559; see also Fecal incontinence therapies effect on IAS and EAS muscle and connective tissue, 558 indications and benefit, 557 mechanism of action and technique, 557–558 mid-and long-term outcomes, 560 strategies to reduce failures and long-term results, 558 RALP, see Robot-assisted laparoscopic prostatectomy Randomized controlled trial (RCT), 5, 352, 403 RAPD, see Robot-assisted pancreatoduodenectomy Rapid prototyping, see Three-dimensional printing RAPTOR (resuscitation with angiography, percutaneous techniques, and operative repair), 701–702; see also Surgery in radiology suite RARC, see Robotic-assisted radical cystectomy RAS, see Robotic-assisted surgery Rasmussen’s SRK framework, 189–190 RATS, see Robotic-assisted thoracic surgery RCCs, see Renal cell carcinomas RCPSC, see Royal College of Physicians and Surgeons of Canada RCT, see Randomized controlled trial RDF, see Routine fluorocholangiography RDP, see Robotic distal pancreatectomy Rectal cancer management algorithm, 98 Rectal prolapse, 573; see also Transanal Hybrid colon resection

Index 741 Recurrence-free survival (RFS), 343 Recurrent diverticulitis, 521–522; see also Laparoscopic surgery for diverticulitis Recurrent inguinal hernia repair, 617 challenges, 618 completed TEP laparoscopic repair, 619 incarceration with or without bowel compromise or infection, 618 laparoscopic techniques, 617 recurrence with pain from mesh or nerves, 618–619 recurrent direct inguinal hernia, 619 prior repair, 618 risk of testicular injury, 618 selecting technique to repair recurrent hernia, 617 totally extraperitoneal repair, 618 transabdominal preperitoneal repair, 617–618 Recurrent laryngeal nerve (RLN), 498 Reduced port laparoscopy, 418; see also Laparoscopic cholecystectomy Reinforced meshes, 591; see also Mesh Relative risk (RR), 239 Remote-access surgeries, 497; see also Endoscopic/remote-access endocrine surgery Remote telementoring, 182; see also Telementoring Renal cell carcinomas (RCCs), 651; see also Laparoscopic nephrectomy Reoperative bariatric surgery, see Laparoscopic reoperative bariatric surgery Reoperative fundoplication, 298 acute paraesophageal hernia recurrence, 301 acute recurrent hiatal hernia, 304 choice of fundoplication, 300 computed tomography, 299 considerations, 300–302, 304 dissection technique and extent, 302 dysphagia postfundoplication, 301 endoscopic images after fundoplication, 300 esophageal manometry, 300 gastric and esophageal perforations, 304 hiatal mesh, 302 history of timeline and symptom severity, 298 indications for reoperation, 298, 299 intraoperative technical considerations, 302 management of intraoperative complications, 304 mesh reinforcement, 302 for patients with recurrent reflux symptoms, 301 pneumothorax, 304 preoperative evaluation and planning, 298–300 previous surgical approach, 300 procedure in reoperative hiatal surgery, 302 recurrent reflux after fundoplication, 301–302

risks, 300 short esophagus, 304 techniques of reoperative hiatal surgery, 303 24-hour pH testing, 299 upper endoscopy, 299 upper gastrointestinal images after fundoplication, 299 use of intraoperative endoscopy, 302 Reoperative hiatal surgery, 303; see also Reoperative fundoplication ReShape Dual balloon system, 68; see also Endoscopic bariatric therapies; Intragastric balloon DUO integrated, 403 Residual blockade, 234; see also Anesthesia for laparoscopy Respiratory depression, 27 RESTORe Suturing System Device, 68; see also Endoscopic bariatric therapies Restrictive operations, 363; see also Laparoscopic adjustable gastric banding Restrictive procedure, see Sleeve gastrectomy Retrorectus, 608–609; see also Robotic ventral hernia repair Retrorectus repair, 613 Reversal agents, 28 Revisional bariatric techniques, 71; see also Endoscopic bariatric therapies Bard EndoCinch suturing system, 72 Incisionless Operating Platform, 72 materials and methods, 71 scleraltherapy, 71–72 StomaphyX, 72 Suture System, 73 suturing, 72 RF, see Radiofrequency RFA, see Radiofrequency ablation RFS, see Recurrence-free survival RIO System, see Robotic Arm Interactive Orthopedic rIPOM repair, see Robotic intraperitoneal onlay mesh repair Rives-Stoppa repair, 596; see also Laparoscopic incisional and ventral hernia repair RLN, see Recurrent laryngeal nerve ROBODOC, 718; see also Robotics Robot-assisted cholecystectomy, 418; see also Laparoscopic cholecystectomy Robot-assisted laparoscopic prostatectomy (RALP), 647; see also Robotics in urologic surgery benefits of, 647 functional outcomes, 647 oncologic outcomes, 647 operative outcomes, 647 radical prostatectomy, 646 simple robotic prostatectomy, 647–648 Robot-assisted pancreatoduodenectomy (RAPD), 467, 472, 473 advantages of, 472

antecolic two-layer duodenojejunostomy, 471 blood loss, operative time, and conversion rates for PD, 472 cannulation of pancreatic duct, 471 dissection of adventitia to expose SMA, 471 dissection of porta hepatis, 469 division of pancreatic neck, 470 division of SMA arterial tributaries to pancreatic head, 471 docking the robot, 469 duct to mucosa pancreaticojejunostomy, 471 end-to-side hepaticojejunostomy, 471 gastrointestinal continuity restoration, 470–471 Kocher maneuver, 469 learning curve, 473 ligation of gastroduodenal artery, 470 limitations of current technology, 472 mobilization of right colon and pancreatic head, 469 modified Blumgart technique, 470 oncologic outcomes, 473 operating room setup, 468 portion of duodenum for pyloruspreserving PD, 470 postoperative complications, 473 preliminary creation of duodenojejunostomy, 469 preoperative checklist, 468 safety and selection, 467–468 stepwise surgical technique, 468 suggested location of ports, 468 superior mesenteric vein mobilization, 469–470 trocar placement, 468 vascular disconnection of pancreatic head, 470 Robot-assisted radical nephrectomy, 648; see also Robotics in urologic surgery functional outcomes, 649 oncologic outcomes, 648 partial nephrectomy, 648 perioperative outcomes, 648 Robotic access, 241; see also Access in minimally invasive surgery Robotic Arm Interactive Orthopedic (RIO System), 718; see also Robotics Robotic-assisted laparoscopic Heller myotomy, 310; see also Achalasia completed Dor fundoplication, 313 complications, 314 diagnosis of achalasia, 310–311 dissection of crura and exposure of anterior esophagus, 312 Dor fundoplication creation, 313 drawback of, 315 extension of myotomy, 312 fat pad dissection, 312 goal of achalasia surgery, 314 myotomy with preserved anterior vagus nerve, 313

742 Index Robotic-assisted laparoscopic Heller myotomy (Continued) myotomy with submucosal plane visualization, 313 operative room setup for, 311 operative technique, 311–313 outcomes, 314–315 port placement, 311 postoperative care, 313–314 preparation for surgery, 311 effect of previous treatment on Heller myotomy, 311 Robotic-assisted radical cystectomy (RARC), 649; see also Robotics in urologic surgery Robotic-assisted surgery (RAS), 701; see also Surgery in radiology suite Robotic-assisted thoracic surgery (RATS), 643; see also Video-assisted thoracic surgery lobectomy Robotic distal pancreatectomy (RDP), 480, 506 Robotic intraperitoneal onlay mesh repair (rIPOM repair), 609; see also Robotic ventral hernia repair adhesiolysis, 611 hernia defect closure in shoelace fashion, 611 mesh fixation with absorbable barbed suture, 611 mesh placement and fixation, 611 mesh positioning for ventral hernia, 610 patient preparation, positioning, and initial access, 609 surgical technique, 609 trocar placement, adhesiolysis, defect closure, 609, 611 trocar positioning for IPOM and TAPP, 611 Robotic liver resection, 459 contraindications for robotic surgery, 460 general phases in, 461 indications and techniques of, 460–462 operating room setup, 461 outcomes of robotic liver surgery, 462–463 parenchymal transection, 462 port placement for hepatic resection, 462 robotic vs. laparoscopic learning curve, 460 robotic vs. laparoscopic techniques, 459–460 20–10–5 rule, 460 Robotic pancreaticoduodenectomy (RPD), 476; see also Laparoscopic pancreaticoduodenectomy Robotic partial nephrectomy (RPN), 648; see also Robotics in urologic surgery Robotic posterior component separation technique, 588–589; see also Components separation method Robotic radical cystectomy, 649; see also Robotics in urologic surgery Robotic radical nephrectomy (RRN), 648; see also Robotics in urologic surgery Robotic retromuscular mesh repair, 613; see also Robotic ventral hernia repair closure of hernia defect, 614

dissection of contralateral medial edge of rectus sheath, 614 dissection of medial edge of rectus sheath, 614 mesh placement, 614 retromuscular dissection, 613 retrorectus repair, 613 single-docking method, 613 surgical technique, 613 trocar positioning, 613 Robotics Acrobot Sculptor, 717 CASPAR, 716 current computer-assisted surgical systems, 717–718 da Vinci Robotic Surgical System, 717–718 EndoSAMURAI, 718 future direction of surgical robotics, 719 future in minimally invasive surgery, 716 history of surgical robotics, 716–717 miniature in vivo robots, 719 MiroSurge, 718 PUMA, 716, 717 RIO System, 718 ROBODOC, 718 SurgiBot, 718–719 surgical robotics in development, 718–719 ZEUS Robotic Surgical System, 716, 717 Robotic simple prostatectomy (RSP), 648; see also Robotics in urologic surgery Robotics in colorectal surgery, 538 camera control and imaging, 538 cost, 539 dexterity, 538 disadvantages of robotic surgery, 539 ergonomics, 538 flickering image, 540 history of, 539–540 hybrid technique, 544 image brightness, 540 inferior mesenteric artery and vein ligation, 542 lack of haptic feedback, 539 learning curve, 538 left colon procedures, 541–542 left colon/sigmoid/rectum, 546–547 left sigmoid and descending colon dissection, 543 length of procedure, 539 mesorectal excision and rectal division, 542–543 missing image in one or both eyes, 540 patient selection, 540 poor or blurry image, 540 procedures, 540 right colectomy, 540–541, 545–546 robotic outcomes, 545 robotic rectopexy, 545 single-stage robotic technique, 544–545 specimen extraction and reanastamosis, 543 specimen extraction for abdominoperineal resection, 543–544

splenic flexure mobilization, 543 Robotics in urologic surgery, 646 advantages of robotics, 646 bladder surgery, 649 history of surgical robotics, 646 kidney surgery, 648–649 prostate surgery, 646–648 Robotic system, 627; see also Laparoscopic robotics Robotic transabdominal preperitoneal approach (rTAPP approach), 602; see also Inguinal hernia—repair access, 603 anatomical landmarks, 605, 606 caudal extent of dissection, 604 closure of peritoneal flap, 606 dissection of direct hernia sac, 605 dissection of indirect hernia sac, 605 docking, 603 indications for, 602 initial exposure, 603 keeping medial umbilical fold intact, 606 lateral extent of dissection, 604 medial extent of dissection, 604 Mercedes-Benz star, 604 mesh placement, fixation, and peritoneal closure, 605–607 mesh placement to hernia sites, 606 patient positioning, 603 patient selection, 602 postoperative care and follow-up, 607 preoperative preparation, 603 preperitoneal dissection, 604–605 surgical technique, 603 suturing direct hernia defect, 605 suturing peritoneum to peritoneum from down-to-up direction, 606 trocar placement, 603 Robotic transabdominal preperitoneal repair, 612; see also Robotic ventral hernia repair Robotic transversus abdominis release, 614; see also Robotic ventral hernia repair approximation of posterior rectus sheath, 616 closure of hernia defect, 616 contralateral posterior rectus sheath mobilization, 615 contralateral retrorectus dissection after redocking, 616 dissection of transversus abdominis fibers, 615 initial mesh fixation at contralateral side, 615 mesh deployment after cutting stitch, 616 surgical technique, 614 transversus abdominis fascia release, 615 trocar positioning, 615 Robotic ventral hernia repair, 600, 608 preoperative evaluation, 609 preperitoneal mesh position, 608

Index 743 retrorectus, 608–609 robotic intraperitoneal onlay mesh repair, 609–611 robotic retromuscular mesh repair, 613–614 robotic transabdominal preperitoneal repair, 612 robotic transversus abdominis release, 614–616 surgical anatomy and mesh positioning, 608 ROSE procedure (Restorative Obesity Surgery, Endolumenal procedure), 71; see also Revisional bariatric techniques Routine fluorocholangiography (RDF), 419; see also Intraoperative biliary imaging Roux-en-Y gastric bypass (RYGB), 12, 71, 245–246, 372, 373; see also Bariatric surgery; Laparoscopic Roux-en-Y gastric bypass Roux limbs, 373–374; see also Laparoscopic Roux-en-Y gastric bypass Royal College of Physicians and Surgeons of Canada (RCPSC), 22 RPD, see Robotic pancreaticoduodenectomy RPN, see Robotic partial nephrectomy RR, see Relative risk RRN, see Robotic radical nephrectomy RSP, see Robotic simple prostatectomy rTAPP approach, see Robotic transabdominal preperitoneal approach Russell technique, see Introducer technique RYGB, see Roux-en-Y gastric bypass Sacral nerve stimulation (SNS), 562; see also Fecal incontinence therapies indications and benefits, 562 lead position, 564 long-term results, 565 mechanism of action and technique, 562–563 needle insertion and direction, 563 preventing failure and complications, 563–565 Safe Tract technique, 140, 143; see also Percutaneous endoscopic gastrostomy SAG, see Systematic approach group SAGES, see Society of American Gastrointestinal and Endoscopic Surgeons SAIL, see Simulation to Advance Innovation and Learning SAP, see Symptom association probability SBO, see Small bowel obstruction SCARA, see Selective Compliance Assembly Robot Arm SCC, see Squamous cell carcinoma SCIP, see Surgical Care Improvement Project SCJ, see Squamocolumnar junction Scleraltherapy, 71–72; see also Revisional bariatric techniques

SCM, see Sternocleidomastoid muscle SCORE Portal, see Surgical Council on Resident Education Portal SDGs, see Sustainable development goals SECCA, see Radiofrequency energy delivery Sedation-related adverse events, 28–29 SEER, see Surveillance, Epidemiology, and End Results See-through optical display, 705; see also Augmented reality Selective cholangiography, 419; see also Intraoperative biliary imaging Selective Compliance Assembly Robot Arm (SCARA), 718; see also Robotics Selective laser sintering (SLS), 259–260; see also Three-dimensional printing Self-expanding metal stents (SEMSs), 48, 127; see also Esophageal stenting Self-expanding plastic stent (SEPS), 48; see also Esophageal stenting SEMSs, see Self-expanding metal stents SEPS, see Self-expanding plastic stent SFF, see Swanson Family Foundation SG, see Sleeve gastrectomy; Slotted grasper Short esophagus, 304 SI, see Symptom index Sigmoid esophagus, 152 Sigmoidoscopy, 110; see also Endoscopy, diagnostic lower SILS, see Single-incision laparoscopic surgery Simulation-based training, 184, 216; see also Objective metrics in simulation Simulation to Advance Innovation and Learning (SAIL), 224 Single-incision laparoscopic surgery (SILS), 6, 240–241, 516, 719; see also Access in minimally invasive surgery Single-polymer meshes, 591; see also Mesh Single-port access (SPA), 240; see also Access in minimally invasive surgery Single port and reduced port access, 244; see also Laparo-endoscopic single-site surgery approaches to hepatobiliary and solid organ pathology, 246 for bariatric procedures, 245 for colorectal surgery, 246–247 Skill-, rule-, and knowledge-framework (SRK framework), 189–190 SL, see Staging laparoscopy Sleeve gastrectomy (SG), 245, 372, 378; see also Bariatric surgery; Laparoscopic sleeve gastrectomy SLH, see Surgeon’s left hand SLiC procedure, 143, 146; see also Percutaneous endoscopic gastrostomy Slide by technique, 88 Sliding hiatal hernia, 294; see also Hiatal hernia Slotted grasper (SG), 277 SLS, see Selective laser sintering

SMA, see Superior mesenteric artery Small bowel obstruction (SBO), 376, 512 SMART program, see Surgical Multimodal Accelerated Recovery Trajectory program SMV, see Superior mesenteric vein Snare polypectomy, 115; see also Endoscopy, diagnostic lower SNS, see Sacral nerve stimulation Society for Surgery of the Alimentary Tract (SSAT), 21 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 21, 37, 189, 193, 239, 257, 291, 411, 712 Sound waves, 207 Southwestern stations (SW stations), 195 SPA, see Single-port access Sphincterotomy, 126; see also Endoscopic retrograde cholangiopancreatography Splenic flexure, 113 Sports hernia repair, 620 attenuated external oblique aponeurosis, 624 bilateral tension-free mesh repair, 624 diagnosis and examination, 621–622 differential diagnosis, 620–621 dissected inguinal floor, 624 indications for surgical management, 622–623 inguinal floor in abdominal core sports injury, 622 left adductor tear, 622 open mesh repair of right inguinal floor, 625 pelvic MRI images of left rectus tear, 622 pelvic region musculature, 621 postoperative management and return to sport, 626 published results of, 623 right parasymphyseal edema and tear, 623 surgical approaches, 623–625 surgical outcomes, 625–626 tears in distal rectus, 624 Squamocolumnar junction (SCJ), 271 Squamous cell carcinoma (SCC), 326 SR, see Surface rendering SRH, see Surgeon’s right hand SRI, see Stanford Research Institute SRK framework, see Skill-, rule-, and knowledge-framework SSAT, see Society for Surgery of the Alimentary Tract SSGXVIII/AIO (Scandinavian Sarcoma Group), 347 SSI, see Symptom sensitivity index Staging laparoscopy (SL), 253 Stanford Research Institute (SRI), 627 Stent graft, 699 Stenting, 96, 699; see also Lower endoscopy therapeutic dilation and stenting Stereolithography (STL), 258, 259; see also Three-dimensional printing Sternocleidomastoid muscle (SCM), 499

744 Index STL, see Stereolithography StomaphyX suturing system, 72; see also Revisional bariatric techniques Stoma ulceration, 391 Stratasys Objet30 Prime, 259; see also Threedimensional printing Stretta, 55–56 Strip biopsy technique, 61 Structural variables, 199; see also Surgical quality measurement Submucosal endoscopic esophageal myotomy, 149 Submucosal tumors, 60 Sudden infant death syndrome, see Acute life-threatening events Superior mesenteric artery (SMA), 469, 477 Superior mesenteric vein (SMV), 469, 477 Suprapubic hernias, 600; see also Laparoscopic incisional and ventral hernia repair Surface rendering (SR), 703; see also Augmented reality Surgeon’s left hand (SLH), 277 Surgeon’s right hand (SRH), 277 Surgeon’s role in endoscopy, 18, 25 Gastroenterology Core Curriculum, 19 POEM, 19 privileging in flexible GI endoscopy, 23–25 role of, 18–19 surgical endoscopist, 21–22 training in flexible endoscopy, 19–21, 21–22 training in GI endoscopy, 19 training while in practice, 23 Surgery in radiology suite, 698 angiographic vascular procedures, 699–700 computed tomography, 700–701 concept of exposure, 698 magnetic resonance imaging, 701 mixed-reality environments, 701 multi directional fluoroscopy, 698, 700 percutaneous drainage of abscess, 700 RAPTOR, 701–702 ultrasound, 701 SurgiBot, 718–719; see also Robotics Surgical Care Improvement Project (SCIP), 199, 481 Surgical Council on Resident Education Portal (SCORE Portal), 22 Surgical endoscopist, 21–22 Surgical Multimodal Accelerated Recovery Trajectory program (SMART program), 14 Surgical quality measurement, 198, 202 historical context, 199 improving data measurement, 200–201 improving quality of care, 201–202 informed decision-making, 198 outcomes, 200 patient care, 198–199 process, 199–200

quality measures, 199 stakeholders in quality improvement, 198 structure, 199 Surgical robotics, 646; see also Robotics; Robotics in urologic surgery advantages of, 646 in development, 718–719 future direction of, 719 history of, 646, 716–717 Surgical specialty organizations, 14 Surgical stress mechanisms, 7 Surgisis, 78 Surveillance, Epidemiology, and End Results (SEER), 341 Sustainable development goals (SDGs), 710 Suture System, 73; see also Revisional bariatric techniques Suturing devices, 68–69; see also Endoscopic bariatric therapies Swanson Family Foundation (SFF), 712 SW stations, see Southwestern stations Sympathectomy, 635; see also Thoracoscopic surgery Symptom association probability (SAP), 271 Symptomatic gallstone disease, 424; see also Laparoscopic common bile duct exploration Symptomatic pseudocyst, 119; see also Endoscopic procedures of pancreas Symptomatic walled-off necrosis, 119; see also Endoscopic procedures of pancreas appearance of cavity upon entry, 122 cystgastrostomy tract after balloon deflation, 122 direct endoscopic guided access, 121 images before and after necrosectomy, 122 indications and timing for intervention, 119–120 multiple soft double pig tail stent placement, 122 step-up approach, 120–124 WON treated via fully covered lumenapposing stent, 123 Symptom index (SI), 271 Symptom sensitivity index (SSI), 271 Systematic approach group (SAG), 219 Systems Based Practice, 3 TA, see Transversus abdominis TAE, see Transanal excision TAMIS, see Transanal minimally invasive surgery TAP, see Transversus abdominis plane TAPP approach, see Transabdominal preperitoneal approach TAR, see Transversus abdominis release Targeted stretching microbreaks (TSMBs), 225 Target effect, 225 TASC, see Trans-Atlantic Inter-Society Consensus TaTME, see Transanal total mesorectal excision TBW, see Total body weight

TCB, see Tru-Cut biopsy TEA, see Transanal endoscopic applicator TEE, see Transesophageal echocardiography Telemedicine, 181 Telementoring, 180, 183 applications, 180 key terminology, 181 and professional collaboration, 182 in remote and resource-restricted contexts, 182 in surgical education, 180–181 Teleproctoring, 180, 181 Telesimulation, 180, 181 Telesurgery, 180, 181 in remote and resource-restricted contexts, 182 TEM, see Transanal endoscopic microsurgery TEO, see Transanal endoscopic operation TEO-system (Transanal Endoscopic Operations), 576; see also Transanal Hybrid colon resection TEP approach, see Totally extraperitoneal approach Terminal ileum, 114 TES, see Transanal endoscopic surgery TF, see Transoral fundoplication T-fastener device, 354; see also Feeding tube placement T-fastener method, 143, 147; see also Percutaneous endoscopic gastrostomy TGVR, see Transoral gastric volume reduction Therapeutic endoscopic ultrasound, 41; see also Endoscopic ultrasound celiac plexus neurolysis, 42 core biopsy, 41 fiducial placement, 42 fine needle aspiration, 41 injection of chemotherapy, 42–43 pancreatic cyst ablation, 42 pancreatic necrosis, 42 pancreatic pseudocyst, 42 Thoracoscopic surgery, 634 differential diagnosis for mediastinal mass, 635 esophageal myotomy, 637 of esophagus, 637 mediastinal landmarks, 635 mediastinum, 634, 635 parasternal mediastinotomy, 636–637 resection of GIST/leiomyoma of esophagus, 637–638 thoracoscopic thymectomy, 634–635 video-assisted thoracic surgery resection, 635–636 video-assisted thoracic surgery sympathectomy, 636 Thoracoscopic thymectomy, 634–635 Thoracoscopic vagotomy, 397, 399; see also Marginal ulceration dissection of esophagus, 399

Index 745 equipment and port placement, 398 operative details, 398 patient positioning and port placement, 398 preoperative assessment, 397–398 preoperative phase and positioning, 398 relevant anatomy, 398 Thoracoscopy, 639; see also Video-assisted thoracic surgery lobectomy Three-dimensional bioprinter, 263; see also Three-dimensional printing 3D printers, desktop, 259; see also Threedimensional printing 3D printing, see Three-dimensional printing Three-dimensional printing (3D printing), 210, 258, 262, 264 applications of, 258 cardiac surgery, 261 current status of medical, 260 dental surgery, 260 desktop 3D printers, 259 fusion deposition modeling, 260 future of, 262 inkjet printing, 260 invention and discovery phase, 258–259 liver tumor model, 263 model of aneurysm with translucent outer aorta, 263 models of normal and abnormal mitral valves, 261 orthopedic surgery, 261 patient-specific “root analog” implant, 260 patient-specific 3D printed skull plates, 261 patient-specific task trainers, 262 plastic and reconstructive surgery, 260 selective laser sintering, 259–260 stereolithography, 259 Stratasys Objet30 Prime, 259 surgical education, 261–262 technologies, 259 thoracic surgery, 261 three-dimensional bioprinter, 263 3D printed model of knee, 261 3D printed stainless steel dental caps, 260 3D printing of lung and chest wall tumors, 262 3D reconstruction of aortic aneurysm, 263 2D contrast-enhanced axial CT image of abdominal aortic aneurysm, 263 vascular surgery, 261 3D TEE, see Three-dimensional transesophageal echocardiography Three-dimensional transesophageal echocardiography (3D TEE), 207, 211 atrial septal defect closure device, 210 calcified aortic valve, 210 concatenation, 209 evolution of, 208–209 future directions, 210–211 inflated mitral valvuloplasty balloon, 210 in minimally invasive surgery and interventional cardiac procedures, 209

MitraClip in position, 210 multiplanar reformatting, 209 obtaining 3D TEE image, 209 of patient with prolapsed segment of posterior mitral leaflet, 210 for percutaneous closure of atrial and ventricular septal defects, 209–210 for percutaneous coronary sinus catheter placement, 210 for percutaneous valve interventions, 210 principles of TEE, 207–208 principles of ultrasound imaging, 208 tip of 3D TEE matrix probe, 208 3D acquisition of mitral annulus, 209 360°Fundo, 274 calibrating suture length, 275 creating fundoplication, 274, 275 length of measuring suture, 275, 276 path of first suture, 279 path of second suture, 279 regression equation, 275 technique, 276 traction suture, 274 trocar placement, 276–280 Thrombolysis and pharmacomechanical thrombolysis, 699 Through the scope (TTS), 48; see also Esophageal stenting Through-the-scope clips (TTSCS), 75 Through the scope stents (TTS stents), 95; see also Lower endoscopy therapeutic dilation and stenting TIF, see Transoral Incisionless Fundoplication Ti-Knot device, 287; see also External magnetic antireflux ring placement Tissue sealants, 77 TLESR, see Transient lower esophageal sphincter relaxation TME, see Total mesorectal excision TOETVA, see Transoral endoscopic thyroidectomy vestibular approach TOF, see Train-of-four Total body weight (TBW), 69 Totally extraperitoneal approach (TEP approach), 569, 577, 602 Totally laparoscopic right hepatectomy, 435 anesthetic management, 435 conflicts of interest, 439 control of hepatic outflow, 437 economic outcomes, 438–439 French position, 436 hemostasis, drain and specimen extraction, 437–438 hilar dissection and control of hepatic inflow, 436–437 learning curve, 438 liver mobilization, 436 parenchymal dissection, 437 patient positioning, 436 postoperative complications, 438 principles of laparoscopic hepatectomy, 436

specific instrumentation, 436 technical description of, 436 three-dimensional visualization, 438 trocar placement, 436 ultrasound, 436 Total mesorectal excision (TME), 98, 529, 544 colon/rectum resection reporting guideline, 532 instruments, 530 modified lithotomy position, 529, 530 port placement, 530 positioning, 529–530 procedural steps, 530–532 response to neoadjuvant chemoradiation, 532 specimen retrieved during proctectomy, 531 Toupet fundoplication, 282–283; see also Laparoscopic partial fundoplication Traction suture (TS), 277 Train-of-four (TOF), 234 Transabdominal preperitoneal approach (TAPP approach), 577, 602 Transabdominal preperitoneal inguinal hernia repair, 577; see also Hernia repair applications for TAPP approach, 579 closure of peritoneal flap, 579 complications after TAPP approach, 580 discussion, 580–581 incarcerated and strangulated hernias, 579 inguinodynia, 580 internal inguinal ring, 578 mesh placement, 578 patients with previous Pfannenstiel incisional hernias, 580 port-site hernias, 580 recurrent hernias, 580 scrotal hernias and large hernia sacs, 579 seroma formation in large defects, 580 small bowel obstruction, 580 technical aspects, 577–579 trocar placement, 577 urinary retention, 580 visceral injuries, 580 Transanal endoscopic applicator (TEA), 174, 574; see also Transanal Hybrid colon resection Transanal endoscopic microsurgery (TEM), 98, 103, 167, 576; see also Transanal Hybrid colon resection close-up of curved forceps, 100 close-up of straight forceps, 100 equipment, 98–99 finalized assembly of TEM stereoscope, 99 handheld TEM instruments, 100 indications, 98 insertion of TEM rectoscope, 99 lesion dissection, 101 operative technique, 99–100 outcomes, 102 placement of marking suture, 101 ports used for suction, 99

746 Index Transanal endoscopic microsurgery (TEM) (Continued) prone position, 100 rectal cancer management algorithm, 98 rectoscope, 99 surgical team setup, 101 technical variations, 100–102 Transanal endoscopic NOTES proctectomy, 176 Transanal endoscopic operation (TEO), 103, 167 Transanal endoscopic proctectomy for benign disease, 171 Transanal endoscopic surgery (TES), 165 Transanal excision (TAE), 103 Transanal Hybrid colon resection, 573, 576 patient selection and preparation, 573–574 positioning anvil, 575 principle of NOTES, 573 stapling and division of colon via transanal trocar, 575 technical concept, 573 transanal endoscopic applicators, 574 transanal Hybrid NOTES procedures, 576 transanal operative technique, 574–575 trocars used for ta-CR technique, 575 Transanal Hybrid NOTES procedures, 576; see also Transanal Hybrid colon resection Transanal minimally invasive surgery (TAMIS), 103, 168 access platforms, 107 available platforms, 107 comparison with existing techniques, 108 complications, 107–108 functional/anorectal physiology, 108 hybrid technique, 104 indications and contraindications, 103–105 irrigation of excision bed, 106, 107 oncological follow-up, 108 operative technique, 105–107 positioning of patient in lithotomy position, 106 preoperative workup, 105 rectal wall closure, 107 Transanal NOTES, 162, 165–167; see also Natural orifice surgery Transanal NOTES colectomy, 167–168; see also Natural orifice surgery indications for, 171 limitations, 176 platforms and equipment for, 174 taTME for rectal cancer, 172–173 transanal endoscopic proctectomy for benign disease, 171 transanal NOTES completion proctectomy and APR, 174–175 transanal NOTES LAR, 175 transanal NOTES proctectomy, 174 transanal NOTES restorative proctocolectomy, 175–176

Transanal NOTES experience, 165; see also Natural orifice surgery transanal NOSE, 165–167 transanal NOTES colectomy, 167–168 Transanal NOTES LAR, 175; see also Transanal NOTES colectomy Transanal specimen extraction studies, 166 Transanal total mesorectal excision (TaTME), 105, 168; see also Natural orifice surgery dissection steps during, 170 hybrid transanal TME, 168–170 pure taTME, 170–171 for rectal cancer, 172–173 TME specimen, 171 for tumor of mid-rectum, 169 Trans-Atlantic Inter-Society Consensus (TASC), 659 Transaxillary thyroidectomy, 498; see also Endoscopic/remote-access endocrine surgery docking robotic instruments, 499 incision site and myocutaneous flap skin drawing, 498 indication and preparation, 498 myocutaneous flap creation, 498–499 myocutaneous flap retraction, 499 patient positioning, 498 positioning with neck extension and ipsilateral arm forward flexion, 498 postoperative management and outcome, 499 robotic docking for camera trocar and instrument arms, 499 thyroid operation, 499 Transesophageal echocardiography (TEE), 207 principles of, 207–208 Transient lower esophageal sphincter relaxation (TLESR), 270 Transient renal insufficiency (TRI), 661 Transillumination technique for gastrotomy localization, 142; see also Percutaneous endoscopic gastrostomy Transinguinal or transabdominal diagnostic laparoscopy, 684; see also Laparoscopic hernia repair in children Transoral endoscopic thyroidectomy vestibular approach (TOETVA), 498, 501; see also Endoscopic/ remote-access endocrine surgery flap creation and techniques, 501–502 incision sites for, 502 indication and preparation, 501 patient positioning, 501 postoperative management and outcome, 502 procedure, 501 thyroid or parathyroid operation, 502 top-down dissection of thyroid gland, 502 Transoral fundoplication (TF), 56

evidence, 57–58 technique and indications, 56–57 Transoral gastric volume reduction (TGVR), 68 Transoral Incisionless Fundoplication (TIF), 56 Transpyloric Shuttle, 69; see also Endoscopic bariatric therapies Transvaginal (TV), 134; see also Transvaginal NOTES access Transvaginal appendectomy, 157 closure, 159 closure of transvaginal incision, 160 history of, 157 hybrid flexible endoscopic approach, 159 hybrid rigid laparoscopic approach, 159 hybrid transvaginal appendectomy, 159 hybrid vs. pure transvaginal approach, 160 indications and contraindications, 157 laparoscopic vs. endoscopic, 160 operative approaches, 158 outcomes, 159–160 positioning, 157–158 pure flexible endoscopic approach, 158 pure rigid laparoscopic approach, 158 pure transvaginal appendectomy, 158 transvaginal vs. conventional laparoscopic appendectomy, 160 Transvaginal cholecystectomy (TVC), 154 additional introducer sheath inserted along initial port, 155 bladed trocar insertion technique, 155 closure, 155–156 colpotomy, 154–155 contraindications, 154 endograb device, 155 initial abdominal access, 154 intraoperative troubleshooting, 156 outcomes, 156 patient positioning and operative preparation, 154 patient selection, 154 postoperative care, 156 specimen extraction, 155 surgical dissection, 155 testing, 154 Transvaginal colectomy experience, 162–165; see also Natural orifice surgery transanal NOSE, 165–167 transanal NOTES colectomy, 167–168 transanal specimen extraction studies, 166 transvaginal NOSE and assistance, 164 transvaginal NOTES colectomy series, 163 transvaginal NOTES sigmoid colectomy, 164 Transvaginal culdoscopy, 134 Transvaginal NOTES access, 134 access techniques, 135–136 antibiotic prophylaxis, 135 closuretechniques, 136 complications, 137–138 history, 134 indications/contraindications, 134–135

Index 747 insufflation, 136 patient positioning, 135 perioperativeconsiderations, 135 ports and port systems used in, 137 postoperativeconsiderations, 135 potential complications related to, 137 training and credentialing, 138 Triangle of Safety, 136 TV culdoscopy, 134 TV running closure of pure TV appendectomy, 137 vaginal access ports, 136 vaginal preparation, 135 V-NOTES simulator at NOSCAR meeting, 138 Transvascular biopsy, 699 Transversus abdominis (TA), 589; see also Components separation method Transversus abdominis plane (TAP), 9, 235, 597 Transversus abdominis release (TAR), 588, 600, 609; see also Components separation method Traumatic abdominal wall hernias, 684 TRI, see Transient renal insufficiency Triangle of Safety, 136 Trocar access, 238; see also Access in minimally invasive surgery Tru-Cut biopsy (TCB), 341 TS, see Traction suture TSMBs, see Targeted stretching microbreaks TTS, see Through the scope TTSCS, see Through-the-scope clips TTS stents, see Through the scope stents TULP trial, 593 Tumor resection, 504; see also Pancreatic neuroendocrine tumors TV, see Transvaginal TVC, see Transvaginal cholecystectomy 20–10–5 rule, 460; see also Robotic liver resection Überorgan, 331 UC, see Ulcerative colitis UGI, see Upper gastrointestine UGIB, see Upper gastrointestinal bleeding UGI tract, see Upper gastrointestinal tract UKA, see Unicompartmental knee arthroplasty Ulcerative colitis (UC), 533 indications for surgery, 533 J-pouch creation, 534–535 laparoscopic proctocolectomy, 533 mobilization and resection of colon, 533–534 preoperative preparation and port placement, 533 proximal mobilization, 534 rectovaginal cuff, 534 scoring of rectosigmoid mesentery, 534 short rectum, 535 Ultrasonic devices, 228–229

Ultrasonic energy, 228–229 Ultrasound (US), 39, 253, 446, 517, 694, 701; see also Surgery in radiology suite imaging, 208 transducer, 207 waves, 207 Ultraviolet (UV), 258 Unicompartmental knee arthroplasty (UKA), 717 Upper endoscopy, 38 Upper gastrointestinal bleeding (UGIB), 80, 333 acute variceal hemorrhage, 80 argon plasma coagulation, 83 band ligation, 83 bipolar electrocautery, 82 causes of, 81 endoclips, 82–83 endoscopic technique, 81 epinephrine, 81–82 factors of risk scores, 81 Forrest classification of peptic ulcers, 81 management, 80–81 Upper gastrointestinal endoscopy, 37, 130 Upper gastrointestinal tract (UGI tract), 39 endoscopic full-thickness resection, 62–63 endoscopic mucosal resection, 61 endoscopic mucosal vs. submucosal dissection, 62 endoscopic submucosal dissection, 62 evaluation of subepithelial lesions of, 39 hybrid endoscopic-laparoscopic fullthickness resection, 63, 65–66 role for endoscopic resection in, 60 Upper gastrointestine (UGI), 687 Urethral injury, 176 US, see Ultrasound U.S. Food and Drug Administration (FDA), 55, 67, 400, 539, 557, 627, 716 UV, see Ultraviolet Validity, 184; see also Objective metrics in simulation VARD, see Video-assisted retroperitoneal debridement Vascular anomalies, 655 VATS, see Video-assisted thoracic surgery VBG, see Vertical banded gastroplasty VBLaST, see Virtual basic laparoscopic skill trainer Vena cava filter, 700 Venous thromboembolism (VTE), 360, 411 Ventral hernia, 588, 596, 600, 608; see also Components separation method; Hernia repair; Laparoscopic incisional and ventral hernia repair; Robotic ventral hernia repair Ventral incisional hernia repair, 582; see also Components separation method; Hernia repair Veress needle technique (VN technique), 239; see also Access in minimally invasive surgery

Vertebroplasty, 700 Vertical banded gastroplasty (VBG), 363, 392; see also Laparoscopic adjustable gastric banding; Laparoscopic reoperative bariatric surgery Vessel sealer, 628; see also Laparoscopic robotics VEST, see Virtual Electrosurgical Skill Trainer Vicryl meshes, 78 Video-assisted retroperitoneal debridement (VARD), 121, 670 anesthesia, 671 entrance of finger into WOPN cavity next to drain, 672 indications, 670 of infected pancreatic necrosis, 673 initial dissection under direct vision, 673 landmarks identification prior to draping, 672 operative preparation, 672 patient positioning, 671 PCD and, 674 percutaneous drain, 671 position, 671–672 postoperative care, 673 postoperative lavage system, 673 preoperative preparation, 670–671 procedure, 672–673 Video-assisted thoracic surgery (VATS), 634, 639; see also Thoracoscopic surgery resection of neurogenic tumors, 635–636 sympathectomy, 636 Video-assisted thoracic surgery lobectomy, 639 dissection of pulmonary artery branches to right upper lobe, 641 division of fissures, 641 division of right upper lobe bronchus, 642 future directions, 643 hilar dissection, 641 indications, 639–640 left upper lobectomy, 642 lower lobectomies, 642 lymph node dissection, 643 operating room setup, 640 port placement, 640–641 port placement for, 640 positioning and anesthesia, 640 principles, 640 right middle lobectomy, 642 right upper lobectomy, 641–642 specific lobes, 641 surgical technique, 640 Video fluoroscopic swallow study, 267; see also Esophageal function testing Video trainers (VTs), 188 Virtual Airway Skill Trainer, 190 Virtual basic laparoscopic skill trainer (VBLaST), 189 Virtual colonography, 91; see also Colonoscopy, diagnostic

748 Index Virtual Electrosurgical Skill Trainer (VEST), 190 Virtual reality (VR), 188, 703; see also Augmented reality Virtual reality simulation (VR simulation), 188; see also Minimally invasive surgery immersive simulation environment for operating room fire, 190 for laparoscopic cholecystectomy, 196 Rasmussen’s SRK framework and, 189–190 technology, 190–191 VBLaST, 189 VR simulators, 189–190 Virtual simulators, 213; see also Pre-event warm-up VN technique, see Veress needle technique VR, see Virtual reality

VR RENDER, 703; see also Augmented reality VR simulation, see Virtual reality simulation VTE, see Venous thromboembolism VTs, see Video trainers Walled-off necrosis (WON), 118; see also Symptomatic walled-off necrosis Walled-off pancreatic necrosis (WOPN), 670 Warshaw procedure, 506 Weight regain; see also Laparoscopic reoperative bariatric surgery adjustable gastric banding, 389–390 endoscopic treatment of, 390 indications of surgical treatment for, 388 insufficient weight loss, 387 management of, 388 nonoperative treatments, 387–388 procedures, 390 risk factors for, 387

Roux-en-Y gastric bypass, 388–389 sleeve gastrectomy, 390 WHO, see World Health Organization WON, see Walled-off necrosis WOPN, see Walled-off pancreatic necrosis World Health Organization (WHO), 67, 203, 504 Worldwide distribution of surgical procedures, 711 XMR (combined X-ray and MR imaging), 701; see also Surgery in radiology suite Zenker diverticulum, 316; see also Esophageal diverticula ZEUS Robotic Surgical System, 716, 717; see also Robotics Z line, 33