Publications by authors named "Morris Franklin"

33 Publications

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

Int J Colorectal Dis 2017 Oct 14;32(10):1447-1451. Epub 2017 Jul 14.

Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Purpose: Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy.

Methods: A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay.

Results: There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%).

Conclusion: Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00384-017-2865-xDOI Listing
October 2017

Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres.

J Minim Access Surg 2017 Oct-Dec;13(4):269-272

Escuela Nacional de Medicina (National School of Medicine), Tecnologico de Monterrey (Monterrey Tech), Monterrey; Escuela de Ingenieria (Engineering School), Tecnologico de Monterrey (Monterrey tech), Monterrey, Nuevo Leon, Mexico.

Background: Endoscopy has developed rapidly, generating new challenges. Today, there are several procedures done endoscopically with very good results. In the past, the assisted laparoscopic colon polypectomy has been described, reducing the morbidity of a bigger procedure. Nonetheless, little has been said about the use of hybrid surgery in the management of gastric or duodenal polyps.

Objectives: Evaluating the safety and efficacy of the assisted laparoscopic gastric endoscopic polypectomy.

Patients And Methods: A retrospective review of the database at our two centres was performed from 1996 to 2014. Thirteen patients were found in whom an assisted laparoscopic gastric or duodenal endoscopic tumour resection was performed.

Results: Thirteen patients, eight males and five females, with a median age of 61 years and average body mass index of 29.3. The procedure was done effectively and no need for further procedures was required for any patient. No complications were reported in the early post-operative period.

Conclusions: The study shows that assisted laparoscopic gastric endoscopic polypectomy is a feasible and safe procedure that can be used for the management of giant polyps, which cannot be resected with the classical endoscopic polypectomy reducing the morbidity and complications associated with larger procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/jmas.JMAS_15_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607793PMC
July 2017

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

Ann Surg 2013 Sep;258(3):440-9

*Indiana University School of Medicine, Indianapolis, IN †Viginia Mason Medical Center, Seattle, WA ‡Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA §Methodist Dallas Medical Center, Dallas, TX ‖Oregon Health Science University, Oregon Clinic, Portland, Oregon, OR ¶Swedish Medical Center, Seattle, WA **Cleveland Clinic Florida, Florida Atlantic University College of Medicine, Westin, Florida, FL ††University of Miami, Miami, FL ‡‡Florida Hospital, Tampa, FL §§Washington University School of Medicine, St Louis, Missouri, MO ‖‖Texas Endosurgery Institute, San Antonio, TX ¶¶St Vincent's Hospital, Indianapolis, IN ***University of Virginia, Charlottesville, VA; and †††University of Michigan, Ann Arbour, MI.

Objective: To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America.

Methods: A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains.

Results: There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0b013e3182a191caDOI Listing
September 2013

Integration of transanal specimen extraction into laparoscopic anterior resection with total mesorectal excision for rectal cancer: a consecutive series of 179 patients.

Surg Endosc 2013 Jan 26;27(1):127-32. Epub 2012 Jul 26.

The Texas Endosurgery Institute, San Antonio, TX 78222, USA.

Background And Objectives: This prospective study focused on patients with rectal cancer who underwent transanal specimen extraction after laparoscopic anterior resection with total mesorectal excision and specifically aims to investigate whether the transanal approach can be accepted as a safe and effective method for extracting the malignant specimen from the peritoneal cavity.

Patients And Methods: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal malignancy with various tumor-node-metastasis (TNM) classifications from April 1991 to May 2011 at the Texas Endosurgery Institute was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of size of the pathology and distance of rectal lesions from the anal verge.

Results: 179 anterior resections were completed laparoscopically with intracorporeal anastomosis and transanal specimen extraction. The operating time for the entire procedures including resection, anastomosis, and specimen extraction was 170.9 ± 51.2 min, blood loss during the procedures was 86.4 ± 37.7 ml, and distance of the lower edge of the lesion from the anal verge was measured to be 11.3 ± 7.3 cm. Postoperatively, three patients developed anastomotic leakage with a leak rate of 1.7%, and the overall major complication rate after the procedures was 5.0%. Length of hospital stay was 6.9 ± 2.8 days. Two-year follow-up showed development of anal stenosis in three patients (2.0%) and erectile dysfunction in one patient (0.36%) after surgery. Finally, 9 out of 179 patients who underwent laparoscopic anterior resection with transanal specimen extraction were confirmed to have cancer recurrence, with 2-year local recurrence rate of 5.0%.

Conclusions: Transanal specimen extraction in laparoscopic rectal cancer resection is a safe and effective approach with comparable local cancer recurrence rate and postoperative complication rates, suggesting it can be integrated into laparoscopic anterior resection for rectal cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-012-2440-zDOI Listing
January 2013

Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes.

JSLS 2011 Oct-Dec;15(4):475-9

Texas Endosurgery Institute, San Antonio, TX, USA.

Introduction: Loop ileostomy reduces the morbidity associated with pelvic sepsis. However, its reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure.

Methods: We conducted a retrospective chart review of subjects undergoing laparoscopic-assisted loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed.

Results: There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7), and reoperation rate was 12.5% (n=3). Only 1 major complication occurred, an anastomotic dehiscence.

Conclusion: A thorough, well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate and surgical time are comparable to those of the open technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4293/108680811X13176785203950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340955PMC
August 2012

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann's procedure.

Surg Endosc 2012 Oct 28;26(10):2835-42. Epub 2012 Apr 28.

The Texas Endosurgery Institute, 4242 E. Southcross Blvd., Suite 1, San Antonio, TX 78222, USA.

Background: This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

Methods: A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study.

Results: A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %.

Conclusions: Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-012-2255-yDOI Listing
October 2012

Negative pressure therapy: a viable option for general surgical management of the open abdomen.

Surg Innov 2012 Dec 5;19(4):353-63. Epub 2012 Jan 5.

Texas Endosurgery Institute, San Antonio, TX 78222, USA.

Background: Management of the open abdomen (OA) is challenging for surgeons and requires experienced medical teamwork. The need for improvements in temporary abdominal closure methods has led to the development of a negative-pressure therapy (NPT; ABThera OA NPT, KCI USA, Inc, San Antonio, TX).

Method: The authors present a 19-patient case series documenting their use of NPT for OA management in nontraumatic surgery. All received NPT until the fascia was considered ready for closure.

Results: Of 19 patients, 17 (89.5%) achieved fascial closure with a Kaplan-Meier (KM) median time to closure of 6 days. Mean hospital and intensive care unit stays were 32.1 and 26.6 days, respectively. During their hospitalization, 5 patients (26.3%) died, with a KM median time to mortality of 53 days.

Conclusion: These findings demonstrate effective use of NPT for managing the OA in critically ill patients, and this has led the authors to use it in their general surgery practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1553350611429693DOI Listing
December 2012

Laparoscopic appendectomy: vascular control of the appendicular artery using monopolar cauterization versus clips.

J Laparoendosc Adv Surg Tech A 2012 Mar 6;22(2):165-7. Epub 2011 Dec 6.

Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico.

Introduction: Laparoscopic appendectomy is now the standard of treatment for acute appendicitis in medical centers where advanced minimally invasive surgery is performed, and it has become the standard of care in our institution. The techniques for laparoscopic appendectomy are widely described in surgical textbooks, but the vascular control of the appendicular artery is diverse. In this article, we compare the benefits and possible complications of different techniques to obtain vascular control.

Subjects And Methods: This is a retrospective study of prospectively collected data including all cases of laparoscopic appendectomy from September 1990 to August 2009. Here we describe the different methods used, and we present a large series of 729 cases of laparoscopic appendectomy. In the majority of the cases the diagnosis was acute appendicitis followed by laparoscopic appendectomy. In only 124 cases was an incidental appendectomy performed associated with another laparoscopic procedure.

Results: In 350 cases (48%) monopolar cauterization was used to obtain vascular control of the appendicular artery. In the other 379 cases the artery was either clipped or stapled (52%). There were no postoperative complications reported. There was no difference in patient outcome with either approach to obtain adequate vascular control.

Conclusions: The vascular control of the appendicular artery obtained with monopolar cautery is a safe, fast, and economic approach easily done during a laparoscopic or needlescopic appendectomy with no increased risks or complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2010.0312DOI Listing
March 2012

Needlescopic cholecystectomy.

Surg Technol Int 2010 Oct;20:109-13

Texas Endosurgery Institute, San Antonio, TX, USA.

Minimally invasive techniques have revolutionized the art of surgical practice. The laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. In an effort to further enhance the advantages of laparoscopic surgery even less-invasive methods have been attempted, including smaller and fewer incisions. The objective of this study was to describe our results with over 15 years of needlescopic cholecystectomies. At the Texas Endosurgery Institute, 434 operations were done by a single surgeon from 1995 to 2010. Eighty-six percent of subjects were female, and the average age of all subjects was 41.9 years (range 14-82). The average operating time was 59.3 minutes (range 30-200). The 200-minute operation required laparoscopic CBD exploration, accounting for the extended time. Average estimated intraoperative blood loss (EBL) was <15 cc (range 0-50 cc). Two percent of cases required conversion to standard 5-mm cholecystectomy and were completed without incident. All patients are followed up at two weeks and then at six months. Since 1995, only one patient presented with a hernia at the umbilical site. Otherwise, no wound, bile duct, bile leak, bleeding, or thermal injury complications have been identified.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2010

Clinical results using bioabsorbable staple-line reinforcement for circular stapler in colorectal surgery: a multicenter study.

J Laparoendosc Adv Surg Tech A 2010 May;20(4):323-7

Texas Endosurgery Institute , San Antonio, Texas 78222, USA.

Introduction: Anastomotic leakage is a serious postoperative complication of open and laparoscopic colorectal surgery, very often associated with higher morbidity and mortality. Despite proper patient selection and surgical technique, anastomotic leakage cannot be avoided. The use of a synthetic, bioabsorbable staple-line reinforcement material for the circular stapler may help reduce its prevalence.

Methods: From May to December of 2006, 14 doctors, from 18 hospitals in the United States, performed 117 laparoscopic and open colorectal procedures, in which circular bioabsorbable Seamguard (CBSG; W.L. Gore and Associates, Elkton, MD) was used.

Results: Eighty-three patients underwent laparoscopic surgery (70.0%) and 34 open surgery (30%). The procedures included low anterior resection in 49 patients (42%), sigmoidectomy in 46 patients (39.5%), left hemicolectomy in 12 patients (10%), and total colectomy in 10 patients (8.5%). Sixty-four patients had benign disease and 36% malignant disease. Intraoperative anastomotic leakage tests identified 4 patients with leakage (3.4%). All 4 patients had a very low anastomosis (1, 3, 4, and 6 cm, respectively, from the anal verge). Two of the leaks resolved without further intervention. A fecal diversion procedure was performed in the other 2 patients, including 1 patient with rectal bleeding, requiring a transfusion. No clinical complications related to use of CBSG were reported.

Conclusions: The use of Seamguard in colorectal open and laparoscopic surgery may result in a lower incidence of anastomotic leakage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2009.0201DOI Listing
May 2010

Laparoscopic-assisted endoluminal hybrid surgery: a stepping stone to NOTES.

Surg Laparosc Endosc Percutan Tech 2009 Dec;19(6):474-8

Texas Endosurgery Institute, San Antonio, Texas, USA.

Background: Natural orifice transluminal endoscopic surgery (NOTES) is the anticipated progression of minimally invasive surgery. As it approaches, surgeons will need to develop the fundamental skills and spatial orientation needed to perform safely in this new field. The Natural Orifice Surgery Consortium for Assessment and Research has established several fundamental challenges to the safe introduction of NOTES. Our institutional experience with laparoscopic-assisted endoluminal surgery is reviewed to display the techniques and efficacy of procedures that address many of these challenges and may provide a safe transition for the general surgeon to NOTES or as an alternative to pure NOTES.

Methods: A retrospective review of all laparoscopic-assisted endoluminal surgeries from 1991 to 2007 was performed. Patients had been referred to the institution and selected after either unsuccessful attempts from traditional endoscopic resection of pathology by a gastroenterologist or being deemed an unfavorable candidate for traditional endoscopic resection. All procedures involved establishment of pneumoperitoneum, placement of trochar ports under laparoscopic visualization, balloon ports in gastric cases combined with endoscopy, intraluminal insufflation, coordinated resection of intraluminal pathology using both the endoscopic and laparoscopic instruments, and closure of the intraluminal port sites with intracorporeal suturing.

Results: A total of 175 procedures were performed from 1991 to 2007 using these techniques. These procedures varied and included laparoscopic monitored colonoscopic polypectomy, resection of gastric polyps, intraluminal cystgastrostomy, gastric ulcer resection, and foreign body removal. The average age was 55 years (range 38 to 75 y), length of operation 95 minutes (range 60 to 137 min), hospital stay 3.5 days, and 5 complications (2.8%). Of the total procedures, 18 (10.2%) patients were found to have malignancy on frozen section and preceded with a formal resection. There are no cancer recurrences to date with a mean follow up of 74 months (6 to 196 mo).

Conclusions: Our institutional experience with these procedures seems to be a natural transition to developing skills for NOTES procedures and displays a safe and effective approach to a wide range of intraluminal pathology. The general surgeon in practice can use this union of laparoscopy and endoscopy using current instruments and technology for safe transition into the emerging field of NOTES, or even as an alternative to pure NOTES. Mastery of intraoperative endoscopy and intraluminal surgery will be essential to this transition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLE.0b013e3181bd9087DOI Listing
December 2009

Laparoscopic monitored colonoscopic polypectomy: long-term follow-up.

World J Surg 2009 Jun;33(6):1306-9

Texas Endosurgery Institute, 4242 East Southcross Boulevard, Suite 1, San Antonio, TX 78222, USA.

Background: Colonoscopy is widely used to remove benign polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their size, broad base, or difficult location (impossible to see the polyp's base, polyps behind mucosal folds or in tortuous colonic segments). The aim of the study was to evaluate the long-term follow-up and oncologic safety of laparoscopically monitored colonoscopic polypectomy (LMCP).

Methods: From May 1990 to January 2008, all the patients undergoing LMCP were analyzed and prospectively followed with colonoscopic studies at 6 months, 1 year, and every year thereafter.

Results: A total of 209 polyps were removed in 160 patients: 82 men (51%) and 78 women (49%). The mean age was 74.7 years (range 46-99 years). During a mean follow-up of 63.37 months (range 6-196 months) and median follow-up of 65 months, there has been no recurrence.

Conclusions: Long-term follow-up demonstrated that a combined endoscopic-laparoscopic approach is safe and effective. Malignant lesions identified during LMCP can be treated laparoscopically during the same operation, avoiding the need of a second procedure, with good long-term oncologic outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-009-9967-8DOI Listing
June 2009

The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up.

Surg Endosc 2008 Sep 2;22(9):1941-6. Epub 2008 Jul 2.

Texas Endosurgery Institute, 4242 East Southcross Boulevard, Suite 1, San Antonio, TX 78222, USA.

Introduction: The treatment of hernias remains controversial, with multiple prosthetic meshes being exalted for a variety of their characteristics. In the event of incarcerated/strangulated hernias and other potentially contaminated fields the placement of prosthetic material remains controversial because of increased risk of recurrence and infection. Porcine small intestinal submucosa mesh (Surgisis, Cook Bloomington, IN) has been demonstrated safe and feasible in laparoscopic hernia repairs in this scenario. We present our 5-year experience, with placement of Surgisis mesh in potentially or grossly contaminated fields.

Methods: From May 2000 to October 2006, 116 patients (52 male, 64 female) with 133 procedures were performed. Placement of Surgisis mesh for either incisional, umbilical, inguinal, femoral or parastomal hernia repairs in an infected or potentially contaminated setting were achieved, and studied in a prospective fashion.

Results: All procedures were laparoscopically with two techniques [intraperitoneal onlay mesh (IPOM) and two-layered "sandwich" repair]. Mean follow-up was 52 +/- 20.9 months. Thirty-nine cases were in an infected field and the rest in a potentially contaminated field. Ninety-one procedures were performed concurrently with a contaminated procedure. Twenty-five presented as intestinal obstruction, 16 strangulated hernias, and 17 required small bowel resection; 29 were inguinal hernias, 57 incisional, and 38 umbilical. In 13 patients more than two different hernias were repaired. Eighty-five percent 5-year follow-up was achieved, during which we identified 7 recurrences, 11 seromas (all resolved), and 10 patients reporting mild pain. Six second looks were performed and in all cases except one the mesh was found to be totally integrated into the tissue with strong scar tissue corroborated macro- and microscopically.

Conclusions: In our experience the use of small intestine submucosa mesh in contaminated or potentially contaminated fields is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-008-0005-yDOI Listing
September 2008

Transvaginal extraction of the specimen after total laparoscopic right hemicolectomy with intracorporeal anastomosis.

Surg Laparosc Endosc Percutan Tech 2008 Jun;18(3):294-8

Texas Endosurgery Institute, San Antonio, TX, USA.

Laparoscopic surgery for colonic disease has experienced an increased utilization by surgeons owing to decreased morbidity, less pain, earlier ambulation, earlier bowel function, fewer complications, decreased narcotic use, and improved cosmesis compared with open colon surgery. Current techniques require an abdominal incision, albeit smaller than an open laparotomy incision, which increases pain and complication rates such as infection, hernia development, and a less pleasing cosmetic result. The ability to perform a totally intracorporeal anastomosis will be an initial step to allow surgeons to perform natural orifice colon surgery in the future. One benefit of the intracorporeal anastomosis technique is that the only incision needed is for trocar placement. By combining the 2 techniques of totally intracorporeal anastomosis and transvaginal extraction of the specimen, surgeons will have the option to perform a totally laparoscopic colectomy on female patients. This case study describes a patient with a transvaginal route of specimen extraction after an oncologic laparoscopic right colon resection with intracorporeal anastomosis. It is the intent to further advance the technical options in the field of natural orifice surgery with the description of this technique. After completing a totally laparoscopic right colectomy with intracorporeal anastomosis and transvaginal extraction, an excellent postoperative recovery was demonstrated and has shown future potential for natural orifice surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLE.0b013e3181772d8bDOI Listing
June 2008

Laparoscopic intraluminal surgery for gastrointestinal malignancies.

World J Surg 2008 Aug;32(8):1709-13

Texas Endosurgery Institute, 4242 East Southcross Boulevard, Suite 1, San Antonio, TX 78222, USA.

Introduction: Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery.

Materials And Methods: The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing.

Results: From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal.

Conclusion: Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-008-9607-8DOI Listing
August 2008

Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis.

World J Surg 2008 Jul;32(7):1507-11

Texas Endosurgery Institute, 4242 East Southcross, Suite 1, San Antonio, TX 78222, USA.

Background: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary.

Method And Materials: Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed.

Results: Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention.

Conclusion: Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-007-9463-yDOI Listing
July 2008

[Laparoscopic subtotal colectomy. Results from the Texas Endosurgery Institute].

Cir Cir 2007 Nov-Dec;75(6):443-8

Escuela de Medicina, Telnológico de Monterrey, Monterrey, Nuevo Léon, Mexico.

Background: Laparoscopy is currently and progressively gaining acceptance for the management of colorectal disease. More bleeding and longer operating time were initially considered as contraindications to perform laparoscopic colon resections. Other obstacles were technical difficulties, the learning curve and the need for specialized instruments; however, improvements in surgical techniques and technological developments have allowed subtotal laparoscopic colectomy to be feasible.

Methods: This was a retrospective and descriptive study conducted from April 1992 to July 2006. Forty-four patients underwent laparoscopic subtotal colectomy at Texas Endosurgery Institute in San Antonio, TX. Measured variables to evaluate efficacy and safety were operating time, length of hospital stay, time to resume normal diet, conversion to open procedure, morbidity and mortality.

Results: Cancer, familial adenomatous polyposis and ulcerative colitis were the main surgical indications. The procedure was technically successful in 88% of patients. There were five conversions (11.3%). Mean operating time was 210 min. Morbidity and mortality rates were 29% and 2.2%, respectively. Mean length of hospital stay and time to resume normal diet were 11 and 4 days, respectively.

Conclusions: Laparoscopic subtotal colectomy in our institute may be considered as an effective and safe method in the management of colorectal disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2008

The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience.

Surg Laparosc Endosc Percutan Tech 2006 Dec;16(6):411-5

Texas Endosurgery Institute, San Antonio, TX 78222, USA.

Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLE.0b013e31802b68feDOI Listing
December 2006

[Laparoscopic splenectomy: Twelve-year experience in two private institutions].

Cir Cir 2006 Nov-Dec;74(6):443-7

Texas Endosurgery Institute, San Antonio, Texas, USA.

Background: In 1991, Delaitre et al. reported the first successful laparoscopic splenectomy. This procedure has become the best option in patients with hematological diseases and who require surgical treatment. The potential advantages of the laparoscopic approach over the conventional surgery are shorter length of hospital stay, shorter time to resume normal diet and decreased rates of morbidity and mortality.

Methods: From June 1993 to December 2004, 42 patients underwent laparoscopic splenectomy in our two surgical care centers: Texas Endosurgery Institute and Hospital San José-TEC de Monterrey. The measured variables to evaluate efficacy and safety were operating time, length of hospital stay, time to resume normal diet, conversion to open procedure, morbidity and mortality.

Results: Hematological diseases were the most common diagnosis. The procedure was technically successful in 95% of the patients. There were two conversions to open surgery. The mean operating time was 120 min. Mortality rate was 2.3%. The mean length of hospital stay and time to resume normal diet were 4 and 2 days, respectively.

Conclusions: We regard that our series contributes to supporting laparoscopic splenectomy as a safe and effective method, retaining some advantages of minimally invasive techniques.
View Article and Find Full Text PDF

Download full-text PDF

Source
July 2007

Intraluminal approach for resection of a gastric ulcer: a case report.

JSLS 2006 Jul-Sep;10(3):364-7

Texas Endosurgery Institute, San Antonio, Texas 78222, USA.

Laparoscopy, both diagnostic and therapeutic, has been used in the management of gastric pathology because of all the benefits of a minimally invasive procedure, such as faster recovery, shorter hospital stay, fewer wound complications, and other benefits. We report a case involving the resection of a gastric ulcer in a 71-year-old patient. Endoscopy revealed a nonhealing antral ulcer that was not acutely bleeding. With a combined endoscopic and laparoscopic approach, we successfully performed a wide resection by using 2-mm instruments. Laparoscopy was needed to orient the lesion so that a transgastric intraluminal resection could be performed with 2-mm instruments. This case illustrates the feasibility of using a combined endoscopic and laparoscopic technique to treat a lesion that would otherwise require a formal resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015700PMC
February 2007

Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience.

JSLS 2006 Apr-Jun;10(2):155-9

Texas Endosurgery Institute, San Antonio, Texas 78222, USA.

Background: Frequently, critically ill patients suffer from intraabdominal pathology, such as sepsis or ischemia, either as a cause of a critical illness or as a complication from another illness requiring an intensive care unit (ICU) admission. These complications are associated with high rates of morbidity and mortality (between 50% to 100%). The diagnosis of these problems can be difficult in these very ill patients because it may require transport of unstable patients to additional departments outside the ICU setting. One option in the diagnosis of these difficult patients is bedside laparoscopy, as it avoids patient transport, is very accurate, and maintains ICU monitoring.

Methods: From 1991 to 2003, 13 patients underwent bedside diagnostic laparoscopy in the ICU to diagnose intraabdominal pathology in critically ill patients. All the procedures were done at the bedside in the ICU with the patient under local anesthesia and intravenous sedation.

Results: Mean procedure time was 36 minutes (range, 17 to 55). Mean patient age was 75.5 years (range, 56 to 86). There were 8 males and 5 females. Forty-six percent of the patients were diagnosed with mesenteric necrosis and died within 48 hours with no further testing or procedures. One patient with massive fecal contamination died the same day. Thirty percent of patients had a normal intraabdominal examination; of these, 2 died of unrelated illnesses and 2 survived their nonabdominal illness. Fifteen percent were diagnosed with acute acalculous cholecystitis as a complication of their ICU illness, which resolved satisfactorily. No intraoperative complications occurred with the ICU procedure.

Conclusion: Bedside diagnostic laparoscopy in the ICU is feasible, safe, and accurate in the assessment of possible intraabdominal problems in properly selected, critically ill patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016143PMC
January 2007

Needlescopic cholecystectomy: lessons learned in 10 years of experience.

JSLS 2006 Jan-Mar;10(1):43-6

Texas Endosurgery Institute, San Antonio, Texas 78222, USA.

Objectives: Needlescopic cholecystectomy (NC) is a refinement of laparoscopic cholecystectomy (LC) using 2-mm instruments compared with the standard 5-mm and 10-mm ports. We review our experience with needlescopic cholecystectomy.

Methods: From 1994 to 2004, 303 patients underwent NC. All patients were operated on using 2-mm instruments and one 10-mm trocar for the laparoscope. The characteristics of patients, total operation time, complications, postoperative pain, and hospital course were documented.

Results: Patients' average age was 41.86 years; 262 were female and 41 were male. Mean BMI was 25.7. Mean length of surgery was 59.33 minutes. Intraoperative cholangiography was performed in all cases. Mean blood loss was 14.88 mL. One intraoperative complication occurred. Mean hospital stay was 22.68 hours. Postoperative pain was measured on a 0-10 pain scale; on day 0 it was 4.4 and on the first day it was 1.7. Analgesic doses required were 0 doses in 6.89%, 1 in 20.68%, 2 in 24.13%, 3 in 34.48%, 4 in 13.79%, and > 4 doses was not required. No postoperative complications occurred. At 3-month follow-up, patient satisfaction was 100%, and in 99% of patients scars were imperceptible.

Conclusions: NC is safe and feasible without increased operative risk, with better cosmetic results, less pain, and good acceptance among patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015680PMC
September 2006

Bringing order to the chaos: developing a matching process for minimally invasive and gastrointestinal postgraduate fellowships.

Ann Surg 2006 Apr;243(4):431-5

Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR 97210, USA.

Background: Since 1993, there has been an increase in the number of postgraduate fellowships in minimally invasive and gastrointestinal (GI) surgery; from 9 in 1993 to more than 80 in 2004. Early on, there was no supervision or accreditation of these fellowships, and they varied widely in content, structure, and quality. This was widely recognized as being a bad situation for fellow applicants and reflected poorly on the specialties of minimally invasive (MI) and GI surgery. In an effort to bring order to this chaotic situation, the Minimally Invasive Surgery Fellowship Council (MISFC) was founded in 1997.

Method: In 2003, the MISFC was incorporated with 77 founding member programs. The goal of the MISFC was to develop guidelines for high-quality fellowship training, to provide a forum for the directors of MI and GI fellowships to exchange ideas, formulate training curricula; to establish uniform application and selection dates; and to create an equitable computerized match system for applicants.

Results: In 2004, the MISFC has increased to 95 members representing 154 postgraduate fellowship positions. The majority of these positions are primarily laparoscopic in focus, but other aspects of GI surgery including bariatric, general GI, flexible endoscopy, and hepatopancreatobiliary are also represented. Uniform application and selection dates were agreed on in 2001; and in 2003, the Council established a computerized Match, administered by the National Resident Match Program, which was used for the 2004 fellowship selection. A total of 113 positions were open for the match. A total of 248 applicants formally applied to MISFC programs and 130 participated in the match. Ninety-nine positions matched on the December 10th match day, and the remaining 14 programs successfully filled on the following scramble day. Seventeen applicants did not match to a program. Post match polling of program directors and applicants documented a high degree of compliance, usability, and satisfaction with the process.

Conclusion: The MISFC has been successful at realizing its goals of bringing order to the past chaos of the MIS and GI fellowship situation. Its current iteration, the Fellowship Council, is in the process of introducing an accreditation process to further ensure the highest quality of postgraduate training in the fields of GI and endoscopic surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/01.sla.0000205217.45477.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448963PMC
April 2006

Laparoscopic-assisted rectal foreign body removal: report of a case.

Dis Colon Rectum 2005 Oct;48(10):1975-7

Texas Endosurgery Institute, San Antonio, Texas 78222, USA.

Purpose: Rectal foreign bodies are not an uncommon presentation to the emergency department. Frequently they can be removed in the department through the transanal approach. However, this often is not well tolerated by the patient or can force the foreign body more proximal. We present a case of a difficult rectal foreign body in an obese patient that was successfully removed transanally in the operating room with laparoscopic assistance.

Methods: Under general anesthesia, with the patient in Trendelenburg position, laparoscopy was used to push the rectal foreign body from above while it was removed transanally from below. This was performed with one 10-mm and two 5-mm incisions.

Results: The foreign body was successfully removed transanally with laparoscopic assistance, and the patient was discharged within 12 hours from the operation.

Conclusions: The laparoscopic approach to assist in rectal foreign body removal is a good treatment choice for difficult cases. It allows for easy removal, detection of rectal injury, and early discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10350-005-0117-6DOI Listing
October 2005

Laparoscopic right hemicolectomy for cancer: 11-year experience.

Rev Gastroenterol Mex 2004 Aug;69 Suppl 1:65-72

Texas Endosurgery Institute, San Antonio, Texas, USA.

Introduction: Laparoscopic surgery has emerged as the gold standard for many intra-abdominal procedures. Laparoscopic colon surgery is now entering its second decade of practice, and although there are many papers focusing on surgery of the distal colon, only a few have been published regarding right sided lesion approached totally laparoscopically.

Objective: Present data collected-in a prospective manner from a single institute over an eleven year period, focusing on laparoscopic right hemicolectomy for malignancy.

Methods: Patients elected for laparoscopic right hemicolectomy for colon cancer were analyzed prospectively. From May 1991 to May 2002, 98 patients underwent attempted laparoscopic right hemicolectomy for cancer, 44 male and 54 female, with a mean age of 70.6 years, emergent and non emergent cases were included Patients who underwent a diagnostic laparoscopy and those converted immediately to open procedure were excluded from this study.

Results: Ninety-two patients were included in the study, eighty-two of these had a totally intracorporeal anastomosis created, and ten had an extracorporeal anastomosis performed. The mean operative time for the intracorporeal group was 136 minutes, and for the extracorporeal group was 159 minutes. The average number of lymph nodes harvested was 10.8 and the final pathologic analysis showed 26 tumors stage I, 24 stage II, 31 stage III and 17 stage IV.

Conclusions: In experienced hands, laparoscopic colectomy can be performed safely and effectively for the treatment of both benign and malignant diseases of the right colon. This study reaffirms the contention that laparoscopic approach to colon cancer offers equivalent, or in some instances, greater oncologic safety when compared to the open technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
August 2004

Minimally invasive surgeons of Texas: a new concept in fellowship training.

Surg Innov 2004 Dec;11(4):273-5

Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX 77030, USA.

Minimally invasive fellowship training has seen phenomenal growth, with 94 organized fellowship programs in North America. Training experience is varied across programs owing to the differences in surgical practices. Many programs are often weighted to a specific field of advanced laparoscopic surgery, which can limit a fellow's clinical experience. Minimally Invasive Surgeons of Texas (MIST) is a combined organization of four independent private practice and academic MIS fellowships brought together for the common goal of improved fellowship training.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/155335060401100413DOI Listing
December 2004

Safety and efficacy of the use of bioabsorbable seamguard in colorectal surgery at the Texas endosurgery institute.

Surg Laparosc Endosc Percutan Tech 2005 Feb;15(1):9-13

Texas Endosurgery Institute, San Antonio, TX 78222, USA.

Bioabsorbable Seamguard (BSG) is a random-fiber web of polyglycolic acid/trimethylene carbonate. It is completely absorbed within 6 months or less due to its constitution of a bioabsorbable membrane with polyester braided suture. It has been used in obesity surgery and pulmonary surgery as staple-line reinforcement with good results. As such, we believe that BSG may be ideal to use in colorectal surgery as an aid during the healing process of an anastomosis and may help prevent anastomotic bleeding and staple-line disruption. From July 2003 through September 2004, 30 patients underwent placement of BSG for the following procedures: 12 right hemicolectomies, 7 low anterior resections, 5 sigmoid colectomies, 3 total colectomies, 2 partial resections, and 1 colostomy closure. Median follow-up was 7 months (range 1-13). There were no clinical leaks, no strictures, and no bleeding in our early postoperative follow-up period. The use of BSG as a staple-line reinforcer appears to be safe and may be useful in preventing anastomotic leakage, bleeding, and intraluminal stenosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/01/sle0000154019.83584.2eDOI Listing
February 2005

Acute cholecystitis and severe ischemic cardiac disease: is laparoscopy indicated?

JSLS 2004 Jan-Mar;8(1):61-4

Texas Endosurgery Institute, San Antonio, Texas 78222, USA.

Background And Objectives: Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication.

Methods: We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined.

Results: The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred.

Conclusions: Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015516PMC
June 2004