UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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102 Updated Topics in Minimally Invasive Abdominal Surgery causing less collateral tissue damage to within 1.5mm of the grasping jaws 77. Tissuelink (Aquamantys TM) works using transcollation (transforming collagen) technology sealing small biliary radicals, no charringand gives a bloodless operating field. This device delivers radiofrequency energy and saline simultaneously to achieve temperatures of 100 oC 78. The major disadvantage is that is can be slower and is more expensive. A cheap and effective time honoured method is bipolar diathermy giving good haemostasis on the liver parenchyma using a power of up to 80 watts. There have been concerns regarding Argon Beam Coagulation (ABC) and gas embolism 79 because of the stream of argon gas when the instrument is activated particularly on the liver bed when there are large open vessels. It is strongly advisable not to use ABC in this situation. There are no well designed controlled studies comparing different haemostatic techniques during LLR but these have been reviewed in detail elsewhere 80 81. Attention to detail regarding securing the bile ducts, identifying and ligating the medium and larger vascular structures are important in ensuring minimal blood loss, bile leaks and achieving an oncologically sound surgical procedure. To realize this, various techniques might be needed at different stages of the operation and therefore a working knowledge of all available techniques is useful. 7. Laparoscopic versus open liver resection - The evidence 7.1 The learning curve/patient benefit Most studies reporting laparoscopic liver resection report a learning curve. How long that learning curve is depends on the type of resection. Small resections less than 2cm require little additional skill to that needed for a complex laparoscopic cholecystectomy when positioned in the anterior segments V, IVb or left lateral segment on the proviso the surgeon has completed a recognised training program in HPB surgery. For more major resections e.g. right heptectomy, left hepatectomy the bar is significantly raised and should only be attempted by surgeons who regularly perform complex laparoscopic procedures. The main limiting factor is technical difficulty and access. Some would suggest that increasing size of tumour is not a limiting factor 60 but this is not what has been recommended in the Louisville guidelines 11. It cannot be denied that not everyone is suitable for a laparoscopic liver resection. Most centres suggest that up to 30% 68 29 are suitable although those centres performing more major resections regularly report higher rates up to 80% but also report higher rates with hand assisted techniques 82 4. One study suggests a learning curve of 60 cases is adequate to demonstrate quicker operating times and a lower conversion rate 83. Indeed during our 4 year experience the conversion rate has decreased from 14% to 3%. The commonest reason for conversion is usually technical or due to bleeding. Most studies doing detailed analysis report reduced operating time when different era’s are evaluated 68. For example, laparoscopic left lateral resection can become significantly quicker 84 58 as in our experience, yet for major resection (e.g. right hepatectomy) there is still some progress to be made to reduce operating times compared to open (5 hours versus 3 hours) 61,68 even procedures up to 10 hours have been reported 60. Also anatomical resections are generally quicker than non anatomical wedge resections 68. Nonetheless the learning curve is difficult to assess as it depends on the definition of success which to most would be disease free survival which is rarely discussed. One study has addressed this in detail in a
Laparoscopic Liver Surgery non randomized study comparing 120 patients. There does not appear to be any difference in overall 5 year survival in those having either LLR or open resection in terms of disease free survival 85. Most studies report no difference in rates of R0 resection and no increased risk of positive margins after LLR as reviewed elsewhere 10. Although a recent meta-analysis suggests the risk of an R0 resection (
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UPDATED TOPICS IN MINIMALLY INVASIV
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free online editions of InTech Book
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VI Contents Chapter 9 Appendicitis
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Part 1 Laparoscopic Biliary-Pancrea
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4 Updated Topics in Minimally Invas
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10 Updated Topics in Minimally Inva
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14 Fig. 3. Incision of 3,5 cm in le
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30 4. Patients with sickle cell dis
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44 5. References Updated Topics in
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Page 87 and 88: 1. Introduction 6 Hilar Glissonean
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Page 123: Part 3 Laparoscopic Appendectomy
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1. Introduction 10 Laparoscopic Her
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Laparoscopic Hernia Repair Absorba
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Laparoscopic Hernia Repair passes t
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Laparoscopic Hernia Repair The cont
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Laparoscopic Hernia Repair 2.3.3 TA
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Laparoscopic Hernia Repair testicle
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Laparoscopic Hernia Repair semicirc
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Laparoscopic Hernia Repair fascial
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Laparoscopic Hernia Repair elastic
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Laparoscopic Hernia Repair Laparosc
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Laparoscopic Hernia Repair defect.
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Laparoscopic Hernia Repair LeBlanc,
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1. Introduction 11 Laparoscopic Inc
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Laparoscopic Incisional Hernia Repa
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Part 5 Laparoscopic Solid Organ Sur
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202 5. Discussion Updated Topics in
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204 7. References Updated Topics in
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214 8. Surgery Updated Topics in Mi
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14 Laparoscopic Approach to Abdomin
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Laparoscopic Approach to Abdominal
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1. Introduction 15 Role of Endoscop
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Role of Endoscopy in Laparoscopic P
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