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Laparoscopic rectal resection is considered technically more demanding than laparoscopic colectomy. Rectal transection is a challenging part of laparoscopic low anterior rectal resection and restorative proctocolectomy. We describe our technique for laparoscopic rectal transection with a curved cutter, a device initially designed for open surgery, combined with the use of a ring-mounted sterile drape that allows maintenance of sufficient intra-abdominal gas pressure in a series of 34 patients.

SummarySeveral research programmes on telemedicine and telerobotics are currently underway, most of them limited to diagnostics and teleconsultation. A new research and development programme started within the European workframe Advanced Communications Technologies and Services (ACTS), has the aim of developing and building two prototypes of remote controlled robots for interventional and laparoscopic ultrasonography. 11 centres (either clinical or technical) from six countries are taking part in the multimedia interactive demonstrator telepresence project (MIDSTEP). The user requirements for systems for diagnostic and interventional ultrasound (US) have been defined and evaluated in MIDSTEP Work-Package 1, whereas in Work-Package 2, all functional specifications have been included. The system architecture includes hardware, software and a communications network. The hardware consists mainly of a control station and a robot station, which includes a manipulator robot. Within the communication network, the...

Summary. The application of telerobotic technologies to medicine and surgery strictly depends on research and development in five main areas: functionality, environment, physical constraints, communication, and security. The clinical application of robotic technology in the field of microsurgery, orthopaedic surgery, and minimally invasive surgery has shown promising results, pushing researchers to further develop computer-aided surgery as well as diagnostics systems and microrobots. Telemanipulation, interface technologies, sensors, vision systems, virtual reality and function integration are employed to re-design the operating theatre, thus enhancing future applications of robotics in surgery. Because of the restrictions in the surgical field, the construction of miniaturized mechanisms is required, being grounded on different technologies: silicon micro-mechanics, surface micro-engineering and LIGA technology. Nanotechnology, memory alloys and superelastic materials are also employed. Other technologic...

The holding and tensile characteristics of five extracorporeal slipknots in relation to absorbable and nonabsorbable ligature materials have been evaluated in a standardized in vitro test rig. The knots studied: Tayside, Roeder, Melzer (modified Roeder), Cross square, and Blood knots were tied with the following materials: silk, polyamide, Dacron, polydioxanone (PDS), and lactomer (Polysorb). Following construction and slippage (run down) to a fixed-diameter loop around a cylinder, the knots were locked (tightened) using a standardized force after which they were removed from the test rig and subjected to holding strength (force required to induce reverse slippage) and other tensile characteristics (stress, strain, elasticity) by a tensiometer. Analysis of the data has demonstrated the following: (1) The safest slip knots (resist slippage) are the Tayside, Melzer, and Roeder knots tied with lactomer and Dacron. (2) The holding strengths of the Cross square and Blood knots are weak with all ligature materials tested. (3) Polydioxanone is a safe ligature material for the Melzer and Tayside but not the Roeder knot. (4) Extracorporeal slipknots tied with silk and polyamide are less secure than the equivalent knots tied with Dacron, lactomer, and polydioxanone.

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

With the development of endoscopic surgery, new hazards of high-frequency (HF) electrosurgery have been recognized. The potential risks of monopolar electrosurgery, the limitations of bipolar technique, and the need to reduce instrument interchange have favored the use of ultrasonic technology, which becomes more and more popular. This work aims at presenting the main features of the currently available ultrasonically activated scalpels, as well as their advantages, limitations, and indications.

Hepatic surgery has been undergoing progressive modifications in surgical approach to liver, passing through tohraco-phrenolaparotomy to bilateral subcostal incision and current Makuuchi's. Laparoscopic liver surgery should not be considered a new surgery, but simply a new surgical approach, with difficulties but advantages too. Laparoscopic hepatic resections are feasible with low morbidity and mortality; the short and medium term results are comparable to those obtained with open surgery provided that the surgeon has a significant experience in open hepatic surgery, advanced laparoscopic surgery and the availability of all and pertinent instrumentation. The aim of this paper is to show the rationales formal of hepatic resections through the laparoscopic approach, focusing on the necessary instrumentation, the surgical technique and results.

With the improvement of laparoscopic techniques and the development of new and dedicated technologies, endoscopic liver surgery has become feasible. While wedge liver resections are performed more and more frequently, laparoscopic anatomical liver resections are still at an early stage of development and are somewhat controversial. In 1993 we initiated formal laparoscopic liver resections in selected patients. From 1993 to December 1995 20 patients underwent endoscopic formal resections: the procedures comprised six left hepatectomies, five right hepatectomies, one of which extended to the segment IV, three mesohepatectomy, five segmentectomies and one bisegmentectomy. The operation time ranged from 120 to 270 min (average 193 min). In 17 out of 20 cases a Pringle manoeuvre was performed (mean occlusion time 45 min). No intra-operative complications occurred and there were no conversions in the whole series. Average intra-operative blood loss was 397.5 mL and 35% of patients required intro-operative blood transfusions. Post-operative mortality rate was 5% and post-operative morbidity rate was 45% (one coagulopathy with severe trombocytopaenia, six pleural effusions, one bile collection and four hematomas of the trocar sites). Such preliminary data are comparable with those of a group of 65 patients who underwent open anatomical liver resections from 1992 and 1995. Far from being a routine technique in liver surgery, the laparoscopic approach to forma liver resections may be a promising procedure in selected patients.

Background Laparoscopic surgery requires secure and safe methods of ligation and haemostasis. This study evaluated the efficacy of an absorbable ligation clip with a novel compression closure mechanism. Methods A new compression-closure absorbable clip was compared with currently available absorbable and non-absorbable clips used in a variety of laparoscopic procedures in 12 centres worldwide. Results At follow-up to 3 months after the procedure, no complications specific to the use of the compression-closure clip were detected. Operator satisfaction with the clip was high, with criticism directed at its relatively large size. Conclusion This new clip is as safe and effective as presently available metal and absorbable clips in providing haemostasis and securing tubular structures.

Treatment of inoperable pancreatic cancer pain is of paramount importance. The ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. This procedure may be performed under either fluoroscopic or computed tomography (CT) guidance, or it may accompany laparotomy. The authors describe a modified sonographically (ultrasound-US)-guided technique for alcoholization of the celiac ganglions.Twelve patients underwent the neurolytic procedure. Nine of 12 suffered from pancreatic cancer. The remaining three were affected by inoperable hepatic, gastric, or colon cancer, respectively, with multiple hepatic metastases. US-guided alcohol neurolysis was performed by an anterior approach. In the last four patients, PIA (percutaneous injection alcohol) needles, modified by the authors, replaced the spinal needles employed in the first eight patients to inject the alcohol. Pain and pain relief were rated according to a Simple Descriptive Scale (SDS), and treatment success was gauged by declining opiate doses and need for pharmacological therapy. Results after treatment performed using different needles were compared.Procedure-related mortality was zero. Complications of the neurolytic procedure included left pleural effusion in one patient and mild diarrhea in two other patients. Positive, negative, and indeterminant results were noted in nine (75%, p0.001), two, and one patient(s), respectively.The neurolytic technique, although far from being considered a routine procedure, appears to provide patients with safe and effective pain relief for pain unresponsive to conventional medical treatment.

Precise cutting combined with reliable coagulation of the margins of the lesion is an important requirement for dissection techniques in endoscopic surgery. These requirements are met by the two most common ancillary energy sources applied for endoscopic dissection today, electrosurgery and "thermal lasers", mostly the Nd:YAG. For the comparison of the histological effects of monopolar and bipolar high frequency with the Nd:YAG laser an experimental in vitro and in vivo study has been performed. In order to evaluate the advantages of non thermal dissection for endoscopic procedures, a water jet cutting system was included in the in vitro study. In parenchymatous tissue the water jet was found to be the least traumatic technique, followed by bipolar high frequency, laser and monopolar high frequency. The water jet was not applicable for intestinal dissection since uncontrolled bloating of the rectal wall with uncontrolled disruption of the tissue layers occurred. A general disadvantage is that secure haemostasis in the line of incision is hard to achieve. In the microscopic comparison of the shape of the incision, the Nd:YAG laser produced the smoothest lesions with well-defined margins. The monopolar technique was more often associated with irregular and sometimes fissured margins. These results were confirmed in the in vivo part of the study (Transanal Endoscopic Microsurgery).

This paper deals with future aspects and developments in endoscopic sutures, needles, needle drivers, and sewing devices. Shape memory alloys such as superelastic nickel-titanium can be used for surgical needles and hingeless needle drivers. A sewing device consists of a T-Needle which can be shuttled between the jaws of specially designed instruments. The jaws possess small elements that grip the needle tips. The "Needle Rotor" facilitates intracorporeal swivelling and positioning of the needle because one jaw can be moved longitudinally over the other. A new "cutting knot pusher" permits immediate cutting of a slip knot subsequent to tightening.

A combination of laparoscopic and rectoscopic procedures has enabled complete resection of the sigmoid colon and eliminated the need for minilaparotomy when constructing the anastomosis or withdrawing the specimen. This combined procedure was performed in different ways in a series of animal models until the definitive technique had been standardized. These techniques were then successfully used in 15 consecutive medium-sized pigs. Histological evaluation of the specimens, including the anastomosis (examined 2–3 weeks after operation) confirmed the efficacy and safety of the method.

A one year research programme on endoscopic colorectal resections was carried out at the University of Tübingen. Two research lines were planned: the development of the required technologies and the development of the surgical procedure. During the research programme on technologies a new device provided with an air proof system for transanal insertion of the anvil of a divisible stapler and a new technique for closure of the colonic and rectal stumps (cable binding technique) were developed. Such technological innovations enabled the authors to accomplish a new combined laparoscopic-rectoscopic procedure which was performed according to four different variants in a series of 32 animals. The last 15 consecutive successful cases, performed according to the definitive procedure, represented a standardized animal trial before starting the clinical investigation.

Laparoscopic cholecystectomy can be performed with incisions of a maximum diameter of 10 mm. The removal of a stone-filled gallbladder at the end of an operation via the 10-mm port needs often-extensive tissue-consuming manipulations for stone removal or minilaparotomy. Stone fragmentation can be achieved by mechanical crushing and by ultrasound-, electrohydraulic-, and tunable dye laser lithotripsy. The clinical employment of the LaparoLith (Baxter Healthcare Corporation), an instrument which allows mechanical fragmentation of stones inside the gallbladder, is presented here. We have used the LaparoLith in nine patients and have been successful in stone fragmentation in seven of these. The LaparoLith seems to be helpful in laparoscopic cholecystectomy, preventing extension of the subnavel incision.

Laparoscopic modified Taylor's procedure for chronic duodenal ulcer was performed in three patients. A new, specially developed combination instrument allowed the operation to be performed easily, sometimes using only four introduction sites. Coagulation, suction, and rinsing can be performed at the same time, and the hook knife, scissors, or different forceps can be introduced through the operating channel of the instrument. An overcast seam to approximate the seromyotomy was done using the technique developed for transanal endoscopic microsurgery. Instead of the silver clips, specially handmade steel and titanium clips were used to fix the PDS suture. No major postoperative complications occurred. The gastric acid output under basal condition and stimulation showed a decrease ranging from 47% to 79%. Endoscopic examination performed on the 4th postoperative week showed complete recovery in all cases.

The Authors report the results of a National multicentric experience in 1.095 cases of pancreaticoduodenectomy for cancer. In order to evaluate the reliability of pyloric preservation mortality, morbidity, and functional results are discussed.

Eighty-four cases of portal hypertension from cirrhosis assessed by oesophagogastroduodenoscopy before elective surgery are reported. The need for evaluation of both the associated gastrointestinal lesions and the varices in patients with cirrhosis is stressed, to avoid inappropriate medical or surgical treatment.