Journal of Laparoendoscopic & Advanced Surgical Techniques

: Laparoscopic adrenalectomy is safe and effective for small adrenal tumors, but its role for large adrenal tumors and the influence of tumor size on the outcome of laparoscopic adrenalectomy have been questioned.

: Thirty-one patients with unilateral adrenal tumors operated on between January 1997 and April 2000 were selected for this study. The indications for surgery were Conn's adenoma in 16 patients, pheochromocytoma in 7 patients, Cushing's adenoma in 4 patients, and incidental lesions in 4 patients. The patients were divided in two groups: 19 patients with tumors <3.5 cm (Group I) and 12 patients with tumors ≥3.5 cm (Group II). The outcomes of the two groups were compared.

: None of the laparoscopic procedures was converted to open surgery. The tumor size correlated with operative time (r = 0.434; P = 0.015) and blood loss (r = 0.513; P = 0.003), with both being significantly greater for larger tumors. No patient required a blood transfusion during or after surgery. One preoperative complication occurred in Group I. There was no preoperative complication in Group II. The median postoperative hospital stay and opioid requirement did not differ significantly between the groups. One patient in Group I developed pneumonia, while no postoperative complications were recorded in Group II.

: Surgery for large adrenal tumors can safely be performed laparoscopically with outcomes comparable to those of surgery for small tumors.

: The physiologic competency of intrathoracic fundoplications remains controversial. This study compared the physiologic qualities of intra-abdominal Nissen fundoplications (IAF) with those of intrathoracic Nissen fundoplications (ITF) in a porcine model.

: The lower esophageal sphincter (LES) length (cm), LES resting pressure (mm Hg), and intragastric pressure (mm Hg) necessary to produce reflux or wrap distribution were manometrically assessed before and after IAF and ITF in 10 pigs. Mean ± SD were compared using analysis of variance.

: There was no difference in LES length before and after IAF or ITF, but there was a significant increase in resting LES pressure after either IAF or ITF (P < 0.0001). In every fundoplication, physiologic intragastric pressures (<65 mm Hg) could not induce reflux, whereas supraphysiologic intragastric pressures resulted in wrap disruption of the most distal suture in every fundoplication, producing a full-thickness tear in the gastric wall. The amount of intragastric pressure necessary to disrupt either IAF or ITF was significantly greater than the intragastric pressures that produced reflux before fundoplication (P < 0.0001). However, there was no difference in intragastric pressures producing wrap disruption of IAF and ITF.

: Nissen fundoplications remain physiologically competent regardless of intra-abdominal or intrathoracic position.

: Reports of metastatic spread of colon and rectal cancer to port sites after laparoscopic resection of potentially curable lesions has raised doubt regarding the efficacy and safety of laparoscopic technology in cancer surgery. Experimental study in animals has led us to believe that the mode of spread of these metastases is via the direct route. We hypothesized, therefore, that we could decrease the rate of trocar-site recurrences by treating the individual port sites with a topical tumoricidal agent.

: Male BD-IX rats weighing 240 to 360 g were injected with syngeneic colon cancer to simulate free intraperitoneal cancer spread to trocar sites. All rats were subjected to a sham laparoscopic operation after 2 × 10⁵ viable cancer cells had been injected into their peritoneal cavities. Five-millimeter trocars were inserted into each rat after abdominal insufflation to 10 mm Hg. Pneumoperitoneum was maintained for 10 minutes before the trocars were removed simultaneously. Trocar sites were then subjected to one of three treatments, with each animal receiving a maximum of two different treatments. Sites were treated with 70% ethanol (N = 42), povidine/ iodine (N = 40), or no topical treatment (N = 46). Three weeks later, the animals were euthanized and autopsied. Subcutaneous tumors at trocar sites or tumors with >50% volume within the wound were considered implants.

: Control sites revealed a metastasis rate of 41% (19/46). The tumor implant rate was 36% (15/42) at alcohol-treated sites and 20% (8/40) at sites treated with povidone-iodine (P < 0.05).

: Topical administration of povidone-iodine to trocar wounds after laparoscopic surgery can significantly reduce the incidence of port-site metastasis in a syngeneic animal model of colon cancer.

: The shape of laparoscopic instrument handles can cause physical discomfort. This problem may be ascribed to a lack of standards for instrument design. In this study, new ergonomic requirements for the design of laparoscopic dissection forceps were created. Three representative handles (a Karl Storz [click-line] scissors handle, an Access Plus scissors handle, and an Aesculap cylindrical handle) currently available on the market were evaluated according to the new list of ergonomic criteria.

: The handles were subjectively (questionnaire) and objectively (video analyses) tested in order to find out whether the new requirements are valid for the evaluation and design of instrument handles.

: The outcome of the subjective and objective tests matched the predictions by the new criteria list. New criteria were introduced (neutral wrist excursions), and existing general criteria were specified (e.g., a minimal contact area of 10 mm). Significant differences were found among the three handles. The Storz handle met 8 of the 10 requirements, the Access handle met 5, and the Aesculap handle met only 4.

: The new list of ergonomic requirements is a valid tool to determine the ergonomic value of a handle for laparoscopic dissecting tasks. It gains its strength from its specialized character. Significant differences were found among the three tested handles. Cylindrical handles were inferior to scissors handles.