1. Open Versus Laparoscopic Surgery What Is A Myth And What Is Not ! George Ferzli, MD, FACS

6. Esophagectomy * P<.05, compared with TT and THE groups,Mann-Whitney Test Nguyen NT et al, Arch Surg. 2000;135:920-925 6.9 + 5.4 6.3 + 6.0 10.8 + 8.4 No. of nodes removed 22.3 + 16.1 23.0 + 22.3 11.3 + 14.2 * Hospital stay, days 11.1 + 15.7 9.9 + 16.3 6.1 + 11.3 * ICU stay, days 2.9 + 3.1 1.8 + 2.2 0.3 + 0.7 * Intraop. transfusion, U 1142 + 785 1046 + 792 297 + 233 * Blood loss, mL 391 + 144 437 + 65 364 + 73 * Operative time, min THE (n=20) TT (n=16) TM/LE (n=18)

7. Esophagectomy Nguyen NT et al, Arch Surg. 2000;135:920-925 0 0 1 (6) Tracheal-gastric fistula 0 1 (6) 0 Intra-abdominal abscess 4 (20) 0 0 Hoarseness 1 (5) 0 0 Chylous ascites 0 0 1 (6) Delayed gastric emptying 3 (15) 3 (19) 2 (11) Respiratory failure 1 (5) 0 1 (6) Pulmonary embolism 0 1 (6) 0 Gastric conduit ischemia 2 (10) 2 (12) 2 (11) Anastomotic leak 0 1 (6) 0 GI bleeding THE (n=20) TT (n=16) TM/LE (n=18) Complication

11. Esophagomyotomy * P<.05 Dempsey et al, Surg Endosc (1999) 13: 747-750 85 + 60 19 + 16 * Days off work post-op 40% 25% Post-op GERD 80% 84% Overall satisfaction 90% 92% Improved dysphagia 8.8 2.7 * Hospital stay, days 39 + 7 18 + 2 * Parenteral narcotic, mg 5.3 + 1.4 2.1 + 1.0 * Parenteral narcotic, days 2/10 2/12 Mucosal perforation 220 + 156 50 + 26 * Blood loss, mL 122 + 32 137 + 25 Operating time, min Open (n=10) Laparoscopic (n=12)

16. Paraesophageal Hernia Repair Symptomatic Outcomes Hashemi et al, J Am Coll Surg 2000;190:553-561

21. Nissen Fundoplication Complications Laine S et al, Surg Endosc (1997) 11: 441-444 3 0 Wound infection 1 0 Subphrenic abscess 1 0 Pneumonia 2 0 Splenic bleeding and splenectomy 0 1 Intraoperative bleeding 0 2 Esophageal perforation Open Lap. Complication

22. Nissen Fundoplication Proportion of Time (%) Mean pH<4 Laine S et al, Surg Endosc (1997) 11: 441-444

23. Nissen Fundoplication Mean LES Pressure Laine S et al, Surg Endosc (1997) 11: 441-444

24. Nissen Fundoplication Symptoms 3 Months After the Operation Laine S et al, Surg Endosc (1997) 11: 441-444 53% 16% 22% 2% 4% 2% 56% 18% 22% 4% (n=55) (n=55)

25. Nissen Fundoplication Symptoms 12 Months After the Operation Laine S et al, Surg Endosc (1997) 11: 441-444 70% 83% 17% 13% 3% 7% 7% (n=55) (n=55)

27. Laparoscopic Nissen Fundoplication Results * p=0.016, ** p=0.011 (Fisher’s exact test) Bais JE et al, Lancet 2000; 355: 170-74 1 11 Total ** 0 2 Intrathoracic herniation 1 2 Recurrent GERD at 3 months 0 7 Persistent dysphagia * (>3 months) Laparotomy (n=46) Laparoscopy (n=57)

32. Billroth I Gastrectomy P<.05, all features Adachi Y et al, Arch Surg. 2000;135:806-810 4.5 3.9 Time to first flatus, days 7.7% 5.5% Weight loss on day 14 22.5 17.6 Post-op hospital stay, days 5.7 5.0 Time to liquid diet, days 6.2 3.3 Analgesics, times given 33.9 35.6 Serum albumin, day 7 26 4.2 Interleukin-6, day 3, U/mL 5.19 2.91 C-reactive protein, day 7, mg% 8.9 7.28 Granulocyte count, day1 8.22 6.99 Leukocyte count, day 3 11.14 9.42 Leukocyte count, day1 302 158 Blood loss, mL Open (n=53) Laparoscopic (n=49)

33. Billroth I Gastrectomy P=NS, all features Adachi Y et al, Arch Surg. 2000;135:806-810 21% 8% Complication rate 22.1 18.4 No. of lymph nodes 6.0 6.2 Proximal margin, cm 228 246 Operation time, min Open (n=53) Laparoscopic (n=49)

35. Perforated Peptic Ulcer

40. Roux-en-Y Gastric Bypass Perioperative Outcomes Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 .02 46.1 + 20.6 32.2 + 19.8 Return to work, days <.001 17.7 + 19.1 8.4 + 8.6 Return to daily activity, days NS 5 (6.6%) 6 (7.6%) Reoperation, No. of Pts. <.001 4 (IQR 2) 3 (IQR 1) Median hospital LOS, days .03 16 (21.1%) 6 (7.6%) ICU stay, No. of Pts. <.001 395 + 284 137 + 79 Blood loss, mL <.001 195 + 41 225+40 Operative time, min P Value Open GBP (n=76) Laparoscopic GBP (n=79) Results

41. Roux-en-Y Gastric Bypass Mean % of Excess Body Weight loss * * n=60 n=45 n=29 n=56 n=44 n=25 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 * p<.05

42. Roux-en-Y Gastric Bypass Major Complications * P=0.78 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 7 (9.2%) * 6 (7.6%) Total 1 0 Retained laparotomy sponge 2 0 Wound infection 0 1 Gastrointestinal bleeding 1 0 Respiratory failure 1 0 Pulmonary embolism Pulmonary 0 3 Jejunojejunostomy obstruction 0 1 Hypopharyngeal perforation 1 0 Gastric pouch outlet obstruction 1 1 Anastomotic leak Gastrointestinal Open GBP (n=76) Laparoscopic GBP (n=79) Complication

44. Adjustable Silicon Gastric Banding de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 <0.05 11.8 + 10.5 7.8 + 6 Overall hospital stay, days <0.05 15 6 Total readmissions <0.05 3.8 + 1.1 (3-7) 4.7 + 2.1 (3-10) Difficulty of procedure (1-10)(range) <0.05 7.2 (5-13) 5.9 (4-10) Days in hospital, mean (range) <0.05 76 + 20 150 + 48 Surgical time, min P Value Open ASGB (n=24) Laparoscopic ASGB (n=25) Parameter

45. Adjustable Silicon Gastric Banding All values are expressed as mean + SD P value difference before and 52 weeks after is < 0.05 de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 NS 39.1 + 8.2 39.7 + 8.7 BMI 52 weeks after surgery (kg/m 2 ) NS 49.7 + 5.6 51.3 + 10.4 BMI before surgery (kg/m 2 ) 34.4 35 Weight loss (kg) NS 112.0 + 19.1 117.2 + 25.2 Weight 52 weeks after surgery (kg) NS 146.4 + 19.9 152.2 + 31.4 Weight before surgery (kg) P Value Open ASGB (n=24) Laparoscopic ASGB (n=25)

48. Laparoscopic Liver Resection

49. Liver Resection Rau HG et al, Hepato-Gastroenterology 1998; 45:2333-2338 <0.05 11.6 + 12.8 7.8 + 8.2 Post-op hospital stay (days) NS 555.9 + 385.8 457.6 + 343.7 Blood loss (mL) <0.05 128.2 + 37.0 183.5 + 55.1 Operation time (min) NS 10.8 + 4.6 11.6 + 6.1 Parenchymal hepatic resection rate (%) NS 46.8 + 13.9 48.0 + 9.8 Age (years) p value (Mann-Whitney U Test) Conventional (n=17) Laparoscopic (n=17)

51. Laparoscopic Common Bile Duct Exploration

52. PREOP INTRAOP POSTOP ERCP Lap transcystic Lap CBD Open CBD Expectant ERCP Management Options

53. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 1 death. Shorter LOS (3.4d), lesser morbidity (5%), fewer retained stones (5%) for transcystic. 10 123, 91% success 145 99% 1231 Phillips et al 4 deaths. Morbidity 9.1%. 7 with residual stones. 137, 97.1% success 112, 68.8% success 220 - 220 Berthou et al Major complications 3.8%. 1 death. 5% retained stones. 3.2% recurrent stones on f/u 50 107 161 1975 1975 Paganini et al 2 duct injuries. 1 death. 7% morbidity 2.6% retained stones. 17%, 19% conversion 83%, 5% conversion 94% 99.5% 226 Berci et al 8% conversion. 92% success. 1 death. LOS 4.3d 37 13 50 - 50 Shuchleib et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study

54. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 Overall success rate 94%. Complication rate 10% 27 33 80 - 700 Stoker et al Overall success rate 75% 14 46 60 - 60 Khoo et al Overall success 88%. 20 conversions. 22 major & 9 minor complications. 1 death. 92 116 247 - 247 Millat et al 12% conversion. 2 deaths. 15% complication rate. 93% success 63% success 92 - 92 Gigot et al Overall success 82%. No mortality. Morbidity 10% 11 22 39 - 39 Arvidsson et al No late retained stones or stricture. 0 217 217 - 217 Giurgiu et al 15.8% complication rate. 1 death. 13% conversion. LOS 6 days. 55, 85% success 56,80% success 109 132 133 Cuschieri et al No mortality. Morbidity 7.4%. LOS 7.6 days. 101, 96% success 82,67% success 161 - 161 Drouard et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study

56. “ In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence”. 1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A. Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911

64. Results Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT

67. Laparoscopic Pancreatic Resection

69. Laparoscopic Palliative Surgery for Unresectable Pancreatic Cancer

71. Results Rothlin,M et al;Surg Endosc (1999) 13:1065-1069 p < 0.05 p < 0.05 p < 0.06 9 days 21 days HOSPITAL STAY 0% 29% MORTALITY 7% 43% MORBIDITY LAP (n=14) OPEN (n=14)

73. Laparoscopic Versus Open Adrenalectomy

74. Adrenalectomy OA, open anterior; OP, open posterior; Lap, laparoscopic; EBL, estimated blood loss; LOS, length of stay; OI, oral intake * Significant outcome compared to other outcome measures in same series (p<0.05) 8,188 1.9(days) 1.8 4.1 164 118 Lap(10) 11,193 3.2(days) 2.2 5.6 106 * 220 OP(5) 14,487 3.6(days) 3.4 6.2 141 200 OA(5) Korman 93 * 2.1 * 212 228 Lap(10) 801 5.5 139 * 288 OP(13) 1002 6.4 174 391 OA(11) Prinz 175 * 1.1 * 3.4 * 170 * 100 * Lap(20) 320 2.8 9 145 450 Open(20) Guazzoni 13,184 15.9 * 1.6 * 3.2 * 183 * 104 * Lap(24) 12,266 54 2.8 6.2 136 366 OP(17) 16,972 142 6.0 8.7 142 408 OA(25) Brunt Cost ($) Pain meds (mg) OI (days) LOS (days) Operative time (min) EBL (cc) Approach (n) First author

75. Adrenalectomy Thompson GB, Surgery 1997;122:1132-6 0.05 $7000 $6000 Adjusted hospital charges (median) 0.0001 9 7 Patient satisfaction (1-10) 0.0001 3.8 7 Return to normal (weeks) 0.0001 0 54 Late complications (%) 0.25 6 18 Early complications (%) 0.0001 3.1 5.7 Hospital stay (days) 0.50 3.1 5.7 Antiemetic doses 0.75 0.7 1.7 Toradol doses 0.002 28 48 MSO 4 equivalents NS 2 units None Blood transfusion (total group) 0.0002 167 127 OR time (min) p Value Laparoscopic (n=50) Posterior open (n=50)

78. Laparoscopic Versus Open Splenectomy

79. Splenectomy * * * * * * * p < 0.05

80. Splenectomy Donini A et al, Surg Endosc (1999) 13: 1220-1225 - 0 0 Deaths <0.0001 4+2.8 2.4 +1.7 Pain medication (No.of vials) 0.03 13 (23%) 3 (7%) Post-op complications 0.0002 7.2+2.1 5.1+2.7 Post-op stay (days) <0.0001 3.6+0.8 1.7+0.8 Time to oral liquids (days) 0.70 7 (5) 4 (4) Accessory spleens (No. of pts) 0.76 133+42 130+62 Operative time (min) 0.004 15 (26%) 2 (5%) Transfusion (patients) 0.67 347+511 295+269 Blood loss (mL) 0.86 732+1,184 773+1,112 Splenic weight (g) - 39 (18-64) 40 (13-64) Average age (range) p OS (n=56) LS (n=44) Results

83. Small Bowel Obstruction Diagnostic and Therapeutic Laparoscopy 1 (1.5%) 30 (46%) 35 (54%) 65 139 Bailey IS, 1998 0 (0%) 6 (32%) 13 (68%) 19 19 Al-Mulhim A, 2000 3 (7.5%) 26 (65%) 14 (35%) 40 40 Leon EL, 1998 4 (8%) 36 (43%) 47 (57%) 83 83 Suter M, 2000 1 (1.5%) 11 (17.4%) 52 (82%) 63 136 Agresta F, 2000 4 (10%) 13 (32%) 24 (60%) 40 40 Strickland P, 1999 6 (9%) 31 (46%) 31 (46%) 68 150 Navez B, 1998 Iatrogenic bowel injury Converted to laparotomy Laparoscopic treatment Diagnostic laparoscopy Total # Author

85. Laparoscopic Versus Open Colectomy for Cancer

86. Colorectal Resection Laparoscopic vs. open resection for carcinoma RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

87. Colorectal Resection Laparoscopic vs. open resection for carcinoma Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46 19.1% 13% Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III) 22% 12.2% Recurrence rates 6% 0.5% Wound complications 450 150 Blood loss, mL 9 5.6 Hospitalization, days Open (n=224) Laparoscopic (n=192)

88. Colorectal Resection Laparoscopic vs. open resection for carcinoma Curet MJ et al, Surg Endosc (2000) 14: 1062-1066 1 6 4 Late death from cancer (mean follow-up 4.9 years) 12 10 11 Number of lymph nodes 32 26 26 Length of specimen (cm) 8, 100% 5, 28% 1, 5% Complications (n, %) 8 7.3 5.2 Length of stay (days) 7 5.8 4.1 Regular diet (days) 5 4.4 2.7 Clear liquids (days) 6 4 3 ICU stay (days) 683 407 284 Blood loss (mL) 242 138 210 Operating room time (min) Converted (n=7) Open (n=18) Lap (n=18) 1 1 0 Recurrence

89. Colorectal Resection Laparoscopic vs. open resection for carcinoma Santoro E et al, Hepato-Gastroenterology 1999; 46:900-904 1 1 Liver+Peritoneum+ Trocar-site or scar 4 4 Liver+ Peritoneum 5 5 Multiple sites 1 1 Regional 4 2 Liver 5 3 Single site 10 (23%) 8 (20%) Overall metastases 43 40 No. of cases (n) Open Lap. Follow-up

91. Laparoscopic Prostatectomy

92. Laparoscopic Prostatectomy Turk I et al, Eur Urol 2001;40:46-53 6.5 7 10 8 Hospital stay (mean), days 5.5 6.5 19 12 Catheter time (mean), days 0 0 20 2 Transfusion, % 145 140 250 185 Blood loss (mean), mL 0 0 0 0 Conversion, % 200 210 352 265 Operative time (mean), min Procedures 80-125 Procedures 50-79 Procedures 1-10 Total

95. Laparoscopic Inguinal Hernia Repair

97. Inguinal Hernia Repair Cost

98. Inguinal Hernia Repair Operative Time

99. Inguinal Hernia Repair Complications

100. Inguinal Hernia Repair Recurrence

101. Inguinal Hernia Repair Return to Work

103. Open Versus Laparoscopic Surgery Summary X X Hepatectomy X Adjustable silicon GB X Roux-en-Y GBP X Peptic ulcer disease X X Billroth II gastrectomy X Nissen fundoplication X Paraesophageal hernia X X Esophagomyotomy X X Esophagectomy Needs additional trials No Yes Operation

104. Open Versus Laparoscopic Surgery Summary X Inguinal hernia repair X X Prostatectomy X X Colectomy for cancer X Small bowel obstruction X Splenectomy X Adrenalectomy X Palliative pancreatic ca. X X Distal pancreatectomy X Diagnostic laparoscopy / Sono pancreatic ca. X X CBDE Needs additional trials No Yes Operation