Through the Keyhole
Hand-access laparoscopy allows surgeons to perform more complex procedures with smaller incisions so patients have less pain, smaller scars and quicker healing time.
At USC/Norris Cancer Hospital, Keck School of Medicine surgeons have become the first in the nation to successfully perform a Whipple procedure using hand-access laparoscopy.
Dilip Parekh, M.D., chief of tumor and endocrine surgery and professor of clinical surgery, recently completed the procedure-a highly complex surgery on the pancreas, small intestine and bile ducts. Results were so promising that he soon followed it up with another Whipple surgery in a second patient.
"We've done a variety of complex operations successfully with this, but the question was, could we do a Whipple?" Parekh says. "That's one of the most complex operations you can do in general surgery."
He accomplished the feat through the new wave in surgery called hand-access laparoscopy, which brings together the traditional art and honed skill of a surgeon with the minimally invasive techniques of laparoscopy.
Laparoscopy-known by some as keyhole surgery, because it is performed through small slits or punctures in the skin instead of open incisions-has benefited thousands of patients through diminished post-operative pain, smaller scars, less risk of infection and quicker healing time. To perform such operations, surgeons must insert a tiny fiber-optic camera into the abdomen, then cut and suture with long-handled instruments inserted through ports in the skin while watching their work magnified on a video screen.
The technique, though, restricts surgeons' ability to guide instruments and handle and subtly feel organs and structures with their fingers. But newly available medical devices remove some of those limitations.
The GelPort, made by Applied Medical of Rancho Santa Margarita, Calif., and the Lap Disc, manufactured by Ethicon Endo-Surgery Inc., are two such devices. Parekh uses both.
"This is new technology that only has become available within the last few months," Parekh explains. "One of the problems with laparoscopy done the old way, for a surgeon, is that you don't have the ability to put the hand in the abdomen. But with this new technology, you can get the feel and tactile part of surgery."
In the future, the devices will expand the variety of surgeries that are done with minimally invasive techniques, Parekh says, bringing laparoscopy to more complex operations usually performed openly.
Parekh used the GelPort for the recent Whipple procedures. The GelPort is essentially a plastic ring with some key features. It snaps into place in a small skin incision and stretches out the surrounding skin to create an opening large enough for a surgeon's hand. A sleeve and gel inside the ring conform to the surgeon's hand and wrist, forming a perfect seal. That is important because before surgeons can operate on the abdomen laparoscopically, they must inflate it with carbon dioxide gas to better separate and visualize the organs. Any unsealed openings in the abdomen allow gas to leak out.
The U.S. Food and Drug Administration granted marketing clearance for the GelPort and Lap Disc in June. Parekh has used them for several other complicated abdominal procedures, but the Whipple operation posed the biggest challenge yet.
Named after American surgeon Allan Whipple, who first described the operation in 1935, the Whipple procedure also goes by the more unwieldy name of pancreaticoduodenectomy. Surgeons recommend it as the treatment of choice for certain confined pancreatic and bile duct tumors and other conditions in the area that require removal of part of the pancreas.
Parekh says one surgeon attempted a Whipple procedure using traditional laparoscopic techniques in the early 1990s, but the procedure took two-to-three times longer than usual to complete. Further attempts were abandoned.
That is, until earlier this year, when a local woman decided to seek help from her physician to uncover the cause of her jaundice, Parekh says. On examining her with a scope, physicians discovered an early stage cancerous tumor of the ampulla at the opening of her bile and pancreatic ducts. Her best option: a Whipple operation.
During the patient's surgery, Parekh made two 1-centimeter-long incisions for drains, one 1.5-centimeter-long incision for inserting instruments and a laparoscope, and one 6-centimeter-long incision for the GelPort. A traditional Whipple procedure requires a 40-to-50-centimeter-long incision from right to left across the abdomen.
The operation lasted about nine hours, during which Parekh removed tissue from below the pylorus (the valve at the bottom of the stomach) to the jejunum (the second part of the small intestine). Parekh reattached the duodenum (the first part of the small intestine) to the jejunum and reattached the bile duct and remaining pancreas. Done openly, the operation usually takes seven hours.
Whipple procedures are usually considered somewhat grueling for patients, who often face significant pain and need for painkilling drugs, as well as a long recovery. But Parekh's patient only needed continuous narcotics for pain relief for two days, and was able to drink liquids by late in the fourth day after surgery, Parekh notes-both big improvements.
"The hope is to make this an easier operation for patients to deal with," Parekh says.
And his first, pioneering patient?
"She should have a pretty good prognosis," Parekh says. "For these early stage cancers, the 5-year survival rate is 70 to 80 percent. That's a favorable rate for cancers in this area."
Parekh plans to use the GelPort, Lap Disc and hand-access laparoscopy for more and more advanced procedures; he removed part of a patient's liver through the technique, and the speedier recovery and reduced trauma allowed her to go home the day after surgery. And in another surgery, he resected a tumor in a usually difficult-to-remove portion of the liver-a surgery otherwise never done through laparoscopy.
He intends to share the Whipple experience with fellow surgeons through publications, and the procedures were videotaped, as well.
For information about Parekh and pancreatic procedures at USC/Norris, visit www.uscnorris.com/services/pancreatic/information.htm. For more information about GelPort, visit the company's Web site at http://www.appliedmed.com/products-information/hal_gelport.htm
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