Initial experience with a flexible fiberoptic laparoscope

Initial experience with a flexible fiberoptic laparoscope R. A. Sanowski, MD S. Bellapravalu, MD

Flexible fiberoptic endoscopes have replaced the rigid instruments in all areas of diagnostic and therapeutic endoscopy except laparoscopy. Until recently, no fiberoptic system has been available that can replace and prove advantageous compared with the older instruments. In 1981 we used a gas-sterilized Olympus GIF-P2 fiberendoscope to successfully examine the peritoneal cavity.! The procedure proved safe and feasible but cumbersome because of excessive instrument length, inadequate light system, and small accessory channel. Working with available fiberoptic technology, we have designed a flexible laparoscope devoid of these deficiencies and compared it with the rigid instrument in routine peritoneoscopy. TECHNICAL DESIGN AND PROCEDURE

The main features of the instrument manufactured by Machida America, Inc., Orangeburg, New York, are outlined in Table 1. While the effective length is 448 mm, the distal 300-mm section is flexible and the proximal 148 mm is of rigid construction to permit easy passage of the endoscope through a standard lO-mm trochar sheath (Fig. 1). Total tip deflection is 165°. The biopsy channel diameter of 2.8 mm is large enough to accommodate available biopsy forceps, sclerotherapy injection needle, or the quartz fiber of the Nd:YAG laser. Illumination was provided by the Pentax LX-75F light source, but other illuminators with appropriate adapters can be used. Photography with the Pentax MF-l camera and ASA 400 film provided satisfactory documentation of pathology. Following informed consent, 14 patients (age range, 33 to 70 years) were studied with both the Wolf laparoscope (Lumina SL-Telescope, 130° field) and the flexible fiberoptic laparoscope. The indications for the procedure were abnormal liver function tests, 6; suspected metastasis, 3; hepatomegaly, 3; ascites, 1; and cholestasis, 1. The standard technique of laparoscopy was used to establish the pneumoperitoneum with nitrous oxide and passage of the rigid 10-mm trochar and sheath into the left upper quadrant. Following examination of the peritoneal cavity with the rigid laparoscope (RL), the flexible laparoscope (FL) was passed under direct vision (Fig. 2). The instrument was directed into the four quadrants and the position documented by fluoroscopy (Fig. 3). Biopsies of the peritoneal surface or intra-abdominal masses were done with the standReceived September 18, 1985. Accepted and returned for revision October 30, 1985. Revision received November 11, 1985. From the Gastroenterology Section, Veterans Administration Medical Center, Phoenix, Arizona. Reprint requests: R. A. Sanowski, MD, Gastroenterology, Veterans Administration Medical Center, 7th Street and Indian School Road, Phoenix, Arizona 85012. This work was presented at the annual meeting of the American Society for Gastrointestinal Endoscopy, May 15, 1985, New York, New York. VOLUME 32, NO.6, 1986

ard forceps following injection of a small amount of local anesthetic into the peritoneal surface with the sclerotherapy injection needle. Liver biopsies were directed with the FL and performed with a Tru-Cut needle. Only minor modifications were necessary to adapt the trochar for passage of the FL. Rubber gaskets attached to the trochar sheath were predrilled to accommodate the instrument and to make an airtight seal. Sterile water was used to lubricate the shaft of the FL. The trumpet valve of the trochar sheath was depressed as the FL was passed into the peritoneal cavity. Adhesions encountered were incised with the endoscopic scissors passed through the device channel, thus allowing passage into the right upper quadrant in three patients with previous surgery. The FL is 15 cm longer than the standard RL, permitting examination of all quadrants to a greater depth. The instrument was directed over the dome of the liver and into the dependent parts of the peritoneal cavity. Small amounts of ascites were aspirated with an ERCP cannula and syringe. Initially fluoroscopy was used to document depth of passage into the peritoneal cavity. However, after the first three procedures, direct vision was used to guide the instrument. Prior to each use, the FL underwent cold gas sterilization. Table 1. Specifications of flexible laparoscope Effective length Flexible length Rigid section Insertion tube diameter Tip deflection Working channel diameter Field of vision Depth of focus Ocular

448mm 300mm 148mm 8.4mm 105° up 60° down 2.8mm 55· 5-50 mm 20x

Figure 1. Flexible laparoscope and metal trochar sheath. 409

Figure 2. Passage of flexible laparoscope into right upper quadrant under direct vision.

3. Fluoroscopic view of flexible laparoscope over the superior aspect of the right lobe of the liver.

Figure

RESULTS

The FL was easily passed into the peritoneal cavity, and the liver and gallbladder were seen in all cases. The four quadrants could be rapidly examined because of potential tip deflection of 165°. The instrument provided a clear panoramic view of the peritoneal contents with less lateral movement than with the RL. Depth of examination was 35 em, and this length proved ideal for viewing the dome of the liver and lateral gutters of the peritoneal cavity. Visualization was excellent. In general, the pathology discovered was similar, but in three cases metastatic lesions were seen on the dome of the liver that could not be seen with the RL. In three other cases in which the RL could not be passed because of adhesions, the FL easily passed after adhesiotomy (Fig. 4). Photographs taken were of good quality but smaller than those taken through the RL (Fig. 5). Because of the flexible tip the examination was completed in less than 15 min. Despite increased visualization and 410

Figure 4. A

and B, Translaparoscopic adhesiotomy.

greater advancement into the abdomen, the examination was well tolerated by the patients. No infections or other complications were encountered with either instrument. The device channel accommodated all standard instruments including biopsy forceps, cytology brush, aspiration catheter, BICAJ>® probe, endoscopic scissors, and laser light guide. However, the laser was not utilized in the peritoneal cavity. Biopsies were taken of peritoneal implants or liver masses through the device channel, but core liver biopsies were done with a Tru-Cut needle through a second puncture site. DISCUSSION

In all areas of endoscopy, therapeutic capability of an instrument system has led to advances in patient care. Laparoscopy has proved to be an excellent diagnostic procedure, but it is under challenge by invasive radiologic techniques such as ultrasound- and CTguided biopsies. 2 •3 Interventional radiologists are now using large bore needles to obtain biopsies of intraGASTROINTESTINAL ENDOSCOPY

Figure 5. A and B, Biopsy of metastatic carcinoma of the liver. C and D, Biopsy and brushing for cytology of metastatic lesion on dome of liver.

abdominal masses and to decompress pancreatic cysts and intra-abdominal abscesses with a CT-directed needle.:1 Although current indications for laparoscopy are well delineated, 4 in the face of the advances in invasive radiology, there is a perception that the use of laparoscopy is decreasing. 5 However, routine laparoscopy is a safe procedure easily performed in the endoscopy suite under local anesthesia. With the new flexible laparoscope the procedure may be performed with greater ease. Present and future therapeutic apVOLUME 32, NO. 6, 1986

plications of laparoscopy performed with the FL include lysis of adhesions, aspiration of cysts, removal of foreign bodies, insertion of feeding or decompression tubes, and performance of gynecological procedures. Some of these have already been accomplished with the rigid laparoscope. 6 ,7 With the FL the laser fiber can be carried into the peritoneal cavity where its applications could include lysis of adhesions, destruction of tumors, and control of hemorrhage. With the added length of 15 cm the entire peritoneal cavity 411

may be examined by the FL. The RL has been used to examine the retroperitoneal space, and the FL may be able to reach further into this area. s We have not evaluated the feasibility of the FL in gynecological therapy, but this application should be explored. The acceptance of a flexible laparoscope by the endoscopist may be difficult since the rigid scopes have worked so well. However, it took several years for the fiberoptic instruments to be perfected and used in the upper and lower gastrointestinal tract, and only in the past 2 years has the fiberoptic sigmoidoscope replaced the rigid instrument in routine use. We conclude that examination of the peritoneal cavity with this fiberoptic laparoscope proved feasible, safe, and easy. More of the peritoneal contents were seen compared with the rigid instrument. Available biopsy equipment and laser and bipolar probes can be passed through the device channel. Further controlled trials should be carried out and other therapeutic

applications evaluated, especially in regard to gynecological problems.

REFERENCES 1. Sanowski RA, Kozarek RA, Partyka EK. Evaluation of a flex-

2. 3. 4. 5. 6. 7. 8.

ible endoscope for laparoscopy. Am J Gastroenterol 1981;76:416-9. Lightdale CJ. Laparoscopy in the age of imaging. Gastrointest Endosc 1985;31:47-8. Bernardino M. Percutaneous biopsies. Am J Roentgenol 1984;142:41-5. Sanowski RA. Are there any remaining indications for laparoscopy? Surv Dig Dis 1984;2:115-20. Sanowski RA, Sarles H Jr, Bellapravalu S, et aJ. Current status and future of laparoscopy-Is it a dying endoscopic procedure? (abstract). Gastrointest Endosc 1984;30:148-9. Cunningham JT, Tucker TC. Peritoneoscopy in chronic peritoneal dialysis: use in evaluation and management of complications. Gastrointest Endosc 1983;29:47-50. Ash SR, Wolf GC, Block R. Placement of the Tenckhoff peritoneal catheter under peritoneoscopic visualization. Dial Transplant 1981;10:383-5. Ishida H. Peritoneoscopy and pancreas biopsy in the diagnosis of pancreatic disease. Gastrointest Endosc 1983;29:211-8.

Case Reports Duodenal erosion caused by a mesocaval graft Steve Goldschmid, MD Patrick G. Brady, MD Frederick L. Slone, MD M. Steven Farber, MD

The mesocaval "H" graft was developed as an alternative porto-systemic shunt for bleeding esophageal varices secondary to portal hypertension. 1,2 In 1972, Drapanas3 advocated the "H" graft as a simpler, less morbid operation with good long-term results. The graft is anastomosed between the superior mesenteric vein (SMV) and the vena cava almost perpendicular to the course of those vessels. More recently, Cameron et al. 4 described the "c" graft, anastomosing the graft to a more cephalad portion of the SMV in an attempt to increase long-term patency. The "c" graft swings tightly over the second portion of the duodenum. Variceal hemorrhage, shunt occlusion, hepatorenal syndrome, and portosystemic encephalopathy are recently recognized complications of the "c" graft procedure. An extremely rare complication is the erosion of the graft into the duodenum. We present such a case, review the literature, and comment on the role of endoscopy in the disgnosis of this complication. From the Departments of Internal Medicine and Radiology, University of South Florida College of Medicine, Tampa, and James A. Haley Veterans Administration Hospital, Tampa, Florida. Reprint requests: Steven Goldschmid, MD, Division of Digestive Diseases and Nutrition, University of South Florida College of Medicine, Box 19, 12901 North 30th Street, Tampa, Florida 33612. 412

CASE REPORT A 50-year-old white male presented to the Tampa Veterans Administration Hospital Emergency Room with fever over the previous 5 weeks, occurring mostly in the morning for 20 min and associated with chills and diaphoresis. Temperature elevations varied from 101 to 103°F. The patient also complained of generalized weakness, anorexia, a minimal increase in abdominal girth, and a 5-pound weight loss. He denied cough, abdominal pain, diarrhea, nausea, vomiting, or dysuria. The patient had been evaluated twice by his private physician who had given him two empiric 10-day trials of an unknown antibiotic without effect. His past medical history was pertinent for a mesocaval shunt 2 years earlier for bleeding esophageal varices secondary to alcoholic cirrhosis. He had no previous history of encephalopathy or ascites. Physical examination revealed a moderately obese, white male in no distress. Blood pressure was 100/60 mm Hg; pulse, 72 beats/min; respirations, 32/min; and temperature, 101.2°F orally. Scleral icterus, spider angiomata, palmar erythema, bilateral gynecomastia, and testicular atrophy were present. There was a midline scar with a ventral hernia. The abdomen was mildly distended, but there was no evidence of ascites. The liver span was 10 cm. The spleen tip was palpable. There was no tenderness, guarding, or rebound. Admission laboratory data included an alkaline phosphatase of 172 IV/liter; SGOT, 42 IV/liter; LDH, 187 IV/liter; total bilirubin, 4.5 mg/dl; albumin, 2.7 g/dl; prothrombin time, 11.9 sec; and partial thromboplastin time, 35 sec. CBC revealed a hemoglobin of 14.8 mg/dl and a white blood cell count of 12,900/mm3 with 60% polys and 31 % bands. Platelet count was 68,000/mm3 • Electrolytes, BUN, creatinine, urinalysis, ECG, and chest x-ray were unremarkable. Abdominal films revealed the presence of gallstones; sonograGASTROINTESTINAL ENDOSCOPY