TROCAR SITE TUMOUR TROCAR SITE TUMOUR RECURRENCE IN RECURRENCE IN LAPAROSCOPIC LAPAROSCOPIC
SURGERYSURGERY
SURGERY AUSTRALIASURGERY AUSTRALIA
PETER HEWETTPETER HEWETT
TROCAR SITE RECURRENCETROCAR SITE RECURRENCE
►GALLBLADDERGALLBLADDER►PANCREASPANCREAS►STOMACHSTOMACH►BOWELBOWEL►LIVERLIVER►OVARIANOVARIAN
TROCAR SITE RECURRENCETROCAR SITE RECURRENCE
► INITIAL REPORTS OF UP TO 30% OF INITIAL REPORTS OF UP TO 30% OF OPERATIVE CASES!OPERATIVE CASES!
►THEORIES WERE OF CELL THEORIES WERE OF CELL DISSEMINATION BY CO2 INSUFFLATION DISSEMINATION BY CO2 INSUFFLATION OR MECHANICAL TRANSMISSION OF OR MECHANICAL TRANSMISSION OF CELLS TO TROCAR SITES.CELLS TO TROCAR SITES.
INCISIONAL RECURRENCEINCISIONAL RECURRENCE
►2,439 PATIENTS OVER A 30 YEAR 2,439 PATIENTS OVER A 30 YEAR PERIODPERIOD
►1,603 CURATIVE RESECTION1,603 CURATIVE RESECTION►11 (0.45%) ISOLATED RECURRENCE IN 11 (0.45%) ISOLATED RECURRENCE IN
WOUND.WOUND.►(HUGHES et al. Dis Colon Rectum. (HUGHES et al. Dis Colon Rectum.
1983)1983)
INCISIONAL RECURRENCEINCISIONAL RECURRENCE
►21,500 cases from 58 Australian 21,500 cases from 58 Australian Surgeons.Surgeons.
►Wound recurrence .186%Wound recurrence .186%►Wound drain site recurrence .048%Wound drain site recurrence .048%
Wound recurrenceWound recurrence
TrialTrial LaparoscopicLaparoscopic OpenOpen
COSTCOST(median 4.4 yrs)(median 4.4 yrs)
2 / 435 (0.5%)2 / 435 (0.5%) 1 / 428 (0.2%)1 / 428 (0.2%)
LeungLeung(median 4.1 yrs)(median 4.1 yrs)
0 / 1670 / 167 0 / 1700 / 170
LacyLacy(median 3.6 yrs)(median 3.6 yrs)
1/ 1061/ 106 0 / 1020 / 102
Overall cancer recurrenceOverall cancer recurrence
TrialTrial LaparoscopicLaparoscopic OpenOpen
COSTCOST(median 4.4 yrs)(median 4.4 yrs)
76 / 435 76 / 435 (17%)(17%)
84 / 428 84 / 428 (20%)(20%)
LeungLeung(median 4.1 yrs)(median 4.1 yrs)
37 / 16737 / 167 30 / 17030 / 170
LacyLacy(median 3.6 yrs)(median 3.6 yrs)
18 / 10618 / 106 28 / 10228 / 102
TROCAR OR PORT SITE TROCAR OR PORT SITE RECURRENCERECURRENCE
►BASIC EXPERIMENTS TO DETERMINE BASIC EXPERIMENTS TO DETERMINE MECHANISMSMECHANISMS
►FILTERING OF EXHAUST COFILTERING OF EXHAUST CO2 2
►EXAMINATION OF LAPAROSCOPIC EXAMINATION OF LAPAROSCOPIC INSTRUMENTS & TROCARS.INSTRUMENTS & TROCARS.
Insufflating gas in
Water Bath 37°C
Filtered gas out
Laparoscopic grasper
Cannulæ
Humidity sensor
LIM 1215 solution
Colour TV Monitor Sony,
Trinitron PVM-144
3MD
Camera Controller
Olympus OTV-S4 CO2 Insufflator Olympus
Light Source Olympus Xenon 4
Camera Head Olympus MH-201
Supine Pig
Gamma Camera Serle
Anaesthetic Tubing
Mallinckrodt
12 mm Cannulæ Ethicon
Head
Laparoscope Olympus AS214 0°
TROCAR OR PORT SITE TROCAR OR PORT SITE RECURRENCERECURRENCE
0 minutes 30 minutes
LAP BABCOCK
LAP TROCAR
TROCAR SITE
EFFECT OF BLOODEFFECT OF BLOOD
►RADIOLABELLED CELLS WERE RADIOLABELLED CELLS WERE COMBINED WITH BLOOD.COMBINED WITH BLOOD.
► INSERTED INTO A PIG ABDOMEN.INSERTED INTO A PIG ABDOMEN.►CELLS TRAPPED IN A CLOT MATRIX. CELLS TRAPPED IN A CLOT MATRIX.
ALL TROCAR SITES AND INSTRUMENTS ALL TROCAR SITES AND INSTRUMENTS WERE CONTAMINATED WITH A WERE CONTAMINATED WITH A DESUFFLATED ABDOMEN.DESUFFLATED ABDOMEN.
INSUFFLATION VOLUME*INSUFFLATION VOLUME*
►CELL MOVEMENT AROUND THE CELL MOVEMENT AROUND THE PERITONEAL CAVITY IS INCREASED AS PERITONEAL CAVITY IS INCREASED AS THE VOLUME OF INSUFFLATION THE VOLUME OF INSUFFLATION INCREASES BUT THIS HAS NO EFFECT INCREASES BUT THIS HAS NO EFFECT ON TROCAR OR TROCAR SITE ON TROCAR OR TROCAR SITE CONTAMINATION.CONTAMINATION.
INSUFFLATION PRESSURE*INSUFFLATION PRESSURE*
► INSUFFLATION PRESSURE HAD AN INSUFFLATION PRESSURE HAD AN INVERSE RELATIONSHIP TO TROCAR & INVERSE RELATIONSHIP TO TROCAR & TROCAR SITE CONTAMINATION WITH TROCAR SITE CONTAMINATION WITH MALIGNANT CELLS.MALIGNANT CELLS.
TIMING OF LAVAGETIMING OF LAVAGE
► SIGNIFICANTLY GREATER NUMBER OF CELLS SIGNIFICANTLY GREATER NUMBER OF CELLS ON TISSUE RESECTED IN THE POSTOP ON TISSUE RESECTED IN THE POSTOP LAVAGE GROUP.LAVAGE GROUP.
► SIGNIFICANTLY GREATER NUMBER OF CELLS SIGNIFICANTLY GREATER NUMBER OF CELLS IN THE PREOP LAVAGE FLUID.IN THE PREOP LAVAGE FLUID.
► CELL CONTAMINATION OF RESECTED CELL CONTAMINATION OF RESECTED TISSUES DECREASED BY PREOPERATIVE TISSUES DECREASED BY PREOPERATIVE LAVAGE.LAVAGE.
TROCAR COMPOSITION*TROCAR COMPOSITION*
► IN VIVO & IN VITRO MODELS IN VIVO & IN VITRO MODELS
►TUMOUR CELLS ADHERE MORE TO TUMOUR CELLS ADHERE MORE TO METAL THAN PLASTIC TROCARSMETAL THAN PLASTIC TROCARS
►SURFACE ELECTROSTATIC CHARGE OR SURFACE ELECTROSTATIC CHARGE OR IRREGULAR SURFACEIRREGULAR SURFACE
ELECTRON MICROSCOPY ELECTRON MICROSCOPY METALMETAL
TROCAR COMPOSITION*TROCAR COMPOSITION*
►TROCAR DISPLACEMENT LEADS TO AN TROCAR DISPLACEMENT LEADS TO AN INCREASED CELL NUMBER AT TROCAR INCREASED CELL NUMBER AT TROCAR SITES.SITES.
FACTORS IN TROCAR SITE FACTORS IN TROCAR SITE CONTAMINATION.CONTAMINATION.
►MAINTAIN INSUFFLATION PRESSUREMAINTAIN INSUFFLATION PRESSURE►DECREASE PREOP TUMOUR LOADDECREASE PREOP TUMOUR LOAD
PREOP CYTOCIDAL LAVAGE.PREOP CYTOCIDAL LAVAGE.
WASHING INSTRUMENTS & TROCARS WASHING INSTRUMENTS & TROCARS DURING & AT END OF OP.DURING & AT END OF OP.
►MINIMIZE INTROPERATIVE BLEEDINGMINIMIZE INTROPERATIVE BLEEDING►USE NON METAL TROCARSUSE NON METAL TROCARS
Oncologic PrinciplesOncologic Principles
►Trocars sutured into positionTrocars sutured into position►Luminal cytocidal washoutLuminal cytocidal washout►Peritoneal washoutPeritoneal washout
?timing?timing 500ml of 10% betadine500ml of 10% betadine
►Wound protectorWound protector►Cytocidal to port sitesCytocidal to port sites