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