An analysis of the problem of biliary injury during laparoscopic cholecystectomy.
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Bile Ducts↗
Biomedical subjects
N J Soper
Publications and source records attributed to N J Soper.
Laparoscopic hepatobiliary surgery.
Laparoscopic hepatobiliary surgery has advanced rapidly in the past few years. Laparoscopic cholecystectomy has been the most significant advance and its value will become even greater as the incidence of biliary injuries is decreased. LCBDE and staging laparoscopy are very promising procedures. Other hepatobiliary laparoscopic operations such as liver resections and biliary-enteric anastomoses are still in developmental stages and will require a longer period of assessment.
Adult↗
Laparoscopic general surgery.
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Abdominal Pain↗
Laparoscopic Billroth II gastrectomy in the canine model.
The feasibility and safety of laparoscopic Billroth II gastrectomy were evaluated in an animate model. After developing the technique in acute animal experiments, laparoscopic antrectomy and Billroth II anastomosis was performed in six mongrel dogs. Video laparoscopic access to the peritoneal cavity was accomplished with six ports (five, 10 mm; one, 12-18 mm). The operations were performed without complication in 150-200 min (mean +/- SEM, 171 +/- 10 min). The animals tolerated solid oral meals on the 2nd or 3rd postoperative day. One dog developed frequent diarrheal stools and lost 3.4 kg prior to sacrifice 18 days postoperatively when a gastroileostomy was discovered. The remaining five animals did well and were sacrificed at 49-77 days postoperatively. Adhesions were minimal and the gastrojejunostomy was widely patent in all animals without evidence of leakage or obstruction. Laparoscopic Billroth II gastrectomy in the canine model is thus feasible and safe. Using laparoscopic guidance, it may be more difficult to identify the ligament of Treitz, which must be assured at the time of operation.
Anastomosis, Surgical↗
Effect of ileal oleate on interdigestive intestinal motility of the dog.
To determine the effect of ileal oleate on fasting intestinal motility, pairs of duodenal and ileal catheters and bipolar duodenal and jejunal seromuscular electrodes were surgically implanted in six dogs. The ileum was perfused with either normal saline (154 mM NaCl) or oleic acid emulsion (152 mM), while intestinal myoelectric activity was continuously monitored. For transit studies, a bolus of [3H]PEG was injected into the duodenum, and jejunal and ileal alliquots were collected every 15 min for a 6-hr study period. Plasma samples were collected for radioimmunoassays of peptide YY and enteroglucagon. Ileal oleate infusion increased the MMC cycle length and decreased the number of MMCs (P < 0.001) and the myoelectric spike-burst frequency/10 min in the duodenum (P < 0.05). Both duodenal-jejunal (P < 0.05) and duodenal-ileal transit (P < 0.01) were delayed markedly by ileal perfusion with oleic acid emulsion as compared to control studies. Ileal oleate increased plasma levels of peptide YY (P < 0.01) and enteroglucagon (P < 0.01). Ileal perfusion with oleate therefore activated the so-called "ileal brake," diminishing duodenal myoelectric spike bursts and slowing intestinal transit while concurrently increasing plasma levels of peptide YY and enteroglucagon.
Animals↗
Laparoscopic distal pancreatectomy in the porcine model.
Our aim was to assess the feasibility and safety of laparoscopic distal pancreatectomy in an animate model. After developing the technique in acute animal experiments, laparoscopic distal pancreatectomy was performed in five young domestic pigs. Five trocars were used (2-10 mm, 2-12 mm, 1-11 mm) for video laparoscopic access to the peritoneal cavity. The operations were performed without complication in 62-95 min (mean +/- SEM, 77 +/- 7 min). Each animal tolerated oral feedings on the first postoperative day and subsequently gained 6-11 kg (10 +/- 2 kg) in the 4-7-week interval prior to sacrifice. Although there was a significant increase in serum amylase on the first postoperative day, this was associated with a comparable increase in hematocrit, possibly representing hemoconcentration. The weight of the laparoscopically resected pancreatic segment ranged from 16 to 36 g (19 +/- 2 g) while that of the pancreatic head at sacrifice was 13-29 g (21 +/- 3 g). At the time of sacrifice, there were few intraabdominal adhesions and no evidence of fluid collection or pancreatitis. The staple line across the body of the pancreas was grossly intact in all animals. We conclude that laparoscopic distal pancreatectomy in the porcine model is feasible and safe. It may therefore be possible to perform laparoscopic distal pancreatectomy in humans.
Animals↗
Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis.
Laparoscopic cholecystectomy has rapidly become the prime modality for removal of the gallbladder. However, as laparoscopic techniques for treating choledocholithiasis are evolving, we reviewed our experience with acute gallstone pancreatitis since the inception of laparoscopic cholecystectomy. Between November 1989 and March 1993, we treated 57 patients with acute gallstone pancreatitis. Cholecystectomy was performed during the initial admission in 46 patients (81%, group I), while 11 (19%) underwent delayed cholecystectomy at a second admission 2 to 9 weeks later (group II). Within group I, eight patients (17%) were thought to have contraindications to laparoscopic cholecystectomy and underwent open cholecystectomy. In the remaining 38 patients of group I, laparoscopic cholecystectomy was completed successfully. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 of these patients (61%) and endoscopic sphincterotomy was performed in 6 patients (26%). In four other patients, the intraoperative cholangiogram revealed common bile duct stones that were removed using laparoscopic techniques. The 11 patients in group II were all treated by laparoscopic cholecystectomy; of these patients, 3 underwent preoperative endoscopic stone removal and 1 had choledocholithiasis managed laparoscopically. Postoperative hospitalization averaged 4 +/- 1 days (mean +/- SEM), and there was no major morbidity or 30-day mortality. This is the first large series of acute gallstone pancreatitis in the era of laparoscopic cholecystectomy. Our experience suggests that laparoscopic cholecystectomy with or without ERCP should be the primary approach for treating acute gallstone pancreatitis in the 1990s.
Acute Disease↗
Laparoscopic general surgery: current status and future potential.
In the 1990s, a sweeping change has occurred in general surgery driven by patients demanding cosmetically appealing incisions and speedier recuperation. Established surgeons have swarmed to academic and industry-sponsored courses to learn basic laparoscopic techniques. Hospitals have been forced to redesign operating suites and retrain nurses to keep pace with the technological changes. Industry has responded to powerful market forces with new high-tech equipment and a substantial investment for research and development. More and more, surgeons are collaborating with gastroenterologists, sonographers, and interventional radiologists with the hope of advancing minimally invasive surgical techniques. This article highlights the current status of laparoscopic surgery in the United States and foretells exciting advances for the future [1].
Contraindications↗
Laparoscopic surgery: surgical education in the People's Republic of China.
In 1991, because of the international emphasis on laparoscopic surgery, a large contingency of surgeons took on the task of introducing laparoscopy to the People's Republic of China. This trip was a technological feat, since all of the equipment and instrumentation had to be carried into the country. This necessitated a major coordinated effort among professional teaching staff and industry representatives with their transported equipment. This unique educational opportunity is detailed in this article, which highlights, in particular, the contrast between the new "high-tech" surgery and the reality of a developing country.
China↗
The case for routine operative cholangiography during laparoscopic cholecystectomy.
The debate over routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy continues because of a paucity of objective data to support or refute the case for either approach. The introduction of fluoroscopic techniques during the performance of cholangiography is an important step forward because it decreases the operative time for the technique and because real-time visualization may also diminish the number of false-positive and false-negative results. Routine cholangiography improves the surgeon's ability to delineate the biliary anatomy when the need arises and undoubtedly facilitates the development of skills useful for the laparoscopic management of common bile duct calculi. Normal results on intraoperative cholangiography are also reassuring to the surgeon, given the current visual and tactile limitations of laparoscopy. As a result of these considerations as well as our procurement of a digital fluoroscopic system and the need to train surgical residents in cholangiographic techniques, we have adopted a policy of routine fluoroscopic intraoperative cholangiography on all patients undergoing laparoscopic cholecystectomy.
Cholangiography↗
Laparoscopic duodenal diverticulectomy following hemorrhage.
A 53-year-old man on warfarin therapy for an aortic valve prosthesis suffered a massive upper gastrointestinal hemorrhage. Urgent endoscopy revealed active bleeding from the apex of a large duodenal diverticulum. Bleeding was successfully controlled with heater-probe applications, and the patient recovered uneventfully. Because of the patient's lifelong need for anticoagulation therapy, elective laparoscopic duodenal diverticulectomy was subsequently done using intraoperative endoscopic guidance. The patient returned to full activity and diet within 3 days and has remained stable during the postoperative interval. We describe here a new minimal access approach to a complicated duodenal diverticulum combining laparoscopic and endoscopic techniques.
Diverticulum↗
Physiology of the pneumoperitoneum.
This chapter reviews the physiology of the pneumoperitoneum, focusing specifically on the traditional CO2 method and new alternatives which may ultimately replace it. A continued emphasis of providing for a safe, effective and physiologically benign intra-abdominal exposure will be mandatory if laparoscopic procedures of increased complexity and longer duration are to be applied to patients who are old or very young, and ill.
Acid-Base Equilibrium↗
Diagnosis and management of biliary complications of laparoscopic cholecystectomy.
Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.
Abdominal Pain↗
Effect of nonbiliary problems on laparoscopic cholecystectomy.
Laparoscopic cholecystectomy may be performed safely in most patients with symptomatic cholelithiasis. There are few absolute contraindications to laparoscopic cholecystectomy. Many relative contraindications exist, which relate to the surgeon's experience and the ability of the operating team to manage potential complications. Preoperative evaluation should assess the potential nonbiliary problems that affect the performance of laparoscopic cholecystectomy, including severe cardiopulmonary disease, coagulopathy, cirrhosis, and pregnancy. Since most therapeutic laparoscopic procedures are currently performed with a carbon dioxide (CO2) pneumoperitoneum, the physiologic effects of the elevated abdominal pressure and absorbed CO2 must be understood by the surgeon. Specific nonbiliary problems addressed in this review are cardiopulmonary disease, hypercortisolism, cirrhosis and portal hypertension, morbid obesity, previous abdominal surgery, and pregnancy.
Arrhythmias, Cardiac↗
Gastrointestinal pacing.
Gastrointestinal pacing has been used to alter motor function and is effective in animal models in modulating gastric emptying, intestinal transit, and absorption. Application of gastrointestinal pacing to disorders of the human stomach and small bowel is an attractive treatment option that may some day become a clinical reality. Several technical problems must be overcome before further clinical testing can proceed.
Animals↗
Trocar site abscess due to spilled gallstones: an unusual late complication of laparoscopic cholecystectomy.
We describe a case of a 31-year-old woman who had an unusual complication after undergoing laparoscopic cholecystectomy. A subcutaneous abscess developed at the site of a 5-mm subcostal accessory port several months postoperatively. When drained, the abscess contained small gallstones that had spilled into the peritoneal cavity upon extraction of the gallbladder during laparoscopic cholecystectomy.
Abscess↗
Laparoscopic small bowel resection and anastomosis.
Our aim was to assess the feasibility and safety of performing totally intracorporeal laparoscopic small bowel resection and anastomosis using a linear stapling device. Laparoscopic small bowel resection and anastomosis were performed in five young domestic pigs. Five trocars were used (2-5 mm, 2-11 mm, and 1-12 mm) for video laparoscopic access to the peritoneal cavity. Segments of jejunum 5 to 10 cm long were excised using two firings of a 30-mm linear stapler (Endo-GIA). The bowel was anastomosed with the stapler in a functional end-to-end fashion, and the enterotomy was stapled closed. The excised bowel segment was then placed in a nylon entrapment sack, morcellated, and aspirated with an automatic electrical tissue morcellator. The pigs recovered uneventfully, were allowed oral feedings on the day after the operation, and gained weight normally in the postoperative period. Sacrifice after 4 to 10 weeks revealed few adhesions, no evidence of anastomotic leaks, and the anastomoses to be widely patent. Clinical application will be facilitated by the use of longer laparoscopic staplers, but surgeons must also develop suturing skills to assure safe performance of advanced laparoscopic surgery.
Anastomosis, Surgical↗
Retroperitoneal endoscopic adrenalectomy: an experimental study.
Laparoscopic approaches to adrenalectomy have been limited by the retroperitoneal (RP) location of the adrenal glands and their relative inaccessibility transabdominally. We developed a technique for endoscopic adrenalectomy in a domestic swine model using insufflation of the RP space with CO2 and retroperitoneoscopy. The technique for retroperitoneal endoscopic adrenalectomy was first developed in an acute study of three animals. A chronic survival study was then undertaken in six pigs. Unilateral right (n = 3) or left (n = 3) adrenalectomy was performed. Mean RP insufflation time was 14.5 min (range, 7-30 min), and mean dissection time after insufflation was 100 min (range, 80-120 min). Two additional animals died under anesthesia after RP insufflation and placement of the trocars for retroperitoneoscopy but before dissection of the adrenal gland. One death was unexplained at autopsy. The other death was associated with a right-sided pneumothorax attributable to penetration of the diaphragm by a trocar. The remaining six pigs recovered uneventfully from the procedure. Autopsies performed 37 to 51 days postoperatively showed minimal scarring of the adrenalectomy bed. The results suggest that posterior adrenalectomy using RP CO2 insufflation and direct retroperitoneoscopy is potentially applicable to the treatment of small adrenal lesions in humans.
Adrenalectomy↗