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Results of laparoscopic varicocelectomy in three patients are presented. The indications for minor laparoscopic procedures are discussed. In order to see if laparoscopic treatment (LT) can reduce the recurrence rate, a prospective trial of LT versus the Ivanissewish method is suggested.
According to whether uterine artery treatment takes place vaginally or laparoscopically, laparoscopy for hysterectomy can be considered according to two modalities: laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH). The indications for laparoscopy are defined by the limits and/or contraindications of the vaginal route. LAVH is indicated in the following situations: pelvic pain syndrome where diagnosis and treatment can be made at the same time as hysterectomy; minimal endometriosis; past surgical history favouring adhesions formation; necessity to perform an oophorectomy; existence of an ovarian pathology. The elective indications for TLH are the severe pelvic adhesions, deep endometriosis and especially a limited vaginal accessibility associating with a narrow vagina and a fixed or non prolapsed uterus. Laparoscopy thus allows to reduce the number of laparotomies. When on overage three quarters of the hysterectomies (excluding cases of uterogenital prolapse) were up till now performed abdominally, laparoscopy could reduce this rate to approximately 10%.
BACKGROUND/AIMS: Proton Pump inhibitors and laparoscopic techniques have had a dramatic impact on the therapy of gastroesophageal reflux disease. These techniques have introduced new complications associated with the treatment. This study compares the results of a laparoscopic Nissen fundoplication with life-long proton pump inhibitor treatment. MATERIALS AND METHODS: Between May 1991 and February 1996, 274 patients were treated by laparoscopic Nissen fundoplication (LNF). Two hundred twenty-four patients were included in this prospective study. Thirteen patients presented stage V esophagitis (Barrett); 4 had esophagitis stage IV; 16 had stage III, 181 had stage II and 11 had stage I. Five trocars were needed for the operation. After mobilization of the greater curvature, a fundic wrap of 5 cm was created and fixed on the esophagus. RESULTS: Median operating time was 60 min (39-300). There were 5 perioperative complications (a gastric perforation, three pleural perforations, and one liver laceration treated by coagulation). Three conversions to laparotomy were necessary. There were 4 early complications: two pulmonary infections and two re-operations; one case of wrap necrosis with peritonitis, and one case of small bowel perforation. Gastroscopy was performed in 133 cases. The esophagus was normal in 121 cases, an esophagitis stage I was present in 9, esophagitis stage II in 2, esophagitis stage III in one. Median lower esophageal sphincter pressure was 10 mmHg (2.9-30) preoperatively and 19 mmHg (9-40) post-operatively. Median reflux time was 10% (0-65) preoperatively and 1% (0-38) post-operatively. One hundred fifty-four patients were interviewed with a median follow up of 30 months (1-58). One hundred thirty patients were Visick I, 11 Visick II, 8 Visick III and 5 patients needed re-operation; three reoperations because of dysphagia, 1 because of epigastric pain and 1 for heartburn recurrence. CONCLUSIONS: From these results, we conclude that LNF seems to be an attractive alternative to long term medical treatment.
The aim of this study is to compare retrospectively the outcome of patients that underwent tubal surgery by laparotomy or laparoscopy by the same surgeon Thirty two women that presented with distal tubal obstruction were treated by laparoscopic tubal surgery and 38 by laparotomy and microsurgery. Patients were equally matched for age, duration of infertility and severity of disease. In all cases there were no injuries to adjacent groups and no additional surgery was needed. The duration of surgery was 35-60 min for laparoscopy and 70-120 min for laparotomy and mean duration of hospital stay was 2 and 7 days respectively. Of the 32 cases that underwent laparoscopic surgery 10 had intrauterine pregnancies (31.25%) and 2 ectopic (6.2%). Conversely 11 (28.9%) of the 38 cases with tubal microsurgery resulted in intrauterine pregnancy and 4 (10.5%) in ectopic. Our results suggest that laparoscopic tubal surgery is the method of choice for the treatment of distal tubal obstruction.
In this report, we present two cases of small bowel obstruction after laparoscopic herniorrhaphy (LH). One case involved incarceration of the small intestine into the port site, resulting in obstruction in an 80-year-old man on the third day after LH. The other case involved a 78-year-old man with bilateral inguinal hernia and a recurrent type on one side. In this case, a small bowel obstruction occurred due to intestinal herniation through the repaired peritoneum in the pelvic floor. In both cases, the location of the obstruction was diagnosed by means of a computed tomography scan. Subsequently, the trocar incision was extended to relieve obstruction with laparotomy in the first case, and the herniated intestinal loop was extracted followed by reclosure of the defective peritoneum under laparoscopic intervention in the second case. After the second operation, the clinical course of each patient was uneventful, and they were discharged from hospital at 10 days after the second surgery. In conclusion, (a) although patients can greatly benefit from LH, it must be kept in mind that problems can occur and (b) laparoscopic surgery to relieve small bowel obstruction following LH is the preferred procedure.
All laparoscopic appendectomies were analysed retrospectively during 6/1992 and 8/1997 in our hospital. Operation time was 33.6 +/- 12.9 min. In 9 patients the operation had to be converted. Complications occurred in 1.77% (13 patients). 7 complications could be treated laparoscopically and 6 required a laparotomy. The hospital time was 6.4 +/- 2.2 days. The patients needed 1.3 +/- 1.7 days oral analgetics. We believe the laparoscopic appendectomy a reliable operation to treat all inflammatory diseases of the appendix.
Two cases of limited laparoscopic liver resection of benign tumors located in segment II and segment IV have been presented. The tumors were found during preoperative studies of biliary attacks and studied by means of ultrasonography and computed tomographic scan. During laparoscopy, the exact localization and surgical limits of the tumors were determined by visualization and laparoscopic ultrasonography. Dissection during laparoscopy was performed using the endoscopic cavitational ultrasonic surgical aspirator, achieving resection of the tumors with minimal blood loss.
BACKGROUND: The introduction of laparoscopic cholecystectomy (LC) changed the treatment strategies for patients undergoing biliary surgery. There is a lack of data about acute postoperative pancreatitis (APP) as a complication of LC. OBJECTIVES: To determine the incidence, morbidity, and mortality of APP after LC and to analyze the possible intraoperative and pathogenic factors associated with APP. DESIGN: A prospective cohort study of 10174 patients who underwent LC. The data for 32 patients with APP after the completion of LC and 8 patients with APP after an attempted LC that was converted to an open cholecystectomy were analyzed. SETTING: A multi-institutional study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Eighty-one surgical services or surgeons in private practice participated. RESULTS: The incidence of APP after a completed LC was 0.34%. In comparison, the incidence of APP after conversion to an open procedure (0.96%) was significantly (P = .02) increased. A biliary origin of APP could be established in 4 (12.5%) of the 32 patients. No evidence for a causative role of intraoperative cholangiography or trauma to the pancreas was found. Factors shown to be associated with APP were the surgeon's experience level and a high morbidity of 31.3%. The mortality was 3%. CONCLUSIONS: The incidence of APP after LC is low; the risk increases after conversion to an open procedure. In the rare event of an APP after LC, a biliary cause should be suspected. The mortality of patients with APP did decrease substantially compared with those undergoing open biliary surgery.
Laparoscopic excision is a widely accepted and well-described approach to islet cell tumors of the pancreas. We report the case of a patient with biochemically proven insulinoma who underwent successful enucleation using the curved laparoscopic coagulating shears. We discuss the advantages of using laparoscopy to manage these tumors and the increased benefit of using the curved instrument for this type of procedure.
BACKGROUND: The efficacy of conventional laparoscopic cholecystectomy (CLC) was compared with robot-assisted laparoscopic cholecystectomy (RLC). Surgical trainees performed the LC to avoid the surgeon's experience bias. METHODS: Two surgical trainees performed 10 CLCs and 10 RLCs at random with a Zeus-Aesop Surgical Robotic System. The primary efficacy parameters were the total time and the number of actions involved in the procedure. The secondary parameters were setup and dissection times, and the number of grasping and dissection actions. Surgical complications were evaluated. RESULTS: For CLC and RLC, respectively, the total times were 95.4 +/- 28 min and 123.5 +/- 33.3 min and the total actions were 420 +/- 176.3 and 363.5 +/- 158.2. For CLC, the times required for setup (21 +/- 10.4 min) and dissection (50.2 +/- 17.7 min) were less than for RLC (33.8 +/- 11.3 min and 72 +/- 24.3 min, respectively). The numbers of grasping and dissection actions were not significantly different: 41.4 +/- 26.5 and 378 +/- 173.7, respectively, for CLC versus 48.9 +/- 27 and 314.6 +/- 141.9, respectively, for RLC. CONCLUSION: Although feasible, RLC requires significantly more time than CLC because of slower performed actions.
BACKGROUND: Laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOEST) was compared with laparoscopic exploration of the common bile duct (LCBDE) for cholecystocholedocholithiasis in an attempt tried to find the best mini-invasive treatment for the cholelithiasis and choledocholithiasis. METHODS: For this study, 234 patients with cholelithiasis and choledocholithiasis diagnosed by preoperative B-ultrasonography and intraoperative cholangiogram were divided at random into an LC-LCBDE group (141 cases) and an LC-IOEST group (93 cases). The surgical times, surgical success rates, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative lengths of stay, and hospital charges were compared prospectively. RESULTS: There were no differences between the two groups in terms of surgical time, surgical success rate, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative length of stay, and hospital charge. CONCLUSION: Both LC-IOEST and LC-LCBDE were shown to be safe, effective, minimally invasive treatments for cholecystocholedocholithiasis.
BACKGROUND: We set out to assess the safety and efficacy of mini-laparoscopic cholecystectomy (MLC) in uncomplicated situations. METHODS: MLC was performed on 30 consecutive selected patients (< 60 years old, ASA I-II, uncomplicated cholecystectomy) with one 12-mm and three 3-mm ports. The total operating time, conversion rate, degree of postoperative pain, duration of postoperative hospital stay, complications, and cosmetic results were all reviewed and compared with 30 cases of consecutive conventional laparoscopic cholecystectomy (LC). RESULTS: None of the patients in either group required conversion to open cholecystectomy. No complications were observed. The operating time and duration of hospital stay were similar in both groups. The level of postoperative pain was lower in the MLC group (p < 0.001). More patients in the MLC group expressed satisfaction with the cosmetic result (p < 0.05). CONCLUSIONS: MLC was shown to be feasible in uncomplicated situations. Furthermore, it was associated with less pain and produced better cosmetic results than conventional LC. Randomized studies are still needed to confirm these findings.
BACKGROUND: Laparoscopic cholecystectomy (LC) is the preferred treatment for gallstone disease, even in many complicated cases. Perhaps the only downside to LC is a two- to threefold increase in common bile duct (CBD) injuries compared with open cholecystectomy (OC). Intraoperative cholangiography may prevent inj uries, but its routine use remains controversial. Our institution adopted a policy of selective intraoperative cholangiography in 1993. When intraoperative laparoscopic ultrasonography (IOUS) emerged as a viable diagnostic adjunct, it was hypothesized that the routine use of IOUS would facilitate dissection, detect occult choledocholithiasis, and prevent bile duct injuries during LC. STUDY DESIGN: The experience with LC at our university-affiliated teaching hospital was reviewed. Over a 4 1/2-year period (June 1, 1995, to January 31, 2000), two surgeons used IOUS routinely during LC (ultrasonography [US] group, n = 248); three other surgeons did not (non-US group, n = 594). We compared patient data and outcomes between the two groups. Continuous, data are expressed as mean +/- SEM. RESULTS: During the study period, 842 LCs were attempted. Patient age (37+/-1 years) and gender (85% female) did not differ between the groups. In the US group, more patients had acute cholecystitis (p < 0.05). More LCs were performed per year by non-US surgeons than US surgeons (45 versus 37). Despite this, all bile duct complications occurred in non-US cases (2.5% overall): five CBD injuries (0.8%), six bile leaks (1%), and four retained CBD stones (0.7%). In the subgroup of patients with acute cholecystitis, there were fewer conversions to OC in US compared with non-US cases (24% versus 36%, p = 0.09). CONCLUSIONS: IOUS is noninvasive, fast, repeatable, and can corroborate real-time visualization of the operative field. We have found that LC with IOUS is associated with fewer bile duct complications (CBD injuries, bile leaks, and retained CBD stones) than LC without adjunctive imaging. The success rate of LC in cases of acute cholecystitis is slightly higher when IOUS is used as an aid to dissection. In the absence of definitive prospective data, we recommend routine use of IOUS when performing LC, particularly in patients with acute cholecystitis.
Three women experienced bleeding, pain, and pressure symptoms attributable to uterine myomas. Because they were not responsive to conservative therapy, they underwent outpatient laparoscopic myomectomy after 3 months of gonadotropin-releasing hormone agonist administration. The Endo Stitch 10-mm laparoscopic suturing device was used to close the uterus with interrupted and continuous locked sutures. The instrument shortened the operative time by approximately 40 minutes.
We reviewed 600 patients who underwent laparoscopic cholecystectomy (LC) in a teaching community hospital from May 1990 to August 1992. The safety, efficacy, morbidity, and mortality of LC, as performed by one surgeon or under his direct supervision, were studied. Five hundred forty-eight patients (91.3%) were treated electively; 52 (8.7%) were admitted for acute cholecystitis (41) or gallstone pancreatitis (11). Mean operating time was 54 min, with a range of 20 to 145 min. Twenty-four (4%) patients required conversion to traditional (open) cholecystectomy. Operative cholangiograms were completed in 106 patients. These revealed choledocholithiasis in 7. Five hundred thirty-seven patients (89.5%) were discharged within 24 h and 564 (94%) within 48 h. The overall morbidity of 9.2% compared favorably with both open and laparoscopic series previously reported. Three patients (0.5%) had small lacerations of the anterior wall of the common duct. Two were recognized and repaired immediately. The third patient came for treatment on the fifth postoperative day and was stented by a T-tube. There was 1 death in this group--a myocardial infarction on postoperative day 4.
BACKGROUND: Transcutaneous electrogastrography (EGG) is a non-invasive method of examination that allows monitoring of gastric myoelectric activity. The goal of this prospective study was to describe changes in gastric motility in the early postoperative period in extremely obese patients, who underwent planned surgery--Laparoscopic Non-Adjustable Gastric Banding (LNGB) and to establish the specificity of observed differences for this intervention. PATIENTS AND METHODS: Myoelectric gastric activity was evaluated in the perioperative period in 20 extremely obese patients undergoing LNGB. The results of monitoring up to +24 h after the intervention were compared to a group of 15 healthy volunteers, and to a group of 20 patients undergoing laparoscopic cholecystectomy (LC). The recording was performed in both the patient and control groups 24 h before the operation and +5 h, +24 h and +48 h after the surgery, both in the fasting state and after stimulation with a liquid bolus. The data were recorded using the Microdigitrapper device and analyzed using the spectral analysis and Fourier transformation. RESULTS: The finding characteristic in the early postoperative period was a decrease in frequency of both spontaneous and stimulated gastric contractions (bradygastria) at +5 h after the intervention, that was followed by rapid return to baseline activity. In patients after LNGB, the normalization of motility was seen within 24 h, and in patients after LC within 48 h after the intervention. Tachygastria was not found in any patient who did not have complications, but on the contrary it was found in both patients with significant dyspepsia after LC. CONCLUSIONS: In the early postoperative period after LNGB, significant changes in myoelectric gastric activity were seen and were characterized by transient bradygastria. Comparison with the reference group of patients after LC shows that the intensity and duration of basal and stimulated bradygastria has a non-specific relationship with the extent of tissue trauma caused by the intraabdominal surgery. It is not specific for the gastric banding itself. The method of measuring the basal stimulated EGG potentials can be used in routine surgical practice as an auxiliary method for evaluation of the functional status of the gastrointestinal tract after intraabdominal surgery.
We retrospectively evaluated the role of intraoperative cholangiography (IOC) combined with laparoscopic intraoperative ultrasonography (LIOU) for detection of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. We reviewed 184 patients with biliary stones. Preoperatively, all patients underwent ultrasonography (US); 183 of the patients were investigated by cholangiography (oral and intravenous cholangiography in 145 and endoscopic retrograde cholangiography in 44). LIOU was carried out in all patients and IOC was done in 183. LIOU visualized the bile duct in 94.6% of the patients and IOC was successful in 95.6%. CBD stones were detected in a total of 17 patients, 9 (52.9%) of whom were positive on preoperative investigations. The sensitivity for detecting CBD stones was 29.4% with US, 22.2% with oral and intravenous cholangiography, 50.0% with endoscopic retrograde cholangiography, 82.4% with LIOU, and 93.3% with IOC. The diameter of the stones visualized intraoperatively (4.4 +/- 1.2 mm) was smaller than that of the stones detected preoperatively (6.9 +/- 2.6 mm). The stones were removed during laparoscopy in 15 patients and after conversion to laparotomy in 2. None of the patients had residual CBD stones after follow-up for 6 to 50 months. Intraoperative examination using both LIOU and IOC was useful for prevention of residual CBD stones.
OBJECTIVE: To evaluate the role of laparoscopic ultrasonography(LUS) in prevention of bile duct injury(BDI) and residual common bile duct (CBD) calculi during complicated laparoscopic cholecystectomy (LC). METHODS: One hundred and four cases of LC were defined complicated because of anatomic aberrance of the extrahepatic biliary system, unconfirmed exposed cystic duct, suspected CBD calculi or BDI, adhesion or inflammation in the Calot's triangle, acute cholecystitis, and atrophic gallbladder. LUS was performed to scan the extrahepatic bile duct. LC was carried out with assistance of the LUS. RESULTS: Assisted with the LUS demonstrated anatomic relationship between the extrahepatic bile duct and cystic infundibulum or cystic duct, 85 cases of LC were accomplished successfully. 19 were converted to open cholecystectomy because of LUS-indicated potential risk of BDI, CBD calculi, and suspected BDI. CONCLUSIONS: With the extrahepatic bile duct visualized by LUS and contrast of the cystic infundibulum and cystic duct, operators can precisely identify the anatomic relationships between the cystic infundibulum, cystic duct and extrahepatic bile duct. Preoperatively unpredicted choledocholithiasis may be recognized.