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PubMed1996

Reuse of disposable laparoscopic instruments: cost analysis.

OBJECTIVE: To evaluate the cost benefits of reusing disposable laparoscopic instruments. DESIGN: A cost-analysis study based on a review of laparoscopic and thoracoscopic procedures performed between August 1990 and January 1994, including analysis of disposable instrument use, purchase records, and reprocessing costs for each instrument. SETTING: The general surgery department of a 461-bed teaching hospital where disposable laparoscopic instruments are routinely reused according to internally validated reprocessing protocols. METHODS: Laparoscopic and thoracoscopic interventions performed between August 1990 and January 1994 for which the number and types of disposable laparoscopic instruments were standardized. MAIN OUTCOME MEASURES: Reprocessing cost per instrument, the savings realized by reusing disposable laparoscopic instruments and the cost-efficient number of reuses per instrument. RESULTS: The cost of reprocessing instruments varied from $2.64 (Can) to $4.66 for each disposable laparoscopic instrument. Purchases of 10 commonly reused disposable laparoscopic instruments totalled $183,279, and the total reprocessing cost was estimated at $35,665 for the study period. Not reusing disposable instruments would have cost $527,575 in instrument purchases for the same period. Disposable laparoscopic instruments were reused 1.7 to 68 times each. CONCLUSIONS: Under carefully monitored conditions and strict guidelines, reuse of disposable laparoscopic and thoracoscopic instruments can be cost-effective.

Cost-Benefit Analysis↗
PubMed1997

Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series.

BACKGROUND: The risk of bile duct injury in laparoscopic cholecystectomy has been a concern since the procedure became part of the surgical armamentarium. Our study assesses the incidence, types, and treatment for laparoscopic bile duct injury. STUDY DESIGN: Prospective case registration in a national database with participation by all departments of surgery performing laparoscopic cholecystectomy in Denmark since the first operation in January 1991. The case notes for bile duct injury have been reviewed. RESULTS: From 1991 through 1994, 57 of 7,654 patients sustained bile duct injury (0.74 percent; 95 percent confidence interval, 0.55 percent to 0.94 percent), including nine injuries occurring after conversion. The annual incidence did not decrease. Thirty-nine percent of the laparoscopic bile duct injuries were incisions, 39 percent were transections, and 12 percent were clip injuries or strictures. One patient, who sustained transection during open reoperation for bleeding after a converted procedure, died. Bile leaks for reasons other than bile duct injury occurred in 2.1 percent; 71 percent of these were cystic duct leaks. Acute cholecystitis was the indication for laparoscopic cholecystectomy in 968 patients, with 1.3 percent sustaining laparoscopic bile duct injury (95 percent confidence interval, 0.62 percent to 2.08 percent), while the incidence in patients with other indications for laparoscopic cholecystectomy was 0.62 percent (95 percent confidence interval, 0.44 percent to 0.82 percent) (p > 0.05). Preoperative knowledge of bile duct anatomy was available by means of preoperative endoscopic retrograde cholangiopancreatography or intravenous cholangiography in 26 percent of patients undergoing laparoscopic cholecystectomy but this did not reduce the risk of bile duct injury. The frequency of bile duct injury in patients who had intraoperative cholangiography was not significantly different from those who did not. Intraoperative cholangiography was done in 14 cases of injury (diagnostic for injury in 8, misinterpreted in 2, and normal in 4 patients). The case notes described operative difficulties in 11 of 48 cases of laparoscopic bile duct injury, most often because of fibrosis or difficulty delineating the anatomy. CONCLUSIONS: The incidence of bile duct injury in laparoscopic cholecystectomy is higher than previously generally anticipated and did not decrease from 1991 through 1994. Risk factors and possible preventive measures should be evaluated in prospective studies.

Bile Ducts↗
PubMed1999

Laparoscopic colectomy: indications for conversion to laparotomy.

HYPOTHESIS: Although experience with laparoscopic colectomy continues to accumulate, criteria for patient selection for the procedure have yet to be developed. We propose that review of indications for conversion to laparotomy during laparoscopic colectomy should define some of the current technical limitations of the procedure. This information may facilitate development of selection criteria for laparoscopic colon and rectal surgery. DESIGN: Single-institution retrospective medical records review. SETTING: Tertiary referral center. PATIENTS: Two hundred patients who underwent laparoscopic colon surgery, in 47 (23.5%) of whom the procedure was converted to laparotomy. INTERVENTIONS: A registry of 200 patients who have undergone laparoscopic colon surgery was analyzed. Medical records of 47 patients whose procedure was converted were reviewed to assess indications for conversion and identify factors contributing to the need for conversion. RESULTS: Between July 1, 1991, and September 30, 1998, 200 laparoscopic colon procedures were performed: 78 ascending colectomies, 74 descending or sigmoid colectomies, 14 diverting stomas, and 34 "other procedures." The 200 patients were divided into 4 cohorts of 50 consecutive patients to analyze changes with time. The conversion rate was statistically greater in the first quarter (18 patients [36.0%]) than in subsequent quarters (16.0%; P <.05). The rate of conversion to laparotomy for segmental resection of the ascending and descending colon (31/153 [20.3%]) has been equivalent and less than the conversion rate for other procedures (16/33 [48.5%]; P <.05). The distribution of patients by operative indication has been fairly constant. The indication for operation has not influenced the need for conversion. The indications for conversion were technical problems in 15 patients (hypercarbia, unclear anatomy, and stapler misfire), laparoscopic complications in 9 patients (bleeding, cystotomy, and enterotomy), and problems that exceeded the limits of laparoscopic dissection in 23 patients (phlegmon, adhesions, obesity, and adjacent organ involvement by cancer). CONCLUSIONS: Our conversion rate has decreased during our experience, and currently the need for conversion to laparotomy is most frequently caused by situations such as excessive tumor bulk, adhesions, and diverticular phlegmon that exceed the technical limitations of laparoscopic dissection. Colorectal reanastomosis following a Hartmann resection and procedures involving resection of the distal rectum are unlikely to be successfully completed. Although obesity accentuates the technical limitations of laparoscopic dissection, it is an infrequent cause for conversion to laparotomy.

Colectomy↗
PubMed2002

Early and late recipient graft function and donor outcome after laparoscopic vs open adult live donor nephrectomy for pediatric renal transplantation.

BACKGROUND: Laparoscopically procured live donor kidney grafts are increasingly transplanted into pediatric recipients. The safety and efficacy of this changed surgical practice are unknown. HYPOTHESIS: Outcomes of laparoscopic vs open donor grafts in recipients 18 years and younger are equivalent. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center. PATIENTS: Eleven consecutive pediatric recipients of laparoscopically procured kidneys between April 1, 1997, and December 31, 2001, were pair matched for age with 11 recipients of openly procured kidneys between December 1, 1991, and March 31, 1997; the 22 adult donors were also studied. MAIN OUTCOME MEASURES: Recipients: surgical complications, graft function and survival. Donors: perioperative morbidity and length of hospital stay. RESULTS: Twenty (91%) of 22 kidneys were donated by a parent of the recipient. In recipients of laparoscopically procured grafts, we observed significantly lower creatinine clearances and higher creatinine levels on days 1, 4, and 6, but by 1 month, graft function was similar in both groups. No significant differences in surgical complications, delayed function, acute and chronic rejection, and graft survival rates were found. No laparoscopic or open donor required blood transfusion, reoperation, or hospital readmission. One laparoscopic donor (9%) was converted to open nephrectomy. For laparoscopic vs open donors, median operative time was longer (difference, 67 min; P =.08), but median postoperative length of stay was significantly shorter (3 vs 5 days; P =.02). CONCLUSIONS: Laparoscopic live donor nephrectomy has no adverse impact on pediatric recipient outcomes. For donors, the laparoscopic operation is safe and the hospital stay is shortened. These results support the continued use of laparoscopically procured live donor kidneys in pediatric renal transplantation.

Adolescent↗
PubMed2003

Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery.

BACKGROUND: One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary. HYPOTHESIS: Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year. DESIGN: Prospective nonrandomized trial of a consecutive sample. SETTING: University-affiliated community hospital. PATIENTS: Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration. INTERVENTION: All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure. MAIN OUTCOME MEASURES: Recurrences, complications, postoperative lower esophageal sphincter pressure, DeMeester score, esophagogastroduodenoscopy results, and barium swallow results. RESULTS: All refundoplications were completed laparoscopically. There were no intraoperative complications. Twenty-one patients underwent laparoscopic Nissen fundoplication; in 3 patients, a laparoscopic Toupet fundoplication was performed. Previous antireflux procedures included an open Nissen fundoplication (n = 5), a laparoscopic Nissen fundoplication (n = 15), and a laparoscopic Toupet fundoplication (n = 4). Postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. During a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. The mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm Hg) and 1 year (11.9 mm Hg) after refundoplication. The mean DeMeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication. CONCLUSION: Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.

Female↗
PubMed2003

Complications after laparoscopic gastric bypass: a review of 3464 cases.

HYPOTHESIS: The type and frequency of complications after open Roux-en-Y gastric bypass (GBP) have changed with the development of laparoscopic technique. BACKGROUND: The number of laparoscopic GBP cases performed in the United States has increased dramatically during the past several years. We compared the type and frequency of complications after laparoscopic and open GBP. METHODS: We searched MEDLINE from January 1, 1994, through December 31, 2002, using the keywords morbid obesity, laparoscopy, bariatric surgery, and gastric bypass. We selected studies on laparoscopic or open GBP with more than 50 patients and published in the English language for analysis. We excluded studies with reoperative Roux-en-Y GBP cases or other bariatric procedures. The type and frequency of postoperative complications were recorded from each study. We used chi2 and Fisher exact tests to determine statistical significance. RESULTS: Ten laparoscopic GBP studies with 3464 patients and 8 open GBP studies with 2771 patients were considered. The mean of the reported average age for patients undergoing laparoscopic GBP was 41 years compared with 43 years for open GBP. The mean percentages of female patients were 87% for laparoscopic GBP and 82% for open GBP; the mean reported average body mass index (calculated as weight in kilograms divided by the square of height in meters), 48.7 and 49.5, respectively. Compared with open GBP, laparoscopic GBP was associated with a decrease in the frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there was an increase in the frequency of early and late bowel obstruction, gastrointestinal tract hemorrhage, and stomal stenosis. There were no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia. CONCLUSIONS: The type and frequency of postoperative complications after laparoscopic and open GBP are different. Certain complications increase with laparoscopic GBP, probably owing to the learning curve of this complex procedure, whereas other complications decrease because of the advantages of the smaller access incision.

Adult↗
PubMed1992

Laparoscopic versus open appendicectomy: a prospective evaluation.

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.

Acute Disease↗
PubMed2001

Laparoscopic revision of failed antireflux operations.

BACKGROUND: A small number of patients fail fundoplication and require reoperation. Laparoscopic techniques have been applied to reoperative fundoplications. We reviewed our experience with reoperative laparoscopic fundoplication. METHODS: Reoperative laparoscopic fundoplication was undertaken in 28 patients, 19 F and 9 M, of mean age 56 years +/- 12. Previous antireflux procedures included 19 open and 12 laparoscopic antireflux operations. RESULTS: Symptoms were heartburn (90%), dysphagia (35%), and atypical symptoms (30%%). The mean interval from antireflux procedure to revision was 13 months +/- 4.2. The mean DeMeester score was 78+/-32 (normal 14.7). Eighteen patients (64%) had hiatal breakdown, 17 (60%) had wrap failure, 2 (7%) had slipped Nissen, 3 (11%) had paraesophageal hernias, and 1 (3%) had an excessively tight wrap. Twenty-five revisions were completed laparoscopically, while 3 patients required conversion to the open technique. Complications occurred in 9 of 17 (53%) patients failing previous open fundoplications and in 4 of 12 patients (33%) failing previous laparoscopic fundoplications and included 15 gastrotomies and 1 esophagotomy, all repaired laparoscopically, 3 postoperative gastric leaks, and 4 pneumothoraces requiring tube thoracostomy. No deaths occurred. Median length of stay was 5 days (range 2-90 days). At a mean follow-up of 20 months +/- 17, 2 patients (7%) have failed revision of their fundoplications, with the rest of the patients being essentially asymptomatic (93%). CONCLUSIONS: The results achieved with reoperative laparoscopic fundoplication are similar to those of primary laparoscopic fundoplications. Laparoscopic reoperations, particularly of primary open fundoplication, can be technically challenging and fraught with complications.

Adult↗
PubMed2005

Laparoscopic TME-the surgeon's or the patient's preference.

Since laparoscopic surgery in rectal cancer was introduced ten years ago large patient collectives have been published by several authors in the meantime. The literature was carefully reviewed to analyse data on postoperative complications, long term prognosis and quality of life after laparoscopic surgery for rectal cancer to answer the question whether laparoscopic surgery is still just feasible or maybe has even reached the golden standard. The review showed that there is not a single prospectively randomized trial published comparing laparoscopic vs. open surgery for rectal cancer. It is clearly evident that until now the most laparoscopic series are published with patients selected according to criteria that vary significantly especially regarding the kind of procedures performed (anterior, low anterior, intersphincteric resections and abdomino-perineal excision), other demographic items like gender, body mass index, eventual prior laparotomies, emergencies and tumor related characteristics like tumor stage or T-categories. At the moment any data concerning outcome from prospectively randomized trials comparing laparoscopic versus open surgery for rectal cancer are missing. Therefore, there is more speculation and belief concerning the true quality of laparoscopic surgery. The review in the literature only indicates, that laparoscopic surgery for rectal cancer is feasible. To prove the potential advantage of laparoscopic surgery in rectal cancer randomized trials are essential. If a surgeon discusses laparoscopic surgery outside a randomized trial, he should go through a questionnaire, presented in the paper which reflects the present situation without any proven advantage and not available long term results and should leave a final decision to the patient.

Digestive System Surgical Procedures↗
PubMed1996

Totally laparoscopic aortobifemoral bypass grafting in an experimental model: description of technique with initial surgical results.

Our aim was to examine the feasibility of a totally laparoscopic insertion of a bifurcated aortofemoral bypass graft in a canine model and to compare the surgical results with those in control animals undergoing standard grafting and laparoscopic-assisted bypass procedures. Using a six-port approach, we exposed and cross clamped the aorta, tunneled a bifurcated Dacron graft, and performed an end-to-end aortic anastomosis while maintaining pneumoperitoneum by means of CO2. Proximal anastomoses were performed with 4/0 double-ended continuous Prolene sutures and distal anastomoses were performed through standard groin incisions. Total operating and aortic cross-clamp times were measured as was the total blood loss for each procedure. Clinical outcome was also documented. Eight female laboratory-bred hounds underwent successful totally laparoscopic aortobifemoral bypass grafting, eight underwent "open" grafting, and eight underwent laparoscopic-assisted bypass. Mean operating time was 193 minutes in the animals undergoing totally laparoscopic insertion vs. 156 minutes in the open group and 180 minutes in the laparoscopic-assisted group. Aortic cross-clamping time was also significantly longer at 87 minutes vs. 43 minutes (p < 0.001) in the totally laparoscopic group, but blood loss was less. All eight laparotomy and laparoscopic-assisted dogs were still alive with no complications at 28 days, whereas three of the eight in the totally laparoscopic group showed evidence of temporary paraplegia. This experimental study demonstrates that a totally laparoscopic approach can be used to insert a bifurcated aortofemoral bypass with a proximal end-to-end anastomosis but currently does not save time and may increase the risk of neurologic complications.

Anastomosis, Surgical↗
PubMed1994

Interleukin-6 response to laparoscopic and open colectomy.

PURPOSE: It has been postulated that cortisol and interleukin-6 play a significant role in the modulation of the early inflammatory response following surgical intervention. There are no available data on the normal responses of these mediators following major laparoscopic procedures. The purpose of this study was to assess changes in cortisol (by fluorescence polarization immunoassay), interleukin-6 (by enzyme-linked immunoassay), and interleukin-1 (by enzyme-linked immunoassay) after elective laparoscopic colon resections. METHODS: All patients undergoing colon resection between February 1, 1992 and April 30, 1992 were eligible for study. Selection of laparoscopic (N = 12) vs. open (N = 41) resection was determined by the attending surgeon. All patients received a standard general anesthetic with endotracheal intubation. Cortisol, interleukin-6, and interleukin-1 were measured at preinduction, 1 hour, 2 hours, 3 hours, 4 hours, and 5 hours after the induction. Interleukin-6 and interleukin-1 were additionally measured at 12 hours, 24 hours, and 72 hours after induction. Comparisons were made between the laparoscopic patients (N = 12) and age, sex, and operation-matched open patients (N = 12). RESULTS: Cortisol levels rose in the early postoperative period in both open and laparoscopic groups with no significant differences occurring between the cohorts at any of the measured time intervals. The interleukin-6 levels of the laparoscopic cohort (N = 12) were significantly lower than those of the open cohort (N = 12) between 3 and 24 hours postinduction (P < 0.05). Interleukin-1 levels remained undetectable in virtually all patients irrespective of operative technique or postoperative interval. There was no correlation between peak interleukin-6 levels and operative times (laparoscopic, r = 0.31; open, r = 0.36) or blood loss (laparoscopic, r = 0.10; open, r = 0.20). CONCLUSION: The results indicate that laparoscopic colon resections do not appear to alter cortisol or interleukin-1 responses when compared with open colon resection. There is, however, a significant blunting of the interleukin-6 response associated with the use of laparoscopic techniques for colectomy compared with standard laparotomy.

Blood Loss, Surgical↗
PubMed1997

Intermittent sequential compression of the lower limbs prevents venous stasis in laparoscopic and conventional colorectal surgery.

PURPOSE: This study was designed to evaluate the influence of intraoperative intermittent sequential compression (ISC) on venous blood return from the lower limbs during laparoscopic and conventional colorectal colectomy. METHODS: Fifty patients undergoing laparoscopic (n = 25) or conventional (n = 25) colorectal surgery were included in a prospective study. Peak venous flow (PFV) and the cross-sectional area (CSA) of the femoral vein were assessed by Doppler ultrasound examination intraoperatively. RESULTS: Age, gender, and body mass index were comparable between both groups. Baseline PFV was 21 +/- 6.6 cm/s in the conventional and 18.4 +/- 6.4 cm/s in the laparoscopic group (P = 0.2). ISC increased PFV to 156 +/- 29 percent of the baseline value in the conventional group and to 161 +/- 29 percent in the laparoscopic group. PFV decreased after abdominal insufflation to 127 +/- 19 percent of the baseline value in the laparoscopic group and after laparotomy to 134 +/- 27 percent in the conventional group (P = 0.3). PFV decreased slightly in both groups during surgery but remained well above the baseline value. Baseline CSA was 1.02 +/- 0.17 cm2 in the conventional group and 1 +/- 0.23 cm2 in the laparoscopic group. ISC decreased CSA to 0.91 +/- 0.18 cm2 (conventional) and 0.85 +/- 0.18 cm2 (laparoscopic) after initiation of ISC. CSA was 0.92 +/- 0.18 cm2 after abdominal insufflation in the laparoscopic group, and it was 0.93 +/- 0.18 cm2 after laparotomy in the conventional group (P = 0.4). During surgery, there were no differences in absolute CSA or CSA changes compared with the baseline value in both groups. Postoperative circumference of the calf and thigh were not different between both groups. Postoperative thromboembolic complications did not occur. CONCLUSION: ISC effectively increases venous blood flow from the lower limbs during conventional and laparoscopic colorectal resections and may decrease the risk of postoperative deep vein thrombosis. Therefore, ISC is strongly recommended in every prolonged laparoscopic procedure.

Aged↗
PubMed2001

Results of laparoscopic vs. conventional appendectomy in complicated appendicitis.

BACKGROUND: Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered. METHODS: Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy. RESULTS: Complicated appendicitis (n = 299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percent vs. 15/82; 18.3 percent; P < 0.003), which led to a decrease of the total complication rate in the intention-to-treat group (21/217; 9.7 percent vs. 19/82; 23.1 percent; P = 0.004). The rate of intra-abdominal abscess formation was nearly the same after laparoscopic appendectomy (4.1 percent) and open appendectomy (4.9 percent). The total complication rate was higher in complicated appendicitis than in acute appendicitis (P < 0.005) but was independent of the laparoscopic technique. The conversion rate was higher in complicated appendicitis than in acute appendicitis (21.2 vs. 2.3 percent; P < 0.001). CONCLUSION: In comparison with open appendectomy, laparoscopic appendectomy (by itself and in an intention-to-treat view) leads to a significant reduction of early postoperative complications in complicated appendicitis and therefore should be considered as the procedure of choice.

Abscess↗
PubMed2001

Laparoscopic total colectomy for acute colitis: a case-control study.

INTRODUCTION: There are no previous comparative studies of total abdominal colectomy by laparoscopic methods in ulcerative colitis and Crohn's disease patients requiring urgent colectomy. This study aimed to determine the safety and efficacy of laparoscopic colectomy in these patients compared with those undergoing conventional urgent colectomy. METHODS: Patients undergoing laparoscopic total colectomy for acute colitis were identified in a prospective registry. All patients underwent a total colectomy with creation of an end ileostomy and buried mucous fistula. No patient had fulminant disease (tachycardia, fever, marked leukocytosis, peritonitis), but all were failing to respond to medical treatment. Patients undergoing conventional total colectomy were matched for age, gender, body mass index, diagnosis, disease severity, and operative period. Median values (range) are listed. RESULTS: From 1997 to 1999, there were 19 laparoscopic and 29 matched conventional patients. There were no inadvertent colotomies or conversions in the laparoscopic group. Although there was no difference in operative blood loss in the laparoscopic group (100 (range, 50-700) ml) when compared with the conventional group (150 (range, 50-500) ml), the operative times were significantly longer in the laparoscopic group (210 (range, 150-270) vs. 120 (range, 60-180) minutes, P < 0.001). Bowel function returned more quickly in the laparoscopic group (1 (range, 1-3) vs. 2 (range, 1-4) days; P = 0.003) and the length of stay was shorter (4 (range, 3-13) vs. 6 (range, 4-24) days; P = 0.04). Complications occurred in three (16 percent) laparoscopic patients (2 wound infection and 1 ileus) and in seven (24 percent) conventional patients (3 wound infection, 3 deep venous thrombosis, 1 upper gastrointestinal bleed). CONCLUSIONS: Laparoscopic total colectomy is feasible and safe in patients with acute nonfulminant colitis and may lead to a faster recovery than conventional resection.

Acute Disease↗
PubMed2001

Total mesorectal excision: assessment of the laparoscopic approach.

PURPOSE: Total mesorectal excision offers the lowest reported rates of local recurrence for rectal cancer; however, the ability to perform total mesorectal excision laparoscopically remains unproven. The aim of this study was to assess the feasibility and adequacy of a totally laparoscopic total mesorectal excision for rectal cancer. METHODS: A prospective review of all patients undergoing laparoscopic-assisted surgery for rectal cancer by a single surgeon was undertaken. These were compared with a control group undergoing open rectal resections by another colorectal consultant in the unit (n = 22). Comparison of total specimen length, longitudinal and radial excision margins, and lymph node yield was made between groups. RESULTS: Of 42 laparoscopic-assisted rectal resections attempted, 14 (33 percent) were converted to open procedures and six had their dissection completed open. One resection was considered noncurative. Twenty-one total mesorectal excisions (50 percent) were completed totally laparoscopically. No significant difference was detected between groups for specimen length, radial margin, or lymph node yield. Longitudinal margin of excision was longer in the laparoscopic group (4 (3.5-5) vs. 2.5 (1.05-3.5) cm; P = 0.02, Mann-Whitney). Operating time was significantly longer in the laparoscopic group (180 (168-218) vs. 125 (104-144) minutes; P = 0.003, Mann-Whitney). Data are medians (interquartile ranges). Four patients in the laparoscopic-assisted group had clinical anastomotic leakage vs. one in the open group (P = 0.329, Fisher's exact test). At median follow-up of 38 (range, 6-53) months, one local recurrence had occurred in each group and crude mortality rates were 29 and 23 percent in the laparoscopic-assisted and open groups, respectively (P = 0.736, Fisher's exact test). CONCLUSION: Totally laparoscopic excision of the mesorectum is feasible in 50 percent of patients and where possible yields histologic parameters comparable to open surgery. Early survival and recurrence figures also appear to be comparable.

Adult↗
PubMed2000

Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery.

PURPOSE: To prospectively and blindly compare intraoperative laparoscopic ultrasonography to preoperative contrast-enhanced computerized tomography in detecting liver lesions in colorectal cancer patients. Additionally, we compared conventional (open) intraoperative ultrasonography with bimanual liver palpation to contrast-enhanced computerized tomography in a subset of patients. METHODS: From December 1995 to March 1998, 77 consecutive patients underwent curative (n = 63) or palliative (n = 14) resections for colorectal cancer. All patients undergoing curative resections were randomized to either laparoscopic (n = 34) or conventional (n = 29) surgery after informed consent. All patients underwent contrast-enhanced computerized tomography, diagnostic laparoscopy, and laparoscopic ultrasonography before resection. In those patients who had conventional procedures, intraoperative ultrasonography with bimanual liver palpation was also done. All laparoscopic ultrasonography and intraoperative ultrasonography evaluations were performed by one of two radiologists who were blinded to the CT results. All hepatic segments were scanned using a standardized method. The yield of each modality was calculated using the number of lesions identified by each imaging modality divided by the total number of lesions identified. RESULTS: In 43 of the 77 patients, both the laparoscopic ultrasonography and CT scan were negative for any liver lesions. In 34 patients, a total of 130 lesions were detected by laparoscopic ultrasonography, CT, or both. When compared with laparoscopic ultrasonography, intraoperative ultrasonography with bimanual liver palpation identified one additional metastatic lesion and no additional benign lesions. laparoscopic ultrasonography identified two patients with mets who had negative preoperative contrast-enhanced computerized tomography. CONCLUSIONS: Laparoscopic ultrasonography of the liver at the time of primary resection of colorectal cancer yields more lesions than preoperative contrast-enhanced computerized tomography and should be considered for routine use during laparoscopic oncologic colorectal surgery.

Adenocarcinoma↗
PubMed2002

Laparoscopic common bile duct exploration.

In recent years, laparoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.

Biliary Tract Surgical Procedures↗
PubMed2003

Postoperative cell mediated immune response is better preserved after laparoscopic vs open colorectal resection in humans.

BACKGROUND: Animal studies have documented significantly better preserved postoperative cell-mediated immune function, as measured by serial delayed-type hypersensitivity (DTH) challenges, after laparoscopic-assisted than after open bowel resection. Similarly, in humans, the DTH responses after open cholecystectomy have been shown to be significantly smaller than preoperative responses; whereas after laparoscopic cholecystectomy, no significant change in DTH response has been noted. The purpose of this study was to assess cell-mediated immune function via serial DTH skin testing in patients undergoing laparoscopic or open colectomy. METHODS: A total of 35 subjects underwent either laparoscopic (n = 18) or open colectomy (n = 17) in this prospective but not randomized study. Only patients who were judged to be immunoresponsive by virtue of having responded successfully to a preoperative DTH challenge were eligible for entry in the study. DTH challenges were carried out at three time points in all patients: preoperatively, immediately following surgery, and on the third postoperative day (POD 3). Responses were measured 48 h after each challenge and the area of induration calculated. There were no significant differences between the laparoscopic (LC) and open (OC) colorectal resection groups in regard to demographics, indications for surgery, or type of resection carried out. The percentage of patients transfused was similar in both groups (17%, LC; 12% OC; p = NS). In the LC group, all cases were completed without conversion using minimally invasive methods. There were no perioperative deaths, and the rate of postoperative complications was similar in both groups. The preoperative and postoperative DTH results were analyzed and compared within each surgical group using several methods. RESULTS: In regards to the OC group results, the median sum-total DTH responses for the day of surgery challenges (0.44 +/- 69 cm2) and the POD 3 challenges (0.72 +/- 3.37 cm2) were significantly smaller than the preoperative results (3.61 +/- 3.83 cm2, p <0.0005 vs op day and p <0.0003 vs POD 3 results). When the LC group results were similarly analyzed, no significant difference in DTH response was noted between the pre- and the postoperative challenge results. Additionally, when the median percent change from baseline was calculated and considered for the OC group's DTH results, both postoperative challenge time points demonstrated significantly decreased responses when compared to their preoperative results (vs day of surgery, p <0.007; vs POD 3, p <0.006). Similar analysis of the LC group's results yielded nonsignificant differences between the pre- and postoperative responses. Lastly, when the LC and the OC groups median percent change from baseline results were directly compared for each of the postoperative challenges, a significant difference was noted for the POD 0 challenge (LC, -21%; OC 88%; p <0.004) but not for the POD 3 challenge. CONCLUSIONS: The postoperative DTH responses of the open surgery patients were significantly smaller than their preoperative responses. This was not the case for the laparoscopic group (a combination of fully laparoscopic and laparoscopic-assisted resections). When the open and laparoscopic groups results are directly compared, regarding the results of the day of surgery DTH challenges, the LC groups median percent change from baseline was significantly less than that observed in the OC group. These results imply that open colorectal resection is associated with a significant suppression of cell-mediated immune response postoperatively, whereas in this study laparoscopic colorectal resection was not. Further human studies are needed to verify these findings and to determine the clinical significance, if any, of this temporary difference in immune function following colon resection.

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