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PubMed1999

Randomized, controlled trial of bupivacaine injection to decrease pain after laparoscopic cholecystectomy.

OBJECTIVES: To determine if intraoperative instillation of bupivacaine would decrease early postoperative pain after laparoscopic cholecystectomy, if the patients would consequently require less narcotic postoperatively and if such patients would elect to be discharged on the day of operation if given the choice. DESIGN: Double-blind, randomized, controlled trial. SETTING: A tertiary care hospital in Hamilton, Ont. PATIENTS: Fifty patients underwent laparoscopic cholecystectomy. Day-surgery patients had the choice of staying overnight for discharge the following day. They were compared with a control group of 47 patients who had laparoscopic cholecystectomy but did not receive bupivacaine. INTERVENTION: Instillation of 20 mL of 0.5% bupivacaine with epinephrine into laparoscopic cholecystectomy port sites intraoperatively before closure. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores assessed 4 times postoperatively, the choice of patients to leave hospital the same day or to remain in the hospital overnight; the level of postoperative narcotic usage. MAIN RESULTS: Mean VAS pain scores (range 0 [no pain] to 5 [severe pain]) at less than 2 hours and at 6 hours after surgery were 2.9 and 2.9, respectively, in the bupivacaine group compared with 4.5 and 4.0, respectively, in the control group (p = 0.001 and 0.025). VAS scores at 10 hours postoperatively and the next morning did not differ between the groups. More patients in the bupivacaine group elected to go home on the day of surgery (p = 0.034). Narcotic usage was not significantly different. CONCLUSION: Instillation of bupivacaine into port sites should be standard practice for elective laparoscopic cholecystectomy.

Adult↗
PubMedDate not supplied

Improved acceptability of laparoscopic surgery and increasing rate of cholecystectomy implications for surgeon and patients.

BACKGROUND/AIMS: The aim of our study was to evaluate the impact of introduction of laparoscopic cholecystectomy (LC) and reasons for the increase in cholecystectomy rate, by a retrospective review of all admissions for gallbladder disease before and after the introduction of laparoscopic surgery in our department. METHODOLOGY: Chi-squared test was used for statistical analysis of the comparisons. RESULTS: Comparing the 2 periods, cholecystectomy rate increased by 35% (p<0.01) and patients aged 25-44 years were more likely to undergo LC (p<0.001); a 35% decrease in unjustified refusal (p<0.02) was also observed. The number of both longstanding disease patients and asymptomatic ones operated upon was not different (p=1; p=0.06), while a 46% increase (p=0.02) in cholecystectomy rate was shown in patients with low-grade symptoms or at 1st colic episode. CONCLUSIONS: An increase in the patient pool due to improved acceptability was responsible for the increase in cholecystectomy rate after introduction of laparoscopic surgery, rather than lowered surgical threshold, as previously suggested by other authors. Judiciousness is required to prevent the increased acceptability of LC from leading to its uncontrolled and unrestricted use, as alteration of the surgical threshold may occur without surgeon awareness, particularly when dealing with low grade symptomatic patients.

Adolescent↗
PubMed1999

Synchronically performed laparoscopic cholecystectomy and hernioplasty.

Cholecystectomies and hernioplasties are the two most frequently performed surgical interventions. The laparoscopic technique can be offered for the simultaneous treatment with both operating indications. The synchronical operation can give all the advantages of the minimally invasive technique. Authors had performed laparoscopic cholecystectomy with laparoscopic hernioplasty in five cases. Two inguinal and three postoperative hernias were reconstructed. The cholecystectomy was performed with a "three punction method", and the hernioplasty by using the same approach, completed by inserting a fourth assisting trocar as required. The hernial ring was covered with an intraperitoneally placed mesh, which was fixed by staplers (the so-called "IPOM-method": intraperitoneal on-lay mesh). There was no intra-, nor postoperative complication. The hernioplasty combined with laparoscopic cholecystectomy did not have effect on postoperative pain and nursing time. The return to the normal physical activity was short, similar to laparoscopic hernioplasty (in 1-2 weeks). Authors conclude that the simultaneous, synchronous laparoscopic cholecystectomy and hernioplasty is recommended and should be the method of choice because it is more advantageous for patients.

Adult↗
PubMedDate not supplied

Can sonographic signs predict long-term results of laparoscopic cholecystectomy?

BACKGROUND/AIMS: To determine whether sonographic signs of the gallbladder can predict the long-term outcome of laparoscopic cholecystectomy (LC). METHODOLOGY: All 346 patients, who underwent LC at our institution between January 1, 1993 and March 1, 1996, were interviewed using a structured questionnaire on the persistence of pre-operative abdominal symptoms. Patients without a sonographic examination 6 months prior to surgery were excluded. Sonographic parameters, scored on the pre-operative examination, were evaluated by univariate analysis using the relief of abdominal symptoms as a dependent variable. RESULTS: The response rate of correctly returned questionnaires was 68%. The follow-up ranged from 14-53 months. Fourteen percent (18/133) of all patients reported persistence of abdominal complaints after cholecystectomy. Grit in the gallbladder on the pre-operative ultrasound examination was significantly associated with a higher relative risk (RR) for persistence of pre-operative abdominal symptoms (RR 4.5, 95% confidence intervals (CI) 2.0-10.1). The presence of echogenic bile (RR 1.9, 95% CI 0.8-4.9), gallbladder distention (RR 1.9, 95% CI 0.6-5.7), and gallbladder wall thickening (RR 1.5, 95% CI 0.5-4.1) were associated with the persistence of symptoms. A contracted gallbladder (RR 0.6, 95% CI 0.4-1.1) and stone impaction (RR 0.44, 95% CI 0.1-1.8) were associated with the relief of abdominal symptoms. None of these sonographic signs reached significance. There was no difference in the post-operative symptoms rate between patients with a laparoscopic cholecystectomy and those who were converted to an open cholecystectomy. CONCLUSIONS: This retrospective study showed that the sonographic sign of grit in the gallbladder is associated with a high relative risk for persistent abdominal symptoms after cholecystectomy. These findings will be re-evaluated in a prospective study to estimate the definitive clinical importance.

Adolescent↗
PubMedDate not supplied

Value of liver biopsy combined with cholecystectomy.

BACKGROUND/AIMS: Many authors value routinely performed liver biopsy concomitant with cholecystectomy as a procedure of great diagnostic importance in regard to diagnosis and treatment of liver disease. Without reason, fewer perioperative liver punctures have been performed since the beginning of minimal invasive surgery, even so, laparoscopic cholecystectomy provides an equal opportunity for taking liver biopsies for diagnostic purposes. This study aims to determine the prevalence and extent of liver disease in patients undergoing cholecystectomy for gall stone disease. METHODOLOGY: Within the pre-laparoscopic era, 565 cholecystectomies with concomitant liver biopsies were performed. The results were evaluated retrospectively. Serious pathohistologic findings were defined by the stage of pathologic changes demanding prognostic and/or therapeutic consequences. RESULTS: One hundred and ten patients (19.5%) had normal liver biopsies. Severe pathologic liver changes were diagnosed in 58 (10.3%). Taking all liver biopsies showing liver changes, prognostic and therapeutic relevance were represented in 52% of our patients. CONCLUSIONS: Having proof of the high rate of pathologic liver changes resulting in liver disease we advocate liver biopsy in connection with cholecystectomy as an important procedure, if open or laparoscopic surgery of the extrahepatic biliary tract is performed.

Adolescent↗
PubMed1999

[Laparoscopic cholecystectomy. A recommendable indication in acute cholecystitis?].

While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.

Acute Disease↗
PubMedDate not supplied

Criteria and benchmarks for laparoscopic cholecystectomy in a free-standing ambulatory center.

BACKGROUND AND OBJECTIVES: Keys to economic survival in an era of decreasing reimbursement include controlling costs and avoiding complications. In an effort to reduce costs, laparoscopic cholecystectomy has been performed with same-day discharge from a hospital setting. The free-standing ambulatory surgery center offers even greater cost savings if safety can be assured. Facility charges, surgical technique and instrument selection influence the costs of the procedure. METHODS: A database was accumulated prospectively on the first 100 laparoscopic cholecystectomies performed in a free-standing ambulatory surgery center to assess costs, logistical constraints, and safety. RESULTS: Laparoscopic cholecystectomies were accomplished in 99 of 100 patients. One patient was suspected of having cancer during laparoscopy and was transferred to a nearby hospital for open cholecystectomy. There were no other postoperative hospitalizations for complications. The fixed facility charge for the procedure was $2,990, and the total costs for all routinely disposable items (gowns, gloves, instruments, and adhesive bandages was $98. The mean OR time was 29 minutes (standard deviation 13.7). CONCLUSIONS: The free-standing ambulatory surgery center is an appropriate facility for an experienced operating team to perform laparoscopic cholecystectomy in selected patients. The surgeon's selection of appropriate energy sources and instruments is essential to complete the operation in a most cost-effective manner.

Adult↗
PubMedDate not supplied

[Diagnostic problems and results of laparoscopic cholecystectomy in chronic acalculous cholecystitis].

We report on our experience with laparoscopic cholecystectomy in 15 patients, 12 females and 3 males (mean age: 44 years), with chronic acalculous cholecystitis. These patients presented with recurrent episodes of biliary colic together with a dysmorphic or dysfunctioning gallbladder as confirmed by ultrasound and/or cholescintiscan with 99m-Tc HIDA performed in fasting conditions and after meals. First of all, we considered the possible presence of concomitant digestive disease (peptic ulcer disease, recurrent pancreatitis, irritable bowel syndrome, chronic hepatitis) potentially responsible for the pain. Ultrasound investigations revealed a pathological gallbladder in 10 patients. Cholecystectomy was curative in 8/10. Cholescintiscan revealed a pathological gallbladder in 8 patients and cholecystectomy was curative in only 5 of these. No postoperative deaths or significant complications occurred. The mean duration of the operation (35 vs 48 min) and hospital stay (2.1 vs 2.8 days) were reduced in comparison to 346 cholecystectomies performed for gallstones. After 6-36 months' follow-up, resolution of symptoms was successful in 10/15 cases (66.6%); in 3 cases, only dyspepsia was reduced, whilst in the other 2 cases, who also presented concomitant irritable bowel syndrome and gastroduodenitis, there was no improvement in pain. In all but the latter two cases (86.6%), histological examination revealed chronic gallbladder inflammation. In conclusion, laparoscopic cholecystectomy was curative (66.6%) or led to an improvement in symptoms (20%) in patients with chronic acalculous cholcystitis. Cholescintiscans were not always diagnostic for the disease, whereas ultrasound findings were more useful as an indication for surgery.

Adult↗
PubMed2001

[Ambulatory laparoscopic cholecystectomy is as effective as hospitalization and from a social perspective less expensive: a randomized study].

OBJECTIVE: To compare the effects and costs of an ambulatory treatment versus an overnight stay for laparoscopic cholecystectomy. DESIGN: Prospective, randomised. METHOD: In the St Antonius hospital, Nieuwegein, the Netherlands, 86 patients with symptomatic cholelithiasis without comorbidity underwent either ambulatory (AM: 42 patients: 8 men and 36 women; mean age: 48.9 years (SD: 11.9)) or overnight stay (OS: 44 patients: 10 men and 32 women; mean age: 44.9 years (SD: 11.8)) laparoscopic cholecystectomy in the period 1 November 1997-30 September 1999. The following were registered: operative time, complications, hospital stay and readmissions, as well as reported pain, nausea, activity resumption, quality of life and patient satisfaction. The cost analysis was performed from a societal and hospital perspective. RESULTS: In the OS group one laparoscopic procedure was converted to open cholecystectomy, two relaparotomies were performed due to intra-abdominal haemorrhage and 1 patient had a catheter inserted due to urine retention. Two patients were readmitted, one for postoperative pancreatitis and the other for a retained bile duct stone. In the AM group one laparoscopic procedure was converted to open cholecystectomy, in 1 patient a wound abscess was treated with drainage in the outpatient clinic, in 1 patient there was peroperative stone loss without further complications and in 1 patient a catheter was placed to drain peroperative bile and blood loss. In the AM group 11 (26%) patients were kept overnight due to nausea and/or pain (n = 7) or one of the aforementioned complications (n = 4). Two patients were readmitted within 24 hours of being discharged due to abdominal pain. The average hospital stay was 3.1 (OS) versus 1.7 (AM) days. The quality of life, pain, nausea and activity resumption were comparable for both groups. Due to the difference in hospital stay, costs for the ambulatory procedure were lower. CONCLUSION: Laparoscopic cholecystectomy was successfully performed as an ambulatory surgery procedure in 69% of the patients. The quality of life, patient satisfaction and resumption of activities in both groups were comparable. The ambulatory treatment was less expensive.

Adult↗
PubMed2002

[Personal experience with laparoscopic cholecystectomy in acute cholecystitis].

Authors refer about their experiences with operations of acute cholecystitis by laparoscopy. They have evaluated retrospectively 1600 cases of laparoscopic cholecystectomies (LCHE) realized in the period from 1994 to 2000. In 302 (18.8%) cases was realized laparoscopic cholecystectomy for acute cholecystitis, which was confirmed by histopathological finding. During the mentioned period a total number of laparoscopic cholecystectomies for acute cholecystitis (n = 302) rise a number of classical cholecystectomies for the same diagnosis (n = 227). Very important role by authors take early dispatching a patient to a department of surgery and early estimation the diagnosis with consecutive laparoscopic treatment. Rates of peroperation, postoperation complications and reoperations in laparoscopic surgery of acute cholecystitis is comparable with elective laparoscopic cholecystectomy.

Acute Disease↗
PubMedDate not supplied

Long-term results after cholecystectomy alone for patients with pancreaticobiliary maljunction without bile duct dilatation.

A pancreaticobiliary maljunction (PB-MJ) without bile duct dilatation is relatively rare. The standard treatment for these patients remains controversial. In this study, we followed up the patients with PB-MJ without bile duct dilatation who mainly underwent a cholecystectomy alone. Eighteen adult patients with PB-MJ without bile duct dilatation (8 males and 10 females with a mean age of 54.8 years) were treated surgically. When the diameter of the common bile duct was less than 10 mm, such bile ducts were diagnosed to have no dilatation. The main clinical indications for surgery were cholecystolithiasis in 12 patients, choledocholithiasis in 3, cholecystocholedocholithiasis in 1, and carcinoma of the gallbladder in 2. The amylase levels of gallbladder bile in 14 patients ranged from 115 to 454,000 IU/ml. A simple cholecystectomy was performed in 12 patients, a cholecystectomy with bile duct drainage was performed in 3, a cholecystectomy with a choledochojejunostomy without bile duct resection was performed in 1, and a cholecystectomy with a lymph node dissection was performed in 2. Three patients died of other diseases. The remaining 15 patients have all been doing well for 20-209 months after surgery. In conclusion, a prophylactic resection of the extrahepatic bile duct and biliary diversion could be unnecessary for patients with PB-MJ without bile duct dilatation, when no bile stasis, such as choledocholithiasis, is observed.

Adult↗
PubMedDate not supplied

Laparoscopic cholecystectomy and incidental carcinoma of the extrahepatic bilary tree.

BACKGROUND AND OBJECTIVES: Gallbladder carcinoma is found in 0.2% to 5% of patients undergoing cholecystectomy, and gallstones are found in 70% to 98% of patients with gallbladder carcinoma. Early diagnosis of carcinoma is difficult because of the absence of specific symptoms and the frequent association with chronic cholecystitis and gallstones. At present, laparoscopic cholecystectomy is the gold standard for the surgical treatment of symptomatic cholelithiasis and other benign gallbladder diseases. The aims of this study were to evaluate retrospectively the incidence of occasional and occult gallbladder carcinomas to ascertain the effect of laparoscopy on diagnosis and treatment of unexpected extrahepatic biliary tree carcinomas and to assess possible guidelines that can be taken into consideration when the problem is encountered. METHODS: Clinical records of 3900 patients undergoing laparoscopic cholecystectomy were reviewed. Patients with occasional (intraoperative = Group A) or occult (postoperative = Group B) diagnosis of gallbladder or common bile duct carcinoma entered the study group. Follow-up data were obtained in June 2000. RESULTS: A total of 14 patients (0.35%), 3 men and 11 women, mean age 60.8 years (range 37 to 73) with extrahepatic biliary tree carcinoma were found. Occasional carcinomas occurred in 8 patients, occult carcinomas in 6. No deaths occurred in either group. The overall survival at mean follow-up of 30.5 months is 50%. Five patients are disease free, and 2 are alive with evidence of recurrence. DISCUSSION: In 2 large series of unselected consecutive laparoscopic cholecystectomy, only 14 unsuspected malignant tumors of the extrahepatic biliary tree were found (0.35%). The limits of the preoperative workup and the difficult diagnosis of biliary tract carcinoma during laparoscopic cholecystectomy, has led to the present retrospective study and several significant recommendations.

Adult↗
PubMed2002

Does gallbladder ejection fraction predict pathology after elective cholecystectomy for symptomatic cholelithiasis?

Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0-84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed2002

[Laparoscopic cholecystectomy--surgical standard in cholelithiasis].

Laparoscopic surgery showed a dramatic development in the last years of the 20th century. From the beginning laparoscopic cholecystectomy (LCCE) has been the pacemaker of this development. Today laparoscopic cholecystectomy is the first choice for treatment of cholecystolithiasis in nearly all surgical clinics. Therefore laparoscopic cholecystectomy is the most common part of minimal invasive technique. LCCE is the golden standard in therapy of gallstones, more than 90% of cholecystectomies in specialized clinics are done laparoscopically. It is an established, evidence based operation today. Open cholecystectomy is left for special indications only. A problem of LCCE is the occult carcinoma of the gallbladder. In histological proven carcinoma of the gallbladder LCCE is the adequate operation only for Tis and T1 carcinoma. In T2 and T3 carcinoma a radical oncologic resection with lymph node dissection should be performed. Due to the poor prognosis T4 tumors should be left with laparoscopic biopsy only.

Cholecystectomy, Laparoscopic↗
PubMed2003

[Laparoscopic cholecystectomy in day care; implementation of a guideline for clinical practice].

OBJECTIVE: To evaluate the extent to which the guideline to perform laparoscopic cholecystectomy in day care was followed in the institute where the guideline was developed and in the other hospitals in the Netherlands. DESIGN: Retrospective, descriptive. METHOD: For the patients who underwent a laparoscopic cholecystectomy in the Amsterdam University Medical Centre (AMC) during the period 1 January 1998-31 December 2000, data were collected from medical records on how the intervention was performed: in day care or during a hospital admission. The national figures were obtained from SIG Zorginformatie in Utrecht. RESULTS: A total of 262 patients underwent a laparoscopic cholecystectomy at the AMC: 60 men and 202 women, with an average age of 43 years (range: 2-86). A total of 163 (62%) patients were eligible for treatment in day care. Laparoscopic cholecystectomy was performed in day care in the years 1998, 1999 and 2000 in 80%, 92% and 93% of patients respectively (n = 144). Of these 144 patients, 129 (90%) were discharged to home the same day. For the same years, these figures for the whole of the Netherlands were 0.8%, 1.3% and 1.7% respectively. CONCLUSION: The clinical guideline for performing laparoscopic cholecystectomy in day care has been implemented to a large extent in the AMC but has scarcely been implemented at the national level. At the AMC, day care treatment could be carried out for 90% of the patients for whom this had been planned.

Adolescent↗
PubMed1992

[Cholecystectomy and duodenogastric reflux].

With the aim of evaluating whether cholecystectomy causes an increase in duodenogastric reflux (DGR) 34 patient (12 males and 22 females, mean age 50 years) were examined before and 6 months after cholecystectomy. DGR was evaluated by assaying total and individual biliary acids in gastric juice and was expressed as fasting bile reflux (FBR) in mumol/h. The histology of gastric mucosa in endoscopic biopsies taken from the antrum and body was also analysed. FBR of total biliary acids rose from 2.4 mumol/h before surgery to 41.33 mumol/h after cholecystectomy (p = 0.000). A significant increase was observed for all the individual biliary acids. Histological tests of gastric mucosa revealed an increased percentage of chronic atrophic gastritis of the antrum following cholecystectomy. Histological conditions in the body were unaltered. The results of this study show that there is a significant increase in DGR (months after cholecystectomy together with increased histological damage to the mucosa of the antrum. Further studies are necessary in order to evaluate whether the two phenomena are related.

Adult↗
PubMed1992

[Hepatobiliary manifestations in AIDS in adults. Place of cholecystectomy].

In AIDS patients an acalculous cholecystitis may be responsible for abdominal pain subsiding after cholecystectomy. But the indications for cholecystectomy are not clear: cholecystitis is usually associated with diffuse cholangitis and this might cause the symptoms. Since 1985, 8 AIDS patients have undergone cholecystectomy for acute cholecystitis. Ultrasonography revealed a 5 to 12 mm thickening of the gallbladder wall in all of them and gallbladder stones in two; four patients had cholangitis. The decision to operate was based on persistent pain associated with fever, poor general condition and muscular rigidity at palpation. Four patients had septic shock at the time of surgery; one died in the immediate postoperative period. In all other patients pain and septic syndrome subsided. Two patients died of AIDS complications 20 days after surgery; the remaining five died of AIDS 6, 9, 10, 12 and 14 months respectively after surgery; in two of them cholestasis had reappeared due to cholangitis. To summarize, in the 8 AIDS patients studied cholecystectomy was performed for clinical deterioration. Gallbladder pathology was responsible for the abdominal pain and the febrile general condition which was relieved by cholecystectomy.

Acquired Immunodeficiency Syndrome↗
PubMed1992

[Safety of cholecystectomy by laparotomy in elective situation and in emergency].

Cholecystectomy is the only effective treatment of gallbladder stones. A retrospective study was carried out on results of 658 cholecystectomies by laparotomy without choledochotomy performed between January 1987 and December 1989, to determine morbidity and mortality of elective and emergency surgery and by age. Operations for tumors of the gallbladder and choledolithiasis were not included in the analysis. During this period, cholecystectomy was performed electively in 387 cases and under emergency conditions in 261 patients. Mortality and post-operative morbidity were 0% and 14.7% respectively after elective surgery, increasing to 1.1% (Fisher = 0.0617) and 25.2 (p = 0.0004) respectively after emergency operations. This large increase in postoperative morbidity in urgent cases was due to an increase in systemic and not local complications, as a result of the higher proportion of emergency operations with advancing age. Since elective cholecystectomy is safe it can be proposed to patients with symptoms, including the elderly. It is difficult at present to compare results of cholecystectomy by laparotomy with those of laparoscopy since the average age of in the latter category is markedly lower and the number of acute cases still low. The principal advantage of celioscopy could be a long term reduction in systemic complications in emergency operations.

Adolescent↗