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PubMed2001

C-reactive protein (CRP) as a response to postoperative stress in laparoscopic cholecystectomy using the abdominal wall lift, with performed pneumoperitoneum (CO2), and in open cholecystectomy.

The first laparoscopic cholecystectomy was performed thirteen years ago and rapidly became the preferred way of operation in patients suffering from cholelithiasis. The pneumoperitoneum can be responsible for haemodynamic disorders. The abdominal wall lift is an alternative way for pneumoperitoneum during laparoscopic cholecystectomy. The aim of this study was the comparative analysis of operative trauma response in the patients treated by laparoscopic cholecystectomy using abdominal wall lift and in cases which underwent open cholecystectomy or laparoscopic operation using pneumoperitoneum. The concentration of C-reactive protein was measured in patient serum before and twice after surgery. The obtained data underwent a statistic analysis. In all cases the surgery caused the marked changes of CRP-concentration. The mean level of CRP was higher three times in patients after open cholecystectomy than in cases treated by laparoscopic cholecystectomy with the use of abdominal wall lift or with performed pneumoperitoneum. During the experiment the statistically significant different between laparoscopic surgery with the use of the laparolift and laparoscopic with earlier performed pneumoperitoneum was observed. The stress and inflammatory response in cholecystectomy using abdominal wall lift was significant but smaller than the response noted in open cholecystectomy and similar to the response observed after pneumoperitoneum. The replacement of pneumoperitoneum by abdominal wall lift does not change the operative stress in laparoscopic cholecystectomy.

Adult↗
PubMedDate not supplied

Pre- and intraoperative evaluation of biliary system for successful laparoscopic cholecystectomy in porcelain gallbladder patients.

BACKGROUND/AIMS: A porcelain gallbladder is generally thought to be a relative contraindication for laparoscopic cholecystectomy because of the difficulties in grasping the calcified wall of the gallbladder with forceps and making a retraction which would create a good operation field. The aim of this study was to define the clinical criteria for safe laparoscopic cholecystectomy in the treatment of porcelain gallbladders. METHODOLOGY: Between January 1993 and December 2000, 4 patients with porcelain gallbladders underwent laparoscopic cholecystectomy in our department. The significant features of the biliary system which contributed to the surgical results were investigated in these patients. RESULTS: All 4 patients were successfully treated by means of laparoscopic cholecystectomy. The confluence of the cystic duct was clearly demonstrated on the preoperative cholangiogram in all patients. Furthermore, the neck portion of the gallbladder wall, revealed no calcification on the CT scans of 3 patients, although the whole wall of the gallbladder, including the neck portion, showed a circumferential calcification in the remaining patient. Laparoscopic exposure and dissection of the Calot's triangle was relatively easy to perform in the former and was difficult in the latter, and thus, an anterograde laparoscopic cholecystectomy was the procedure of choice. Intraoperative cholangiography clearly demonstrated the confluence of the cystic duct in all of the patients. CONCLUSIONS: Porcelain gallbladder is an indication for laparoscopic cholecystectomy, especially in cases of a patent cystic duct and an uncalcified wall in the neck portion of the gallbladder. Laparoscopic cholecystectomy might be an indication for selected patients with porcelain gallbladder when an uncalcified and patent cystic duct are evident in pre- and intraoperative cholangiograms.

Aged↗
PubMedDate not supplied

Laparoscopic surgery in the pregnant patient--one surgeon's experience in a small rural hospital.

OBJECTIVES: The laparoscopic treatment of urgent surgical conditions that develop in pregnant patients has not been extensively addressed in the current literature. It is a potential issue to which surgeons, especially rural surgeons, should give careful consideration, prior to being faced with an urgent situation during the delivery process. This report details 1 surgeon's experience over a 5-year period with laparoscopic surgery in the pregnant patient, primarily laparoscopic cholecystectomy, at a small rural Nebraska hospital. METHODS: Eleven laparoscopic operations were conducted in 10 patients. RESULTS: One patient underwent 2 separate operations: cholecystectomy at 6 weeks gestation and reduction of ovarian torsion/appendectomy at 20 weeks. One patient, at term, underwent combination cesarian delivery and laparoscopic cholecystectomy. Three patients underwent laparoscopic cholecystectomy during their third trimester of pregnancy. All patients had severe signs and symptoms that threatened successful term gestation and/or failed attempts at conservative medical management aimed at delaying cholecystectomy until after delivery. One complication occurred involving uterine perforation with a blunt 10-mm port canula. No fetal injury occurred, and after initial recovery from the cholecystectomy, the baby was successfully delivered later in the pregnancy via cesarian delivery without adverse sequelae. CONCLUSION: Urgent laparoscopic operations can be carried out successfully in pregnant patients throughout their pregnancy, even in remote locations lacking immediate on-site availability of subspecialty care. The surgeon must be skilled in surgical obstetrics and well trained and experienced in advanced laparoscopic techniques. It is recommended that the same lines of communication and referral for subspecialty involvement be in place as would be required in the management of premature delivery of pregnant patients without surgically urgent disease. Such lines of communication should be developed before the actual need arises. The rural surgeon must have a plan of action well in advance of that first encounter or any subsequent complication.

Adolescent↗
PubMed2002

[Laparoscopic biliary surgery].

Laparoscopic cholecystectomy has become the standard treatment for patients with symptomatic gallbladder disease. However, there is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and conversion to open surgery is required because of technical difficulties or complications. The incidence of bile duct injury has increased in laparoscopic cholecystectomy. Meticulous dissection and intraoperative cholangiography could significantly reduce the rate of that injury. Laparoscopic cholecystectomy for acute cholecystitis is still controversial because of surgical difficulty. In our experience, early laparoscopic cholecystectomy is a beneficial option for patients with acute cholecystitis, and it may even be safe in the acute stage. A better alternative for high-risk early operation and septic cases is percutaneous transhepatic gallbladder drainage. The coexistence of gallbladder cancer should be ruled out and preoperative diagnosis should be done carefully. Laparoscopic management of common bile duct (CBD) stones has many advantages. However it has been reported to be demanding and time-consuming to perform, which limits its widespread adoption. In our experience with 258 patients, laparoscopic CBD exploration was feasible for almost all CBD stones. The technical difficulties associated with laparoscopic CBD exploration could be overcome with the development of suitable equipment and increased expertise.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

Surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis. A prospective study.

The incidence of surgical infections after laparoscopic cholecystectomy is reported to be <2%, because of the minimal trauma due to this approach. We report the results of a prospective study of antibiotic prophylaxis in laparoscopic cholecystectomy, comparing ceftriaxone vs ceftazidime. From Jan 1 to Dec 31 2002 a consecutive series of 242 cholecystectomies were performed, consisting in 18 open cholecystectomies and 224 laparoscopic cholecystectomies, 7 of which (3.1%) were converted to open cholecystectomies for technical and/or anatomical reasons. One hundred and eleven patients received 1 g i.v. ceftazidime 1 h before surgery, and 105 patients 1 g i.v. ceftriaxone on an alternate basis. Thirty-nine patients (17.4%) with acute cholecystitis received at least one booster dose at the end of the operation; 30 out of 39 were given further therapy for 2-3 days, i.e. 1 g i.v. bid. Twenty-two patients treated elsewhere with ceftriaxone or ceftazidime before surgery were transferred to another prophylactic regimen. The final diagnosis in the laparoscopic cholecystectomy group was 219 bile stones, 3 adenomas, and 2 occult carcinomas. We had 4 complications (1.8% of 217 laparoscopic cholecystectomies), 2 of which were minor (infection of the umbilical access by S. aureus) and 2 major (1 biliary fistula [accessory duct] and 1 acute pancreatitis), both treated conservatively. Positive bile cultures (27 cases) were unrelated to the clinical course. The incidence of infections after laparoscopic cholecystectomy in our prospective series was <2%. Ceftriaxone is confirmed as the gold standard in biliary tract surgery, but ceftazidime was equivalent (no statistical difference between the two antibiotics, P=0.59 NS). Ultra-short prophylaxis is enough in most cases, except in cholecystitis. We found no correlation between positive bile cultures and surgical infections after laparoscopic cholecystectomy. The umbilicus was the preferred site of infection in obese patients after the laparoscopic procedure. Major complications are usually related to technical pitfalls.

Aged↗
PubMed1995

The outcomes of elective laparoscopic and open cholecystectomies.

BACKGROUND: The demand for evidence of effectiveness for medical care has prompted the development of epidemiologic approaches to relating the outcomes of care to treatment. This study compares the outcomes of care for patients undergoing the newly introduced laparoscopic cholecystectomy with the results from conventional open cholecystectomies. METHODS: Consecutive cases of elective cholecystectomy from 35 hospitals (all of the metropolitan and selected rural hospitals in Minnesota) were enrolled in the study. Patients were interviewed on admission to establish baseline symptoms and functional status and to confirm risk factors. Their medical records were abstracted to yield information on risk factors, treatment, and hospital complications. To establish outcomes, patients were sent a questionnaire about their symptoms and functional status six months postoperatively. RESULTS: Of 3,448 patients studied, 2,490 (72 percent) had a laparoscopic procedure, including 195 cases that were converted to open cholecystectomies. Functional status data were obtained on 2,481 cases (76 percent). Laparoscopic operation was associated with more operative complications (odds ratio 3.02, p < 0.001), but with fewer general complications (odds ratio 0.32, p < 0.001). The mean time to return to work was 15 days for laparoscopic cases compared to 31 days for open procedures (p < 0.001). The only functional outcome difference between the two procedures was that patients who underwent laparoscopic cholecystectomies were more likely than those with conventional cholecystectomies to be able to perform their usual activities at follow-up evaluation (p < .001). There was evidence of a learning curve; the more laparoscopic procedures a surgeon performed, the fewer the operative (p < 0.01) and general (p < 0.0001) complications. There was no indication that the availability of laparoscopic operation was associated with more operations being performed. CONCLUSIONS: Laparoscopic operation seems to represent a significant advance in getting patients back to a normal life sooner. More attention needs to be given to which patients are most likely to benefit from cholecystectomy of either type. Epidemiologic approaches can be useful in assessing the effectiveness of care. Partnerships between providers and researchers can produce useful effectiveness data by supplementing available clinical records with more detailed outcome data.

Cholecystectomy↗
PubMed1993

Introduction of laparoscopic techniques in gastrointestinal surgery: experience at a Norwegian university hospital as revealed by prospective comparative studies.

Prospective studies compared (a) laparoscopic and open cholecystectomy and (b) laparoscopic and open appendectomy. A second purpose of this study was to assess the value of laparoscopic staging of pancreatic and liver tumors. A total of 141 cholecystectomy cases were studied, comprising a laparoscopic group (n = 50), an open prospective control group (n = 50), and historical controls (n = 41). The need for postoperative analgesics was significantly reduced with the laparoscopic procedure compared with open cholecystectomy. Hospital stay was 1 (1-5) day after laparoscopic cholecystectomy versus 6 (5-28) days after open cholecystectomy. Time away from work was 9 (4-21) versus 28 (21-60) days. These differences were statistically significant (p < 0.001). Complication rates were 8% in both prospective groups. A similar comparative study of laparoscopic appendectomy versus the open technique was undertaken, with 10 patients in each prospective group. Again, hospital stay and time away from work proved shorter for laparoscopic procedures. Finally, 15 staging procedures for pancreatic and liver cancers were performed. One patient with unresectable liver metastases was spared explorative laparotomy.

Appendectomy↗
PubMed1993

[Significance of laparoscopic surgery in the treatment of cholecysto- and choledocholithiasis].

The management of common bile duct stones during laparoscopic cholecystectomy contains some controversy. Our first aim is to detect choledocholithiasis preoperatively making use of a preoperative ultrasound and cholangiogram routinely. Laparoscopic cholecystectomy will follow a preoperative ERCP with endoscopic sphincterotomy and stone extraction in this desirable situation. Cystic duct cholangiography which should become a routine procedure during laparoscopic surgery is feasible in 90-99% and will detect unsuspected common duct stones and iatrogenic bile duct injuries with an accuracy rate of 75.4-90%. This investigation can replace the preoperative cholangiogram in future. A intraoperatively detected common bile duct stone can be managed nowadays by ERCP and sphincterotomy postoperatively or by converting the laparoscopic cholecystectomy into an open common bile duct exploration. Laparoscopic common bile duct exploration is of increasing demand but not yet a routine procedure. If choledocholithiasis will be diagnosed postoperatively, a ERCP with papillotomy will be performed as well. An inquiry among 50 members of the Swiss society of laparoscopic and thoracoscopic surgery (ALTC) with 3718 laparoscopic cholecystectomies pointed out their opinion about the management of common bile duct exploration during laparoscopic surgery in the presented paper.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

Laparoscopic evaluation of the argon beam coagulator. Initial report.

The objective of this study was to evaluate the safety and hemostatic properties of the argon beam coagulator (ABC) at laparoscopy. The study is composed of two parts: laparoscopic results in five anesthetized animals and a preliminary clinical trial in 35 volunteers undergoing laparoscopy. Animals were evaluated during a laparoscopic cholecystectomy training course. Private patients undergoing operative laparoscopy voluntarily consented to a hospital Investigational Review Board-approved protocol to evaluate the ABC. The pigs were 3-month-old, healthy females. The patients were healthy volunteers undergoing laparoscopy for pain, infertility or cholecystectomy. Both pigs and human volunteers underwent operative laparoscopic use of the ABC for hemostasis and selected tissue electrocoagulation using a prototype 10-mm laparoscopic probe. The safety of the ABC was evaluated in the pigs by continuously monitoring heart rate, oxygen saturation and end-tidal CO2. Patients had similar clinical monitoring during operative laparoscopy, with observation of tissue effects of the ABC for hemostasis and tissue electrocoagulation. Laparoscopic use of the ABC in animals and patients produced no observable anesthetic changes, with both pigs and patients recovering normally. The ABC allowed smokeless, hemostatic tissue electrocoagulation, with a rapid non-touching technique easy to apply laparoscopically. We conclude that the ABC can safely be used laparoscopically with excellent hemostasis and effective controlled tissue electrocoagulation. The lack of smoke and the non-touching technique for delivery allow rapid laparoscopic application. The prototype 10-mm delivery probe is cumbersome, and the argon gas flow rate of 4 L/min with firing requires constant venting of the peritoneum with close monitoring of intraperitoneal pressures.

Animals↗
PubMed1993

Safety, efficacy, cost, and morbidity of laparoscopic versus open cholecystectomy: a prospective analysis of 228 consecutive patients.

Laparoscopic cholecystectomy has become the procedure of choice in most hospitals for the resolution of surgically treatable gallbladder disease. Few reports address the results of laparoscopic cholecystectomy in comparison to open cholecystectomy during the same time interval within the same institution. One hundred ninety-six laparoscopic cholecystectomies were performed from April 1990 through February 1991. Initial patient selection was restricted to elective procedures for chronic cholecystitis with expanded indications as experience was gained. Of the 196 cases, 11 required conversion to open cholecystectomy, leaving 185 laparoscopic cholecystectomies for comparison. During the same period, 82 open cholecystectomies were performed. Thirty-nine of these were complicated cases and would not have been considered for laparoscopic cholecystectomy early in the study, leaving 43 routine open cholecystectomies for comparative purposes. In the laparoscopic group, 1.1 per cent of the patients had major operative complications as opposed to the open group, which had none. There were no common bile duct injuries in either group. To provide a true cost-benefit analysis, a group of patients was identified that would qualify for elective, same-day admission for either an open or laparoscopic procedure. Laparoscopic cholecystectomy (LC) was performed on 70 patients, and open cholecystectomy (OC) was performed on 26 patients. A comparison of data from these groups showed no significant difference in age or sex. Hospitalization costs averaged $5,390 for the LC group versus $5,392 for the OC group. Postoperative hospital stay averaged 1.3 days for the LC group versus 3.7 days for the OC group (P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Cholangiography↗
PubMed1996

A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy.

BACKGROUND: In a relatively short period of time, therapeutic laparoscopy has become an everyday part of the general surgeon's life. Although laparoscopy provides distinct clinical advantages, it is not yet clear that it lessens the stress response typical of elective surgical procedures, and as such, the morbidity of surgery. The hypothesis that laparoscopic cholecystectomy produces less of a metabolic and stress hormonal response than open cholecystectomy was tested in a prospective randomized trial. STUDY DESIGN: Twenty otherwise healthy women between 18 and 45 years of age with a history of uncomplicated symptomatic cholelithiasis undergoing either laparoscopic (n = 10) or open cholecystectomy (n = 10) were studied. The hormonal response of the adrenocortical (serum adrenocorticotropic hormone, cortisol, and urinary free cortisol), adrenomedullary (plasma and urinary epinephrine and norepinephrine), thyroid (thyroid-stimulating hormone, thyroxine, and triiodothyronine), pituitary (antidiuretic hormone and growth hormone), and glucose (serum glucose, glucagon, and insulin) homeostatic axes were measured serially over a 24-hour period. RESULTS: No difference was seen between the laparoscopic and open groups in operative time (mean plus or minus standard error of the mean, 70 +/- 6 minutes compared with 77 +/- 6.3 minutes) or hospital stay 1.3 +/- 0.2 compared with 1.1 +/- 0.1 days). Assessment of postoperative pain using an analog pain score was less in the laparoscopic group (4.9 +/- 1.3 compared with 12.3 +/- 2.5, p = 0.01). The response of the adrenocortical, adrenomedullary, thyroid, and glucose axes were similar or identical in both groups. Antidiuretic hormone levels were greater in the laparoscopic group at one hour intraoperatively (281 +/- 79 pg/mL compared with 54 +/- 18 pg/mL, p < 0.01), and at extubation (122 +/- 18 pg/mL compared with 36 +/- 7 pg/mL, p < 0.01). Serum glucose levels were greater immediately following laparoscopic cholecystectomy. Glucose and insulin levels were greater at four, 12, and 24 hours after open cholecystectomy. CONCLUSIONS: Elective laparoscopic and open cholecystectomy for uncomplicated cholelithiasis result in similar degrees of perioperative hormonal stimulation. The different hormonal responses in the immediate and later postoperative periods after laparoscopic and open cholecystectomy suggest differential stressful stimuli between the two procedures.

Adolescent↗
PubMed1997

Laparoscopic versus open cholecystectomy in acute cholecystitis.

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Acute Disease↗
PubMedDate not supplied

Laparoscopic cholecystectomy may disseminate gallbladder carcinoma.

Laparoscopic cancer surgery has been reported to facilitate tumor dissemination. In our experience with 158 laparoscopic cholecystectomies, we encountered 2 cases (1.3%) of unsuspected gallbladder cancer. We report these 2 cases to illustrate the disadvantages of laparoscopic tumor resection. In Case 1, a 60-year-old woman with symptomatic cholecystolithiasis underwent a laparoscopic cholecystectomy revealing an unsuspected gallbladder cancer (pT2). Five months later, localized peritoneal carcinomatosis developed in the right subphrenic space, and she died from disseminated disease 19 months postoperatively. Laparoscopic manipulation may have caused the unusual, localized seeding. In Case 2, laparoscopic cholecystectomy was initiated for a polypoid lesion of the gallbladder in a 69-year-old man. When laparoscopy revealed a concomitant cancer (pT3), resection was converted to an open radical cholecystectomy. He remains alive without evidence of disease 31 months postoperatively. Conversion to open surgery may have contributed to the favorable outcome. The contrast between the 2 cases suggests that laparoscopic cholecystectomy should be converted to open surgery whenever malignancy is suspected. Surgeons should note that laparoscopic resection may disseminate cancer.

Adenocarcinoma↗
PubMedDate not supplied

Laparoscopic appendectomy and cholecystectomy during pregnancy: six case reports.

BACKGROUND: Pregnancy was once considered a contraindication to laparoscopic cholecystectomy and appendectomy. The progression of laparoscopic techniques has resulted in a continued reassessment of laparoscopic procedures during pregnancy. There still exists some controversy as to the safety of laparoscopic procedures during pregnancy. This paper reviews our series of six pregnant patients treated laparoscopically for appendicitis and cholecystitis. METHODS: Charts were reviewed of all pregnant patients who underwent laparoscopic cholecystectomy or appendectomy at St Clare's Hospital Schenectady, New York between 1992 and 1996. Six patients were identified. Patients and obstetricians were contacted to investigate the results of the pregnancy. RESULTS: All patients and fetuses survived the procedure. Two patients delivered prematurely but remote from the operative procedure. All infants were healthy postpartum. One patient underwent an elective abortion as she had planned. The abortion was remote from the surgical procedure. CONCLUSION: Our series adds to the growing evidence that laparoscopic cholecystectomy and laparoscopic appendectomy can be performed safely during pregnancy.

Adult↗
PubMed1999

Functional outcome after laparoscopic or open Nissen fundoplication: a follow-up study.

OBJECTIVE: To compare the results of open and laparoscopic fundoplication. DESIGN: Nonrandomized controlled study with a 3-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. INTERVENTIONS: Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. RESULTS: Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. CONCLUSION: From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.

Adult↗
PubMed2001

Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis.

HYPOTHESIS: The incidence of postoperative intra-abdominal abscess is higher after laparoscopic compared with open appendectomy for perforated appendicitis. METHODS: A historical cohort study of pediatric patients operated on for suspected appendicitis by open appendectomy or laparoscopic appendectomy compares the incidence of postoperative intra-abdominal abscess for each procedure. SETTING: A tertiary care center. PATIENTS: Five hundred thirty-eight pediatric patients were operated on for suspected appendicitis at our institution between 1974 and 1999. Of these, 453 were included in the study. Of the excluded patients, 9 had incomplete medical records, 69 had normal or interval appendectomies, and 7 had appendixes removed by methods other than laparoscopy or right lower quadrant incision. INTERVENTIONS: Open appendectomy performed through a right lower quadrant incision or laparoscopic appendectomy performed through a 3-trocar approach by 1 of 3 pediatric surgeons at our institution. MAIN OUTCOME MEASURE: The incidence of postoperative intra-abdominal abscess after laparoscopic vs open appendectomy. RESULTS: In perforated appendicitis (170 patients), the incidence of postoperative abscess after laparoscopic appendectomy was 24% vs 4.2% after open appendectomy. The relative risk ratio of developing a postoperative abscess after perforated appendicitis was 5.6 (confidence interval, 2.1-16.0) after laparoscopic vs open appendectomy. The results remained significant when controlled for age, sex, intraoperative irrigation, and preoperative antibiotics. Postoperative abscess in all acute, gangrenous, and perforated appendicitis after laparoscopic appendectomy was 6.4% vs 3.0% after open appendectomy. This was not statistically significant. CONCLUSION: There is a significant increase in the incidence of postoperative intra-abdominal abscess with perforated appendicitis after laparoscopic compared with open appendectomy in pediatric patients.

Abdominal Abscess↗
PubMed2001

Systemic coagulation and fibrinolysis after laparoscopic and open gastric bypass.

HYPOTHESIS: Laparoscopic gastric bypass (GBP) induces a postoperative hypercoagulable state that is similar or reduced compared with open GBP. SETTING: University hospital. PATIENTS: Between May 1999 and June 2000, 70 patients were randomly assigned to laparoscopic (n = 36) or open (n = 34) GBP. Deep venous thrombosis (DVT) prophylaxis consisted of antiembolism stockings and sequential pneumatic compression devices. MAIN OUTCOME MEASURES: Plasminogen, thrombin-antithrombin complex (TAT), prothrombin fragment 1.2 (F1.2), fibrinogen, D-dimer, antithrombin III (AT), and protein C levels were measured at baseline and at 1, 24, 48, and 72 hours postoperatively. A venous duplex examination of both lower extremities was performed preoperatively and between the third and fifth day postoperatively. RESULTS: The 2 groups were similar in age, weight, and body mass index. Plasminogen levels decreased, and TAT, F1.2, and fibrinogen levels increased after laparoscopic and open GBP. There was no significant difference in these levels between groups. D-dimer levels increased in both groups, but the levels were significantly higher after open GBP than after laparoscopic GBP (P<.01). Antithrombin III and protein C levels decreased in both groups. The reduction of AT (at 1 hour) and protein C (at 72 hours) was significantly less after laparoscopic GBP than after open GBP (P<.05). Postoperative venous duplex examination revealed DVT in 1 (2.9%) of 34 patients after open GBP but in none of 36 patients after laparoscopic GBP. One patient developed pulmonary embolism after open GBP. CONCLUSIONS: Laparoscopic GBP induces a hypercoagulable state similar to that of open GBP. Our findings suggest that DVT prophylaxis should be used during laparoscopic GBP as in open GBP.

Adult↗
PubMed2005

Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study.

HYPOTHESIS: Laparoscopy has become a popular approach for the surgical treatment of benign and even malignant colorectal diseases. Several authors have reported better preserved immunity in patients undergoing laparoscopic compared with conventional colorectal surgery. The present study addresses the hypothesis that specific and nonspecific immunity are differently affected by laparoscopic and conventional colorectal surgery. DESIGN: Nonrandomized control trial. SETTING: University hospital. PATIENTS: Seventy prospectively enrolled patients with colorectal diseases undergoing laparoscopic (n = 35) or open (n = 35) surgery. MAIN OUTCOME MEASURES: Blood samples were taken prior to surgery as well as on days 1, 3, and 5 after surgery. Cell numbers of lymphocyte subpopulations as well as natural killer cells were determined by flow cytometry, and interleukin 6 and C-reactive protein serum levels were measured. RESULTS: Significant differences between study and control patients (P<.05) were detected regarding circulating interleukin 6 and C-reactive protein levels with a reduced proinflammatory response to surgery in patients after laparoscopic surgery. Furthermore, postoperative natural killer cell counts were significantly higher in patients after laparoscopic surgery. The levels of B lymphocytes and T lymphocytes and helper T-cell counts and cytotoxic (suppressor) T-cell counts did not show significant differences after open or laparoscopic surgery. CONCLUSIONS: Our findings indicate a less pronounced proinflammatory response to surgical trauma in patients after minimally invasive surgery. The nonspecific immune response appears to be less affected by laparoscopic surgery when compared with open surgery while the specific cell-mediated immunity is equally affected. These findings are important because a divergent effect on specific and nonspecific immunity of laparoscopic surgery for colorectal disease has not been reported before.

Aged↗