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Six hundred fifty-eight laparoscopies were performed at St. Luke's Hospital, Kansas City, Missouri, USA, between March 1, 1976 and February 28, 1977. One hundred sixty-eight (25.5%) were performed for diagnostic purposes. A review of the preoperative diagnoses and the laparoscopic findings demonstrates the value of laparoscopy as a diagnostic procedure.
BACKGROUND AND OBJECTIVES: A preliminary study on the use of laparoscopy-assisted approach to treat gastric carcinoma resulted in higher morbidity. STUDY DESIGN: A prospective phase II study of laparoscopy-assisted distal gastrectomy (LADG) was performed for patients with preoperative diagnosis of T1 N0 stage cancer located in the lower or middle-third stomach. Bleeding amount, operating time, mortality, morbidity, and the number of lymph node retrieval were recorded and compared with the preliminary series reported previously by the same authors. RESULTS: Between 2000 and 2002, 47 patients were accrued. The mean blood loss and postoperative hospital stay were significantly decreased compared with the previous series, whereas the operating time was not. There were no in-hospital deaths, with the incidence of anastomotic leakage significantly decreased. All patients remain disease-free to date. CONCLUSIONS: LADG can be performed safely and morbidity, no longer, is a drawback by experienced hands that have reached plateau of the learning curve, although it remains a time-consuming procedure. Its application to gastric cancer surgery is feasible for early stage cancer, and its applicability to the treatment of T2 stage cancer will be the next issue to be explored.
There is good category II/III evidence that video-laparoscopic staging is valuable in certain gastrointestinal (gastric, esophageal, pancreatic, and hepatobiliary) and intra-abdominal lymphomas, but no category I evidence (based on prospective randomized trials). The evidence available is all retrospective, but of sufficient consistency to indicate that laparoscopic staging adds to the primary (imaging) staging and often alters the clinical stage of the disease and hence the management of the individual patient. The advent of laparoscopic contact ultrasound (LCU) scanning has improved the staging accuracy for pancreatic and hepatobiliary neoplasms. The laparoscopic approach also offers a means of surgical palliation in certain patient groups. However, there are a number of unresolved issues concerning the use of video-laparoscopy. The most important concerns whether staging laparoscopy should be performed immediately before scheduled surgery or as a separate intervention. The cost-efficacy of these two management options needs to be evaluated in prospective studies. In some centres, laparoscopic staging is being conducted by gastroenterologists and hepatologists. This raises issues of safety and ability to undertake certain procedures that may be necessary during the laparoscopic staging.
With the advent of minimally invasive laparoscopic techniques, most gynecologic procedures for benign conditions can be performed in an outpatient setting. However, the role of such techniques in gynecologic oncology is not well defined. By reviewing the literature and presenting some new data, we attempt to elucidate the applications of operative videolaparoscopy in gynecologic oncology. Advanced laparoscopic techniques are utilized for the management of cervical cancer as well as the staging and treatment of endometrial and ovarian cancers. Such techniques are used in performing radical hysterectomy for early stage cervical cancer, pelvic and paraaortic lymphadenectomy, and second look laparoscopy following chemotherapy for ovarian cancer. Even though preliminary data are encouraging, large prospective controlled studies with long-term follow-up are necessary to better define the role and limitations of laparoscopy in the treatment of gynecologic malignancies.
In patients with suspected recurrent cervical cancer after radiation therapy, it can be very difficult to pathologically confirm recurrence and clinically determine if tumor is resectable via a curative pelvic exenteration. Despite very thorough preoperative investigation uncertainties often remain, so patients ultimately undergo exploratory laparotomy. Unfortunately, inoperable disease is frequently discovered then. We report the use of operative laparoscopy in three patients with recurrent stage IIIB cervical cancer. The age ranged from 38 to 79 years. The mean duration of the procedure was 146 min (range 110-180 min) and blood loss was minimal. The procedure was well tolerated in all patients. There was no intraoperative complication but one deep thrombophlebitis occurred postoperatively. The procedure was successful in all cases in confirming recurrence and selecting out patients who were not surgical candidates for pelvic exenterations. Operative laparoscopy is a less invasive procedure that may be a valuable step in the workup of patients with recurrent cervical cancer. With experience in retroperitoneal surgery, the procedure can be carried out safely. We believe that this approach could prevent unnecessary laparotomies, shorten the hospital stay and the postoperative recovery, and contribute to a better quality of life for women with inoperable disease.
BACKGROUND: The aim of this study was to evaluate the accuracy and safety of laparoscopic second-look operations in patients with ovarian cancer. METHODS: We retrospectively reviewed the medical records of all patients who have undergone laparoscopic second-look procedures for ovarian cancer at our institution. RESULTS: From July 1993 to December 1998, 150 patients underwent laparoscopic second-look operations. The mean age of patients was 53 years (range, 25-78 years). The majority of patients (87%) had Stage III or IV disease at initial surgery; the remainder were Stage II or unstaged. Eighty-two patients (54%) had had optimal cytoreduction at the time of their initial surgery. All patients had completed primary chemotherapy and were clinically disease-free based on imaging studies and CA-125 levels at the time of second look. Sixty-nine patients (46%) were found to have pathologically negative second looks; thus, the rate of positive second-look evaluations was 54%. The rate of conversion to laparotomy was 18/150 (12%). In 3 cases this was secondary to bowel injury; one patient sustained a bladder injury; the remainder of conversions to laparotomy were for secondary cytoreduction. There was only 1 case where the patient was found to have extensive adhesions and laparoscopy was abandoned. The overall rate of major complications was 2.7%. CONCLUSIONS: In our experience, laparoscopy is a safe and accurate method of second-look assessment in patients with ovarian cancer. The incidence of complications is low, particularly in this group of patients, all of whom have undergone prior abdominal surgery. The rate of negative evaluations and the rate of recurrences in patients with negative second looks are equivalent to those described in studies of second-look assessment by laparotomy.
In two patients a pancreatic mass, 6 and 4 cm in diameter, respectively, was detected using imaging techniques. Computed tomography, ultrasound, and angiography revealed no evidence of a metastatic lesion in the liver. In the first patient, exploration was done prior to a possible radical operation. Multiple hepatic metastases forming thin, flat lesions on the surface of the liver were present and palliative surgery only was done. In the other patient, laparoscopy was done before surgical exploration and multiple hepatic metastases on the surface of the liver were clearly evident. Laparoscopy can help to avoid unnecessary explorations in patients with large pancreas cancer.
We report a case of metastatic lobular breast carcinoma with extrahepatic gastrointestinal disease. On the basis of clinical findings, radiologic investigations, computerized axial tomography, gastrointestinal endoscopy, and gastric biopsy, the diagnosis of gastric and ileal Crohn's disease was made. The correct diagnosis of peritoneal carcinomatosis was made at laparoscopy. This case exemplifies the utility of laparoscopy in establishing the diagnosis and staging for abdominal disease of uncertain etiology.
Urological laparoscopy has gained increasing acceptance recently. Alterations in renal water and electrolyte homeostasis by carbon dioxide peritoneal insufflation, retroperitoneal insufflation and abdominal wall lifting were measured in 30 well-hydrated pigs over a 2-h period. Oliguria was observed after gaseous insufflation but not alter lifting the abdominal wall. Return to normal urinary output was observed at 30 min after release of pneumoretroperitoneum, and 60 min after pneumoperitoneum. Creatinine clearance declined, while the clearance rates of potassium, sodium and urea remained unchanged during peritoneal and retroperitoneal insufflation. An elevated serum aldosterone concentration was found which may mediate the increased urinary excretion of potassium and decreased urinary excretion of sodium found during peritoneal insufflation. Renal function remained stable, despite an elevation of serum creatine kinase being elicited after lifting the abdominal wall. In conclusion, significant changes in water and electrolyte homeostasis occurred gaseous, not gasless, laparoscopy in pigs.
Although laparoscopic cholecystectomy is now an accepted part of resident training, the impact of operative laparoscopy (OL) upon the residency environment has not been examined in detail. We reviewed the first 3 years' experience with OL and the process by which it was introduced into our residency program. Data were obtained from our prospective computerized surgical laparoscopic registry as well as from a survey conducted midway in this experience. At that time, a questionnaire was sent to current residents in the program and residents who graduated after the inception of the OL program were interviewed by telephone. OL cases increased each year and comprised a progressively greater percentage of total cases. Residents performed over 97% of cases, with attending surgeons as first assistants. Initially, only senior-level residents participated as surgeons; however, after the first year we noted a significant tendency for cases to filter down the ranks. Junior-level residents have already participated in more laparoscopic than open cholecystectomies and expressed considerable concern about training in open procedures. Graduated residents without exception were able to obtain privileges to perform OL without additional training. They did not feel that resident education was compromised by the advent of laparoscopy. Both current and graduated residents considered didactic sessions including animal laboratories and simulators an important part of training.(ABSTRACT TRUNCATED AT 250 WORDS)
The purpose of this study was to discuss the place and the specific modalities of laparoscopic surgery in the management of ovarian dermoid cysts. This retrospective and noncomparative study was carried out in 65 patients who presented dermoid ovarian cyst between January 1986 and December 1990 in our institution. The surgical treatment was performed purely by laparoscopy in 86.2% of the cases (56 patients). The modalities of laparoscopic surgery were as follows: ovariectomy (8 cases; 14.3%), transparietal cystectomy (4 cases; 7.1%) and intraperitoneal cystectomy (44 cases; 78.6%). In 15 cases (15/44 = 34%) the intraperitoneal cystectomy was carried out without opening the cyst and the intact cyst was extracted using an endoscopic impermeable sack. We observed no cases of chemical peritonitis. The risk of recurrence after conservative treatment is 4% (two patients) and out of the ten patients for whom a second-look laparoscopy was performed only two (20%) presented adhesions. Laparoscopic treatment of dermoid ovarian cysts is feasible, safe, and effective. The treatment can be conservative in over 80% of the cases. The specific risk of chemical peritonitis can be countered by a change in the cystectomy technique. The use of an impermeable laparoscopic sack permits extraction of the cyst without any peritoneal contamination.
UNLABELLED: The purpose of this study was to develop a technique and assess the ability of a laparoscopic ultrasound probe to delineate biliary antomy and to determine the presence or absence of duct stones. METHODS: Five pigs had ultrasonography of biliary structures and liver at laparoscopy followed by cholangiograms and anatomical dissection. Five patients had ultrasonography of the biliary tract at laparoscopic cholecystectomy. RESULTS: All animals had adequate visualization of important hepatobiliary structure, and an optimal method of accessing these structures at laparoscopy was established. Patients had ultrasonography which used methods developed in the animal trial. All had adequate visualization of the entire common bile duct confirmed by cholangiography. Limitations in demonstrating the relationship of the cystic duct to the common duct were technical and can be corrected. CONCLUSION: Laparoscopic ultrasonography has significant potential for delineation of biliary anatomy and determination of presence or absence of duct calculi. Clinical implementation could minimize the risk of iatrogenic duct injury and the need for operative cholangiography.
Between 1970 and 1983, we performed 1121 diagnostic laparoscopies in 1119 patients. More than 50% of the examinations were performed for malignant disease. An adequate examination was accomplished in 917 (82%) procedures. The most frequent reason for inadequate evaluation was the presence of dense intraabdominal adhesions from previous surgery. We observed 105 (9.4%) minor complications and 20 (1.8%) major complications including one death following hemorrhage from liver biopsy. Major complications included abdominal wall hematoma, perforated abdominal viscus, hemoperitoneum, bleeding from liver biopsy, and respiratory depression. We observed a trend to decreased use of laparoscopy. Ascites of unknown origin and certain specific situations in patients with chronic liver disease remain as major indications for this diagnostic technique.
A prospective controlled study of the diagnostic accuracy of blind percutaneous liver biopsy in comparison to laparoscopy plus guided biopsy for the recognition or exclusion of cirrhosis has been performed. One hundred twenty-six patients with a clinical diagnosis of chronic, diffuse, well-compensated liver disease were randomized into two groups and submitted either to percutaneous blind liver biopsy (PB: 64 patients) or to laparoscopy with guided biopsy (LB: 62 patients), in order to assess the accuracy of either procedure in diagnosing cirrhosis. PB correctly recognized or ruled out cirrhosis in 52 patients (82%). Inconclusive results were mostly false negative, as demonstrated by the presence on endoscopy of esophageal varices or by subsequent LB. LB demonstrated presence or absence of cirrhosis in all patients. The difference between the rate of accurate results of the two procedures is statistically significant. It is concluded that in patients without esophageal varices, LB should be the investigation of choice for the assessment of liver structure since the presence of cirrhosis can be missed in up to 20% of cases by PB.
Laparoscopic tubal sterilization was performed on 179 women using general anesthesia, and tubal sterilization via mini-laparotomy was performed in 52 cases using local anesthesia. The patients ranged in age from 25 to 41 years, with 73.2% between 31 and 40 years. The mean operative time of laparoscopy and mini-laparotomy were 14.2 and 11.6 minutes, respectively. Both the laparoscopy group and the mini-laparotomy group were found to be similar with regard to age, gravidity and number of abortions. Pelvic inflammatory disease (PID) was not observed in any patient during the follow-up period (3 months). Two wound infections were detected within the first week following mini-laparotomy, and these were treated on an out-patient basis by relevant antibiotics. Among the 179 patients in whom laparoscopic tubal sterilization was performed, tubal rupture occurred in 3 cases (1.67%) which were electrocoagulated easily, and unplanned laparotomy was performed in a patient in whom bowel injury during mini-laparotomy was suspected.
In rats with experimental liver injuries and humans with various liver diseases, fluorescence from the liver surface after intravenous injection of 10% fluorescein-sodium was investigated. Our improved fluorescence laparoscopy allowed clear fluorescent images. In normal rats and in cases of nonspecific reactive hepatitis, fluorescence was first found in the portal area of the liver surface; it was then observed spreading into the lobules towards the central veins. In damaged livers of both rats and human, bright fluorescence was observed in arterioles, necrotic foci, and fibrotic areas on the liver surface. The patterns of fluorescence which appeared in the early phase after intravenous injection of fluorescein-sodium seemed to reflect the shapes and distribution patterns of the portal areas. These results suggest that observations with improved fluorescence laparoscopy are useful for diagnoses of liver diseases.
Trends of examinees and complications of laparoscopy were examined by a questionaire sent to all representative institutions in Japan. As a conclusion, the rate of complication by this examination was 10 times higher, while its mortality was 25 times higher, as compared with gastroenterological endoscopic examination. This article may indicate the present status of laparoscopy in Japan.
In 1983, we reported on the role of laparoscopy in the Infertility Clinic at the Rotunda Hospital. We now present the current position and the effect of a laparoscopic investigation on subsequent patient management. At laparoscopy, 31% of patients had evidence of pelvic inflammatory disease and 5% had endometriosis. Management was altered in 39 (43%) patients. When reviewed, 14 (23%) patients had conceived, 5 patients without medical intervention and more patients with secondary infertility. The incidence of pelvic inflammatory disease is increased and of endometriosis is unchanged from the previous report.