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At least 163 records · Page 9Linked to original sources
PubMed2006

Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass.

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75-182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4-78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.

Adult↗
PubMedDate not supplied

The Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) A retrospective review of 379 patients undergoing laparoscopic splenectomy.

In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.

Adolescent↗
PubMed1995

A comparative study of open, laparoscopic intracorporeal, and laparoscopic assisted low anterior resection and anastomosis in pigs.

This study was done to investigate whether laparoscopic intracorporeal (LI) or laparoscopic assisted (LA) colon resection results in improved anastomotic healing compared with open colon resection (OR). Thirty-six domestic swine were randomly assigned to undergo either LI, LA, or OR of the rectosigmoid. For OR cases, the sigmoid was resected through a midline incision, and a transanal end-to-end stapled anastomosis was constructed with an ILS device. For LA and LI cases, the sigmoid was laparoscopically mobilized and divided distally, using 5 trocar sites. For LA cases, the proximal sigmoid was brought out through an enlarged trocar site and resected; the ILS anvil was secured to the proximal end, and the colon was replaced in the abdominal cavity where the anastomosis was completed by transanal insertion and firing of ILS device. For LI cases, the sigmoid was resected laparoscopically and retrieved through a 33 mm trocar. The ILS anvil was introduced via the same trocar, and the device was laparoscopically secured with two Endoloop (Ethicon Endo-Surgery, Cincinnati, OH) pursestring sutures. The anastomosis was completed the same way as for LA cases. Animals were killed at 7 days, at which time the anastomoses were evaluated by barium enema, bursting pressure, and histologic appearance. There were no radiographic anastomotic leaks. The mean bursting pressure was 205 +/- 65 mmHg for the 13 OR animals, 240 +/- 53 mmHg for 11 LA animals, and 242 +/- 43 mmHg for the 12 LI animals (N.S.). Histologic evaluation for inflammation indicated no significant differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomosis, Surgical↗
PubMed1993

Laparoscopic supracervical hysterectomy. A comparison of morbidity and mortality results with laparoscopically assisted vaginal hysterectomy.

Laparoscopic applications in hysterectomy promise to be a factor in decreasing both economic and medical morbidity. However, with the need for both advanced laparoscopic skills and good vaginal surgical techniques, the meaningful conversion rate (total abdominal hysterectomy to laparoscopically assisted vaginal hysterectomy) appears to be low. A less morbid approach may be subtotal hysterectomy, in appropriate candidates, particularly if this procedure is readily accomplished by an increased number of physicians. A comparison of outcomes in 50 laparoscopically assisted vaginal hysterectomy patients versus 50 laparoscopic supracervical hysterectomy patients was made, demonstrating that the subtotal procedure was significantly less morbid.

Adult↗
PubMed1997

[Laparoscopic correction of recurrent gastro-esophageal reflux following laparoscopic fundoplication (4 cases)].

A series of 98 laparoscopic fundoplications, included 7 cases (7.1%) of recurrent gastro-oesophageal reflux. Six of these cases occurred within 12 months of surgery. Four were successfully treated by a second laparoscopic procedure. The mean interval between the initial and corrective operations was 10 months. Factors related to failure were: technical errors, operative inexperience, obesity and the size of the hiatus hernia (when crural closure was not performed). Laparoscopic re-operation to was relatively easy and without mortality but had an increased risk of pleural effusions. The mean length of hospital stay for re-operations was identical to that of initial operations (4 days). No further recurrences were noted after a mean follow-up of one year (280-475 days). We conclude that early failures following laparoscopic fundoplication can be effectively dealt with laparoscopic surgery.

Adult↗
PubMed2004

Efficacy and safety of reuse of disposable laparoscopic instruments in laparoscopic cholecystectomy: a prospective randomized study.

BACKGROUND: The aim of this prospective randomized study was to investigate the efficacy and safety of the reuse of disposable laparoscopic instruments (DLI) in laparoscopic cholecystectomy. METHODS: A total of 125 consecutive patients with symptomatic cholelithiasis were randomly assigned to undergo laparoscopic cholecystectomy with single-use DLI (group 1, n = 62) or DLI that were reused (group 2, n = 63) after high-level disinfection by alkalinized 2% glutaraldehyde. Operative and postoperative outcomes were investigated. RESULTS: There was no significant difference between group 1 and group 2 in mean operating time, linear analogue pain scale score, duration and amount of analgesic administration, or hospital stay. Total incidence of complications (3.2% vs 4.8%, p = 0.50) and infection rates (1.6% vs 3.2%, p = 0.57) were also similar when group 1 was compared to group 2. CONCLUSION: This study showed that reusing DLI did not change the operative and postoperative outcomes or the infection rate for laparoscopic cholecystectomy when strict rules for disinfection were followed.

Adult↗
PubMed2005

Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial.

HYPOTHESIS: The use of smaller instruments during laparoscopic cholecystectomy (LC) has been proposed to reduce postoperative pain and improve cosmesis. However, despite several recent trials, the effects of the use of miniaturized instruments for LC are not well established. We hypothesized that LC using miniports (M-LC) is safe and produces less incisional pain and better cosmetic results than LC performed conventionally (C-LC). DESIGN: A patient- and observer-blinded, randomized, prospective clinical trial. SETTING: A tertiary care, university-based hospital. PATIENTS: Seventy-nine patients scheduled for an elective LC who agreed to participate in this trial were randomized to undergo surgery using 1 of the 2 instrument sets. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, previous major abdominal surgical procedures, and acute cholecystitis or acute choledocholithiasis. INTERVENTION: Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments. MAIN OUTCOME MEASURES: Patients' age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results. RESULTS: Thirty-three C-LCs and 34 M-LCs were performed and analyzed. There were 8 conversions (24%) to the standard technique in the M-LC group. No intraoperative or major postoperative complications occurred in either group. The average incisional pain score on the first postoperative day was significantly less in the M-LC group (3.9 vs 4.9; P = .04). No significant differences occurred in the mean scores for pain on postoperative days 3, 7, and 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (visual analog scale score of 0) at 28 days postoperatively (P = .05). Cosmetic results were superior in the M-LC group according to both the study nurse's and the patients' assessments (38.9 vs 28.9; P<.001, and 38.8 vs 33.4; P = .001, respectively). CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed using 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. The use of mini-laparoscopic techniques resulted in decreased early postoperative incisional pain, avoided late incisional discomfort, and produced superior cosmetic results. Although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective LC.

Analgesia↗
PubMedDate not supplied

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis.

Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2005

Laparoscopic cholecystectomy using a newly developed laparoscope manipulator for 10 patients with cholelithiasis.

BACKGROUND: Laparoscopic surgery has continued to gain popularity in almost all fields of abdominal surgery, and robotic systems have been introduced in general surgery. Naviot is a new remote-controlled laparoscope manipulator system controlled by the operator's hand. This study assessed its introduction into clinical practice. METHODS: A group of 10 consecutive patients with cholelithiasis underwent laparoscopic cholecystectomy assisted by the Naviot system (Naviot group). Another group of 41 patients who underwent laparoscopic cholecystectomy with a conventional human camera holder (human camera group) were selected for a comparison of their operative results with those of the Naviot group. RESULTS: The operative time of 89.3 +/- 27.1 min for the Naviot group was significantly longer than that of 74.8 +/- 28.1 min for the human camera group (p < 0.05). However, when the setup time for the Naviot system was excluded, the operative time was not significantly different from that for the human camera group. Other operative results showed no significant difference between the two groups. CONCLUSIONS: The authors believe that the new Naviot system is feasible for clinical use, and that it enables surgeons to perform solo gastrointestinal surgery.

Aged↗
PubMed1998

Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic cholecystectomies.

BACKGROUND: Spilled gallstones after laparoscopic cholecystectomy may cause abscess formation, but the exact extent of this problem remains unclear. METHOD: The data (collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery) on 10,174 patients undergoing laparoscopic cholecystectomy at 82 surgical institutions in Switzerland between January 1992 and April 1995 were retrospectively analyzed with special interest in spilled gallstones and their complications. RESULTS: In 581 cases (5.7%) spillage of gallstones occurred; 34 of these cases were primarily converted to an open procedure for stone retrieval. Of the remaining 547 cases only eight patients (0.08%) developed postoperatively abscess formation requiring reoperation. CONCLUSIONS: Spillage of gallstones after laparoscopic cholecystectomy is fairly common and occurs in about 6% of patients. However, abscess formation with subsequent surgical therapy remains a minor problem. Removal of spilled gallstones is therefore not recommended for all patients, but an attempt at removal should be performed whenever possible.

Adolescent↗
PubMed1999

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. METHODS: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). RESULTS: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p = 0.01). CONCLUSIONS: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease.

Adult↗
PubMedDate not supplied

Laparoscopic-assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: a randomized clinical trial.

STUDY OBJECTIVE: To compare laparoscopic-assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) for the treatment of endometrial cancer. DESIGN: Randomized, controlled trial. DESIGN CLASSIFICATION: Randomized controlled trial (Canadian Task Force classification I). SETTING: Two gynecologic oncologic units of university hospitals. PATIENTS: Seventy-two women with endometrial cancer randomized to undergo either LAVH or TLH. INTERVENTIONS: Total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, peritoneal washing, and systematic pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: Parameters of technical feasibility (operating time of hysterectomy phase, estimated blood loss, perioperative complications) were considered as major statistical endpoints. Thirty-seven women were allocated to the LAVH arm, and 35 were allocated to the TLH arm. Mean total operating time was significantly shorter in the TLH than in the LAVH group (184.0 +/- 46.0 vs 213.2 +/- 39.4 minutes, p = .003). The hysterectomy phase was longer in the LAVH than in the TLH group only in overweight (77.9 +/- 9.8 vs 68.1 +/- 9.3 min, p = .005) and obese patients (87.7+/- 13.1 vs. 62.1+/- 9.9 min, p < .0001). The median estimated blood loss during hysterectomy was similar between groups. Intraoperative complications occurred in three (8.1%) patients in the LAVH group and in one patient (2.8%) in the TLH group (p = .61). No difference was found in the postoperative complication rate between women undergoing LAVH and those who had TLH (24.3% vs 17.1%, p = .56). Within a median follow-up period of 10 months (range 3-17 months), 2 patients in the LAVH group developed recurrent disease. No port site metastasis and no vaginal cuff recurrence were detected in either group. CONCLUSION: Both LAVH and TLH can be performed successfully to manage endometrial cancer, with similar surgical outcomes. Obese patients benefit more from TLH than from LAVH in terms of shorter operating time.

Adenocarcinoma, Papillary↗
PubMed2002

[Laparoscopic and conventional cholecystectomy. Didactic concept for training and introduction of laparoscopic cholecystectomy and preventing complications].

AIM: This study has assessed the suitability of an educational concept for the introduction and training of laparoscopic cholecystectomy, a newly established operational procedure, within an university teaching hospital with a large number of surgeons. PATIENTS AND METHODOLOGY: Since introduction of the first laparoscopic cholecystectomy all cholecystectomies were prospectively assessed over a period of two years (from May 1990 till May 1992). The educational concept applied was such that a given surgeon would first receive training from an instructor for 15 procedures and then assume responsibility for instruction of a subsequent trainee. RESULTS: In two years 355 patients underwent cholecystectomy. 60% of the operations were performed laparoscopically and 40% of the operations performed openly. During the two year period 13 surgeons were trained in the new technique, with an average of 16 operations per surgeon. Throughout the introductory phase there were no serious complications, and in particular no damage to the bile duct. DISCUSSION: The advantage of this introductory training phase has repeatedly been subject of discussion in the literature. In the meanwhile guidelines from specialist bodies and national institutions exist for regulating the education of new surgical techniques. In the past few years introduction to new techniques has gradually shifted toward training on the skill-stations and virtual reality trainers. CONCLUSION: The described educational concept for the introduction and training of laparoscopic cholecystectomy has been well approved and accepted since the early 90's.

Cholecystectomy↗
PubMed1999

An easy and effective method of cholangiography in laparoscopic cholecystectomy: laparoscopic cholecystocholangiography.

BACKGROUND: There is ample evidence that the incidence of operative cholangiography has declined since the introduction of laparoscopic cholecystectomy. It has been suggested that one of the reasons for this decline is the technical difficulty of cystic duct catheterization. A method of cholangiography which does not require such catheterization has been developed by others. This paper examines the ease and effectiveness of operative cholangiography performed by direct puncture of the gall-bladder. METHODS: A retrospective study was made of the records of 380 consecutive patients who underwent attempted laparoscopic cholecystectomy. After exclusion of patients in whom laparoscopic cholecystectomy was abandoned in favour of open cholecystectomy and those patients in whom operative cholangiography was not attempted, the records of 325 patients were available to the study. The operation notes of each patient were studied to determine whether, in the operator's opinion, a successful cholangiogram had been obtained. RESULTS: There were 290 patients in whom cholangiography was attempted using direct gall-bladder puncture (cholecystocholangiography (CCC)). There were 35 patients in whom cholangiography was attempted via cystic duct cannulation (CDC). Cholecystocholangiography was successful in 86% of those cases in which it was attempted. Cystic duct cannulation was successful in 83% of those cases in which it was attempted. CONCLUSION: Cholecystocholangiography is a valid alternative to cystic duct catheterization in its ability to achieve intra-operative cholangiography in the setting of laparoscopic cholecystectomy.

Adolescent↗
PubMed1996

A new technique for laparoscopic cholecystectomy--retrograde laparoscopic cholecystectomy: an analysis of 81 cases.

BACKGROUND AND STUDY AIMS: A new technique of laparoscopic cholecystectomy is presented here. This new method, retrograde laparoscopic cholecystectomy (RLC) from fundus to cystic duct downward, may have advantages when exposure of the cystic duct and the common duct are difficult and therefore hazardous. PATIENTS AND METHODS: We carried out laparoscopic cholecystectomy in 173 patients; RLC was performed in 81, The operative procedure is as follows: first, the cystic duct and artery are exposed at the junction of the ampulla. The cystic duct is clipped, and the artery is divided. Removal of the gallbladder is then started from the fundus to cystic duct downward. After the gallbladder has been dissected from the liver bed, the cystic duct is double-clipped and divided. This approach provides better visualization of the gallbladder, cystic duct, and common duct, with less chance of common duct injury, due to clear identification of the ductal system, without the need for intraoperative cholangiography. RESULTS: Eighty-one RLCs were performed without severe complications, either immediate or late. The mean operating time was 23 minutes shorter in RLC than in the usual laparoscopic cholecystectomy, because intraoperative cholangiography was used much less often. CONCLUSION: RLC appears to be a safe procedure, and does not affect the conventional method.

Adult↗
PubMed2006

Laparoscopic end-to-end choledochocholedochostomy for bile duct injury during laparoscopic cholecystectomy.

Bile duct injury is one of the serious complications associated with laparoscopic cholecystectomy. If the bile duct injury is circumferential or the bile duct is transected, conversion to open surgery is usually done. With the continuing development of laparoscopic techniques, procedures that previously seemed implausible can now be performed laparoscopically. We describe a case of successful laparoscopic end-to-end choledochocholedochostomy after the common bile duct was mistaken for the cystic duct intraoperatively and transected.

Cholecystectomy, Laparoscopic↗
PubMed1995

Does hypercarbia develop faster during laparoscopic herniorrhaphy than during laparoscopic cholecystectomy? Assessment with continuous blood gas monitoring.

The use of CO2 to create and maintain a pneumoperitoneum during laparoscopic surgery may lead to hypercarbia and acidosis. CO2 is also insufflated into the preperitoneal space to create and maintain a pneumopreperitoneum for laparoscopic herniorrhaphy. This study examined the influence of CO2 pneumopreperitoneum on the development of hypercarbia and acidosis assessed with continuous intraarterial blood gas monitoring. Changes in blood gas values were measured with both continuous intraarterial and intermittent blood gas monitoring. Over a 4-mo period, blood gas values of 14 patients undergoing laparoscopic herniorrhaphy (pneumopreperitoneum) were compared with those of 13 patients undergoing laparoscopic cholecystectomy (pneumoperitoneum) in a tertiary referral center. Additionally, heart rate and blood pressure were measured during stable ventilation at constant insufflation pressure. Pneumopreperitoneum resulted in a significantly faster development of hypercarbia (P = 0.023) and acidosis (P = 0.027) than pneumoperitoneum. These results were not explained when corrected for changes in hemodynamic and ventilatory variables using analysis of covariance. We conclude that the more rapid development of hypercarbia and acidosis during pneumopreperitoneum can be explained by increased CO2 absorption through an increasing gas exchange area during the procedure and through a larger wound bed.

Absorption↗
PubMed1994

Laparoscopic management of complications following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis. Although published morbidity and mortality rates compare favourably with open cholecystectomy, bile duct injuries occur far more frequently and technical complications unique to the laparoscopic approach account for a significant number of postoperative deaths. The majority of these complications are dealt with by laparotomy. Two technical complications encountered in a series of 170 patients undergoing laparoscopic cholecystectomy and their subsequent management are presented. One patient suffered a diathermy injury to the common hepatic duct and postoperative bile leak. This was managed successfully by repeat laparoscopy and peritoneal lavage combined with endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the hepatic duct. Another patient sustained a perforated duodenum complicated by peritonitis, subcutaneous wound infection and generalized sepsis. The perforation was repaired at a second laparoscopy using intracorporeal suturing and Tissucol. It is demonstrated that it is possible to deal with some of the technical complications of laparoscopic cholecystectomy with a combination of minimally invasive techniques, sparing the patient from the additional risk of laparotomy.

Adult↗