Laparoscopic herniorrhaphy: review of complications and recurrence.
Sayad P. Hallak A. Ferzli G.
Department of Laparoscopic Surgery, Staten Island University Hospital, New York 10305, USA.
Laparoscopic hernia repair has evolved considerably since its introduction. Different methods have been described, and multiple studies have been performed reporting widely varying outcomes. This study was undertaken to review all the major publications on laparoscopic herniorrhaphy from 1993 to 1996 and evaluate the rates of recurrence and complications involved in the various techniques. In a total of 11,222 laparoscopic hernia repairs, the procedure performed most frequently was the transabdominal preperitoneal patch (TAPP), followed by the total extraperitoneal patch (TEP). There were 300 (2.7%) recurrences. From 9,955 hernia repairs, there were 1,534 (15.4%) complications. Hematoma/seroma (456), neuralgia (199), urinary retention (150), and chronic pain (39) were the most frequently reported complications. Laparoscopic herniorrhaphy is a higher effective method of hernia repair with results comparable with the open technique. TAPP is still the most widely performed technique. TEP is becoming more popular, mainly because of its excellent outcome. The major drawback of TEP is the difficulty of reproducibility by different general surgeons with comparable results. Other techniques such as plug and patch carry a high rate of recurrence and complications and should probably be completely abandoned.
The incidence of secondary hernias diagnosed during laparoscopic total extraperitoneal inguinal herniorrhaphy.
Woodward AM. Choe EU. Flint LM. Ferrara JJ.
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
During a 24-month period beginning in July of 1995, laparoscopic total extraperitoneal inguinal herniorrhaphy was attempted in 53 patients. All procedures were performed at a single institution, by senior-level general surgery residents, with the same attending surgeon functioning as first assistant. Three patients required conversion to an "open" procedure (all had a prior history of herniorrhaphy or lower abdominal surgery), leaving 50 patients for analysis. Preoperatively, a unilateral hernia was evident on clinical grounds in 29 patients, the remaining 21 presenting with signs of a bilateral hernia; of the total, 11 had a history of prior hernia repair on the presently affected side. At surgery, a total of 115 hernia defects (indirect, direct, femoral) were identified, 38% of which were discovered only at the time of surgery. Sixty-four percent of patients were found to have at least one of these "secondary" hernias. After reduction of the hernia(s), all defects were covered with polypropylene mesh secured with spiral tacks. There were 10 perioperative complications, one of which required corrective surgical intervention. Over 70% of patients were discharged on the day of surgery; 92% returned home within 23 h of their operation. The most common reason for delay of hospital discharge was urinary retention. There have been no recurrences in short-term follow-up. Most patients were pleased with the recovery time from and the cosmetic results of their surgery. These results suggest that laparoscopic total extraperitoneal herniorrhaphy represents a safe, effective, cosmetically appealing alternative to open hernia repair. Moreover, this approach may provide an added advantage insofar as identifying additional hernia defects that, when repaired, may ultimately yield a lower recurrence rate than might otherwise have been expected.
Laparoscopy in the diagnosis and management of Crohns disease.
Singh K. Prasad A. Saunders JH. Foley RJ.
Bedford Hospital NHS Trust, UK.
We have tried to evaluate the role of laparoscopy and laparoscopic-assisted surgery in the management of Crohn's disease. Over a 4-year period, we had 38 patients, of which 23 patients were suspected to have Crohn's disease and were admitted for diagnostic laparoscopy while 15 patients had already had a biopsy confirmation of Crohn's disease in the past and were admitted for specifically planned procedures. In the first group of 23 patients, 11 were found not to have Crohn's disease. In the remaining 12 patients, three were proven to have Crohn's disease, but no surgical procedure was undertaken. The remaining nine patients underwent laparoscopic-assisted procedures, of which two required conversion to a laparotomy because of intra-abdominal abscesses. All 15 patients in the second group underwent laparoscopic or laparoscopic-assisted procedures. In total, 14 patients were spared a potential diagnostic laparotomy and could go home the next day. The remaining 24 patients underwent procedures requiring longer hospital stays; five had a purely laparoscopic procedure, 17 had a laparoscopic-assisted procedure, and two required a laparotomy. Although there was little difference in the median stay for patients treated laparoscopically or by laparotomy, it is thought that the extent or severity of the disease process influenced the length of the stay rather than the approach used. The complication rate was similar to that found in Crohn's patients undergoing open surgery. It remains to be seen whether those in the laparoscopically treated group have less adhesive complications than those treated by laparotomy. It is our belief that laparoscopy is a valuable aid in the diagnosis of Crohn's disease. It remains to be proven whether or not laparoscopic-assisted surgery will be of significant value in the treatment of this condition.
High-level disinfection with 2% alkalinized glutaraldehyde solution for reuse of laparoscopic disposable plastic trocars.
Gundogdu H. Ocal K. Caglikulekci M. Karabiber N. Bayramoglu E. Karahan M.
Clinic of Gastrointestinal Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey.
The reusability of disposable plastic trocars after high-level disinfection by alkalinized 2% glutaraldehyde solution was examined in a prospective study from the point of view of infection risk in order to determine the safety and economic benefits. For this purpose, 45 laparoscopic cholecystectomy cases were analyzed microbiologically and clinically. In 30 cases, trocars subjected to 15 min of disinfection by glutaraldehyde were used. In the remaining 15 cases, new trocars were used and a control group was established. In total, eight culture samples were taken from trocars, laparoscope (as it is disinfected by the same method), glutaraldehyde solution and umbilicus of the patients preoperatively; and from the bile in the gallbladder, peritoneal lavage fluid, and epigastric and umbilical incisions postoperatively. Only one of the disinfected trocars yielded a culture-positive result. No culture-positive results were found in the samples taken from laparoscope, glutaraldehyde, and epigastric incisions. Culture-positive results were obtained in 11 cases at the umbilicus, in one case at the peritoneal lavage and in one case at the umbilical incision. None of the patients had infection at the wound site or intra-abdominally. In conclusion, we have shown that disposable plastic trocars subjected to high-level disinfection can be reused safely without infection risk and that cost can be reduced.
Laparoscopic intracavitary drainage of subphrenic abscess.
Lam SC. Kwok SP. Leong HT.
Department of Surgery, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong.
Percutaneous drainage is now the preferred initial treatment of subphrenic abscess. The result is best for simple, unilocular abscesses but less so for complex ones. Failure of drainage can lead to high morbidity and mortality. We describe a case in which a large multiloculated subphrenic abscess was successfully drained laparoscopically without contaminating the general peritoneal cavity.
Laparoscopic surgery and splanchnic vessel thrombosis.
Sternberg A. Alfici R. Bronek S. Kimmel B.
Department of Surgery, Hillel Jaffe Medical Center, Hadera, Israel.
We report a case of fatal mesenteric artery thrombosis following laparoscopic cholecystectomy in a 60-year-old hypertensive woman, whose preoperative complaints were not typical of calculous biliary disease. Two previous case reports have associated laparoscopic cholecystectomy and acute intestinal ischemia; one of these patients died. Experimental and clinical data indicate that carbon dioxide pneumoperitoneum reduces splanchnic blood flow through several mechanical and physiologic mechanisms. Consequently, we believe that, when laparoscopic surgery is contemplated, physicians and patients should be aware of the risk of splanchnic vessel thrombosis, especially when certain pre-existing conditions are present (e.g., impairment of splanchnic vessel flow, hypercoagulable states, etc.). For such high-risk patients, especially when the planned laparoscopic procedure may be lengthy, gasless or low-pressure laparoscopic surgery, or even reversion to traditional open surgery should be considered.
A laparoscopic approach to posterior gastric wall leiomyomectomy.
Piskun G. Fleites JC. Shaftan GW. Fogler RJ.
Department of Surgery, The Brookdale University Hospital and Medical Center, Brooklyn, New York 11212, USA.
Leiomyomas represent 2% of gastric tumors. Commonly, gastric leiomyomas are clinically silent. Most often they become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa. Surgical extirpation of the tumor is the standard treatment. Gastric leiomyomectomy was done routinely through open laparotomy until availability of laparoscopic equipment and techniques. Recently, there have been a few published reports regarding laparoscopic or laparoscopic-assisted removal of smooth muscle gastric tumors. There is little data, however, describing or discussing a laparoscopic approach to gastric leiomyomas located on the posterior gastric wall. We describe two different laparoscopic approaches to posterior wall gastric leiomyomas that we used in two patients. The postoperative recovery of both patients was remarkably quick and uneventful.
Simplified technique for unrolling prosthetic mesh during laparoscopic ventral hernia repair.
Gersin KS. Ponsky JL. Heniford BT.
Minimally Invasive Surgery Center, Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
Laparoscopic ventral herniorraphy is an attractive alternative to conventional open repair. It preserves the benefits of minimally invasive surgical procedures by offering decreased discomfort and hospital stay while affording a low recurrence rate. Although technically feasible, unrolling a large piece of prosthetic mesh within the peritoneal cavity is often time consuming and the most frustrating step in the procedure. Our group describes a simplified technique for unrolling mesh that is quick, easy to perform, and requires no specialized equipment.
Retroperitoneal abscess as a complication of retained gallstones following laparoscopic cholecystectomy.
Parra-Davila E. Munshi IA. Armstrong JH. Sleeman D. Levi JU.
Department of Surgery, University of Miami, Jackson Memorial Hospital, Florida 33101, USA.
Retroperitoneal abscess formation secondary to retained spilled gallstones after laparoscopic cholecystectomy is a rare complication. We describe the case of a patient with this complication as well as a novel method utilizing interventional radiologic localization with subsequent operative drainage and removal of the stones. A review of the literature is provided.
Laparoscopy to correctly diagnose and treat Crohns disease of the ileum.
Internal Medicine Unit, Hospital Casa Maternitat, Corporacio Sanitaria Clinic, Barcelona, Spain.
A 27-year-old woman with a past history of pulmonary tuberculosis presented with right iliac fossa pain and low-grade fever. She was empirically treated for Crohn's disease despite undergoing multiple investigations that failed to provide a strongly suspected diagnosis. After 3 days of therapy, her symptomatology aggravated, and signs suggestive of intestinal obstruction developed. Placing the patient in the left lateral decubitus position before sterile draping, intracorporeal laparoscopy was performed, and Crohn's disease involving the terminal ileum but sparing its most distal 25 cm was confirmed. During the procedure, creeping mesenteric fat, a characteristic feature of Crohn's disease, was seen. Also, some adhesions in the right iliac fossa and a firm 3-cm inflammatory mass were found. Both division of mesentery along with terminal ileum resection and ileocolonic anastomosis were successfully performed intracorporeally, without need to convert to open surgery. In select cases of right iliac fossa pain in which diagnostic and therapeutic results are inconclusive or equivocal, laparoscopy can be useful to correctly diagnose and treat inflammatory bowel disorders such as Crohn's disease. Moreover, we suggest that intracorporeal laparoscopic surgery can be effective in the treatment of these conditions even in some cases with intestinal complications such as inflammatory masses and adhesions.
Morgagnis hernia resolved by laparoscopic surgery.
Del Castillo D. Sanchez J. Hernandez M. Sanchez A. Domenech J. Jara J.
Department of Surgery, University Hospital of St. Joan, Rovira i Virgili University School of Medicine and Health Sciences (C/Sant Joan s/n), Reus, Spain.
Morgagni's hernias represent between 2 and 4% of the whole of nontraumatic diaphragmatic hernias in the adult, and the treatment (even with minimal symptoms) is always with surgery. We present the case of a 50-year-old woman with an oppressive, postprandial discomfort in the right side of her thorax and with increased pain when supine. The x-ray examination indicated a large portion of transverse colon inside the thoracic cavity. Once the diagnosis of Morgagni's hernia had been obtained, she was scheduled for laparoscopic surgery to reduce the hernia and to reconstruct the defect of the diaphragm using a polypropylene mesh.