Surg Endosc

How often might a trans-cystic-duct stone extraction be feasible?

Vracko J. Wiechel KL.
Department of Gastroenterological Surgery, Medical Centre, University of Ljubljana, Slovenia.
BACKGROUND: Although the sizes of the cystic duct and concomitant bile duct stones are fundamental in evaluating the possibility of a trans-cystic-duct approach as an alternative to cholangiotomy, no conclusive data are supplied in the reports on laparoscopic cholecystectomy. METHOD: The narrowest inner diameter of the cystic duct and the diameter of the largest concomitant bile duct stone are compared in a prospective study of 30 consecutive patients. RESULTS: The bile duct stones were smaller than the cystic duct in 14 patients, 47%, and of equal size in nine, 30%. They were larger than the cystic duct in the remaining seven patients, 23%, with a difference of only 1 mm in five patients and of 2 and 4 mm, respectively, in two. CONCLUSIONS: Physical conditions allowing a trans-cystic-duct stone extraction were present in 23 of 30 patients and an attempt might have been possible after, for example, cystic duct dilatation in a further five.

Evaluation of laparoscopic management of common bile duct stones in 220 patients.

Berthou JC. Drouard F. Charbonneau P. Moussalier K.
Clinique Chirurgicale Mutualiste, Lorient, France.
BACKGROUND: The aim of this study was to evaluate the feasibility and results of laparoscopic management of common bile duct stones (CBDS). METHODS: From October 1990 to November 1996, 220 patients with CBDS have been managed laparoscopically. CBDS were suspected or diagnosed preoperatively in 130 patients (59.1%) and at intraoperative cholangiography (IOC) in 90 patients (40.9%). A transcystic duct extraction (TCDE) was attempted in 112 patients and a primary choledochotomy in 108 patients. RESULTS: TCDE was successful in 77 cases (68.8%). The 35 failures were treated by 29 laparoscopic choledochotomies, 1 intraoperative and 5 postoperative endoscopic sphincterotomies (ES). A choledochotomy was thus performed in 137 cases and was successful in 133 cases (97.1%). The four failures were managed by three laparotomies and one postoperative ES. The overall success rate was 95.5% (210/220). There was 4 deaths (0.9%) within the 1st postoperative month in ASA 3 patients and the morbidity rate was 9.1% (20/220). There were 7 residual stones (3.2%). CONCLUSIONS: Laparoscopic desobstruction of CBDS appears to be safe and effective and has the advantage to be a single-stage procedure. It could become in the future with refinement of instrumentation and skill of surgeons the best treatment for the majority of patients harboring CBDS.

Follow-up of 161 unselected consecutive patients treated laparoscopically for common bile duct stones.

Paganini AM. Lezoche E.
Cattedra di Chirurgia Generale I, Universita di Ancona, Ospedale Umberto Ist, Italy.
BACKGROUND: Aim was to study the incidence of recurrent ductal stones and of biliary strictures at follow-up after laparoscopic treatment of gallstones and common bile duct stones and to update the short-term results. METHODS: Ductal stones were proven in 161 patients of 1,975 (8.1%) undergoing laparoscopic cholecystectomy. Laparoscopic transcystic CBD exploration was the method of choice. If this was unsuccessful, laparoscopic choledochotomy was performed. After treatment, all patients were enrolled in a continued, ongoing follow-up study. RESULTS: Laparoscopic CBD exploration was completed in 157 cases (transcystic 107, choledochotomy 50). Retained stones occurred in eight patients (5%) and major complications (cystic duct leakage, hemoperitoneum) in six (3.8%); mortality occurred in one high-risk patient (0.6%). Follow-up available in 154 patients (two unrelated deaths) for a period of up to 62 months showed the occurrence of recurrent ductal stones in five cases (3.2%) and no signs of bile stasis, suggestive of ductal stricture, on the basis of clinical and laboratory findings. CONCLUSIONS: This prospective, ongoing follow-up study demonstrates that laparoscopic treatment of gallstones and common bile duct stones in unselected patients is feasible and safe.

Prospective randomized comparison of laparoscopic ultrasonography using a flexible-tip ultrasound probe and intraoperative dynamic cholangiography during laparoscopic cholecystectomy.

Birth M. Ehlers KU. Delinikolas K. Weiser HF.
Diakonie-Hospital Rotenburg/Wumme, I. Chirurgische Klinik fur Allgemein-, Viszeral-, und Thoraxchirurgie, Rotenburg/Wumme, Germany.
BACKGROUND: We performed a prospective randomized comparison of laparoscopic intraoperative ultrasonography (LIOU) and dynamic intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). METHODS: LIOU and IOC were attempted in 518 consecutive patients scheduled for laparoscopic cholecystectomy. The order in which the diagnostic procedures were performed was randomly assigned. RESULTS: LIOU failed in two patients (0.4%), and there were 41 (7.9%) failed IOC. The common bile duct (CBD) was visualized reliably with both methods. Our patients showed sensitivities of 83.3% and 100% and specificities of 100% and 98.9%, with an overall accuracy of 99.2% and 98.9% for LIOU as compared to IOC for identifying unsuspected common bile duct stones. The time necessary for the examination was significantly shorter in LIOU than in IOC (7 versus 16 min). CONCLUSION: LIOU performed by experienced surgeons is a good and effective method to assess the CBD, including the neighboring structures of hepatoduodenal ligament. Using powerful, flexible-tip ultrasound probes, CBD exploration can be done in a longitudinal fashion, which is necessary for good anatomical clarity. A lack of adverse effects, shorter examination times, and lower costs are some of the advantages of this method. The most important advantage is the possibility of unlimited repetition, especially if there is difficulty identifying anatomic structures. In addition, there are some indications that LIOU has the potential to recognize major iatrogenic bile duct injuries.

Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery. Laparoscopic Colorectal Surgery Study Group (LCSSG).

Kockerling F. Schneider C. Reymond MA. Scheidbach H. Konradt J. Barlehner E. Bruch HP. Kuthe A. Troidl H. Hohenberger W.
Department of Surgery, University of Erlangen, Germany.
BACKGROUND: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. METHODS: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. RESULTS: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. CONCLUSIONS: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period.

Common bile duct T-tubes. A caveat and recommendations for management.

Jacobs LK. Shayani V. Sackier JM.
George Washington University, Washington, DC 20037, USA.
Operations on the common bile duct can result in severe long-term consequences. To prevent some of these complications, it is common practice to drain the biliary tree with a T-tube. The T-tube is usually removed 2 weeks after it was placed. There have been numerous reports of bile leak following T-tube removal in the literature. These leaks can result in bile ascites, biloma, or bile peritonitis. Control of bile leaks can be accomplished in a number of ways, including endoscopically or radiologically placed stents or drains and radiologic techniques to drain the fluid collections. We describe a novel technique that can be utilized at the time of T-tube removal that will allow immediate control of the bile leak and prevent the complications of bile accumulation within the peritoneal cavity. We have performed fluoroscopic removal of T-tubes on two patients and found no complications with the technique. We have successfully visualized the T-tube tract in both patients. The T-tube tract can be visualized at the time of T-tube removal in an effort to prevent the complications of tract disruption and subsequent bile leak.

Two unusual cases of postcholecystectomy pain.

Airan MC.
Department of Surgery, Good Samaritan Hospital, Downers Grove, IL 60515, USA.
I report on two patients who were initially diagnosed with sphincter of Oddi dysfunction (S.O.D.) because of postcholecystectomy pain in the right upper quadrant; both had other causes of pain. One patient had an aberrant hepatic duct that drained into a remnant of the cystic duct resulting in formation of stones. The second patient had adhesions of the stomach to the liver with the ligamentum teres bowing across the antrum. Gastroenterologists and endoscopic surgeons should be aware of causes of postcholecystectomy pain that are unrelated to sphincter of Oddi dysfunction.

Indications for laparoscopic colorectal surgery. Results from the Medical Centre Alkmaar, The Netherlands.

Molenaar CB. Bijnen AB. de Ruiter P.
Department of Surgery, Medical Centre Alkmaar, The Netherlands.
BACKGROUND: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. METHODS: Our main aim was to define more specifically the indications for laparoscopic colectomy. RESULTS: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. CONCLUSIONS: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20-50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting.

Local epinephrine facilitates laparoscopic Heller myotomy.

Kuster GG.
Division of General Surgery, Scripps Clinic, La Jolla, CA 92037, USA.
Incomplete myotomy and mucosal perforation are the most common technical complications of laparoscopic esophageal myotomy. The muscle layers of the lower esophagus are infiltrated with a 1:100,000 epinephrine solution using a thin needle. Gentle pressure is applied with a peanut sponge to diminish the edema produced by the injections. The longitudinal fibers are separated with a dissector and the semicircular fibers are lifted from the submucosa with a dissector or a hook. The muscle transection is done simply by tearing the fibers or cutting them with scissors. No coagulation is required. Infiltration and topical application of epinephrine solution allowed the performance of 22 laparoscopic esophageal myotomies with excellent visualization, complete muscle division, and without any esophageal or gastric perforation. Injection and topical application of epinephrine solution to the area of the esophagus and stomach which will be subjected to myotomy greatly facilitates the procedure and helps to avoid complications.

Laparoscopic anatomical hepatic resection. Report of four left lobectomies for solid tumors.

Samama G. Chiche L. Brefort JL. Le Roux Y.
Department of General and Digestive Surgery, CHU, Caen, France.
Four patients underwent a laparoscopic left hepatic resection for solid tumor, two for metastasis from colonic cancer, and two for focal nodular hyperplasia (final diagnosis). The procedure was performed according to the rules of conventional hepatic surgery and cancer surgery. No blood transfusion was necessary. No surgical complication occurred. In malignant disease, laparoscopy allows a good staging and the performance of a real no-touch technique; the specimen is removed in a plastic bag without contact to the abdominal wall. In symptomatic benign disease the esthetic benefit of the laparoscopic approach is real. In asymptomatic benign disease, laparoscopy could allow large biopsies in the case of uncertain diagnosis or dangerous resection. It allows safe resections in the case of small, well-located tumors. This approach requires sophisticated material and extensive experience in both laparoscopy and hepatobiliary surgery.

Laparoscopic repair of a paraduodenal hernia.

Uematsu T. Kitamura H. Iwase M. Yamashita K. Ogura H. Nakamuka T. Oguri H.
Department of Surgery, Iwata Municipal General Hospital, Japan.
Paraduodenal hernias have traditionally been treated by conventional laparotomy. We report the first case of a left paraduodenal hernia treated laparoscopically. A 44-year-old man was admitted with abdominal pain and nausea. Computed tomography and an upper gastrointestinal series with small-bowel followthrough showed accumulation of the small bowel on the left side of the abdomen. A laparoscopic repair was performed. The small bowel was observed beneath a thin hernia capsule. Approximately 1.5 m of jejunum was easily reduced into the abdominal cavity. The hernia orifice (5-cm diameter) was closed intracorporeally with five interrupted sutures. Good exposure of the operative field is critical to this procedure; poor exposure may limit the applicability of the laparoscopic approach. This minimally invasive operation is currently indicated in nonobstructive paraduodenal hernias, especially on the left.

Laparoscopic management of cystic disease of the liver.

Hodgson WJ. Kuczabski GK. Malhotra R.
Brooklyn Hospital Center, NY 11201, USA.
BACKGROUND: Laparoscopic management of cystic disease of the liver, including severe polycystic disease, is evolving. METHODS: Wide unroofing, or "fenestration," as is required for a successful result in open cases, leads to complete resolution of the cysts. This can even occur in chronic cysts, with wide-enough unroofing, given time. RESULTS: In polycystic disease, adequate fenestration of superficial, cysts allows deeper cysts to prolapse and be similarly fenestrated, thus reducing pressure effects on the liver and restoring normal function. CONCLUSION: However, because of the distortion of anatomy by this disease, it is important that an experienced liver surgeon perform such a complex procedure, as operative complications could be severe.

Comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy.

Ninomiya K. Kitano S. Yoshida T. Bandoh T. Baatar D. Matsumoto T.
Department of Surgery I, Oita Medical University, Japan.
BACKGROUND: Impairments in hemodynamics during pneumoperitoneum (PP) have been noted. This study compared changes in hemodynamics and surgical stress response with PP and abdominal wall lifting (AWL) during laparoscopic cholecystectomy. METHODS: Twenty patients with symptomatic cholecystolithiasis were assigned to PP (n = 10) or AWL (n = 10). Cardiac output (CO), stroke volume (SV), and ejection fraction (%EF) were measured by transesophageal echocardiography. Clearances of para-aminohippurate (CPAH) and sodium thiosulfate (CSTS) were determined as measures of renal function. Levels of interleukin-6, C-reactive protein, white cell count, and neutrophil elastase were evaluated as indicators of surgical stress. RESULTS: In the PP group, CO, SV, and %EF were depressed significantly during pneumoperitoneum. Immediately after and 15 min after insufflation, the CPAH and CSTS were decreased by 78.0% and 73.8%, respectively. None of the hemodynamic parameters changed significantly in the AWL group. Surgical stress response was not different significantly between the two groups. CONCLUSIONS: In contrast to pneumoperitoneum, AWL did not alter cardiac function or renal hemodynamics. AWL may be useful in patients with cardiovascular or renal disorders.

Resolving gastroesophageal reflux with laparoscopic fundoplication. Findings in 138 cases.

Leggett PL. Churchman-Winn R. Ahn C.
Department of Surgery, University of Texas-Houston Medical School, Houston 77030, USA.
BACKGROUND: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting. METHODS: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures. RESULTS: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases. CONCLUSIONS: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications, operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be successfully transferred from academic medical centers to the community hospital setting.

A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables.

Schrenk P. Woisetschlager R. Rieger R. Wayand WU.
Ludwig Boltzmann Institute for Surgical Laparoscopy, Linz, Austria.
BACKGROUND: Modified logistic regression analysis of 24 variables in 300 patients undergoing laparoscopic cholecystectomy found the following parameters independently predictive for a difficult operation: right upper quadrant pain (p < 0.01), rigidity in right upper abdomen (p < 0.01), previous upper abdominal surgery (p < 0.01), biliary colic within the last 3 weeks (p < 0.05), white blood cell count > 10 x 10(9)/l (p < 0.05), thickening of the gallbladder wall (p < 0.05), hydroptic gallbladder (p < 0.05), pericholecystic fluid (p < 0.01), shrunken gallbladder (p < 0.01), and no filling of the gallbladder in preoperative intravenous cholangiography (p < 0.05). METHODS: Based on these variables a diagnostic model was developed to predict the difficulty of a laparoscopic cholecystectomy, with scores ranging from 0 (ideal case) to IV (conversion to open cholecystectomy expected) prior to surgery. RESULTS: When the reliability of our model was examined in a second study in 340 consecutive patients undergoing laparoscopic cholecystectomy 80% of the patients were predicted correctly. CONCLUSIONS: Our model should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties and the experience of the surgeon.

Clinical use of a front lifting hood rectoscope tube for transanal endoscopic microsurgery.

Yamashita Y. Sakai T. Maekawa T. Shirakusa T.
Second Department of Surgery, Fukuoka University School of Medicine, Japan.
BACKGROUND: Transanal endoscopic microsurgery (TEM), a procedure developed by Buess et al. requires a specially designed surgical rectoscope system, and adequate training for its operation is mandatory. In order to simplify the performance of TEM, and to allow the use of additional surgical instruments and devices, we have developed a new rectoscope tube. METHODS: The forward half of the tube can be opened longitudinally by hand. Our working insert platform is hollowed and includes a channel for an endoscope. The resection procedure can be performed under normal atmospheric pressure. This newly developed rectoscope system has already been employed clinically. TEM was performed using our original forward lifting hood rectoscope tube in 20 patients, including 12 cases of sessile adenoma and eight cases of early carcinoma. RESULTS: The forward hood of the tube was opened to the maximum angle of 25 degrees in eight patients and 15-20 degrees in the other 12 patients. The visible field of the rectal interior was extended in direct proportion to the angle. Through our working insert platform, instruments and devices could be used for either laparoscopic or open surgery. CONCLUSIONS: These modifications have made TEM easier and will therefore make the procedure available to more surgeons.

Splenic hematoma. A rare complication of colonoscopy.

Reissman P. Durst AL.
Department of General Surgery, Hadassah University Hospital, Jerusalem, Israel.
An extremely rare yet potentially fatal complication of colonoscopy is reported. A 52-year-old female developed a splenic subcapsular hematoma following routine colonoscopy. Conservative treatment was successful. In the English literature, only 14 similar cases have been reported. Treatment of a splenic flexure lesion, previous surgery with splenocolic adhesions, and inflammatory bowel disease increase the risk of such a complication. Increased awareness by surgeons and gastroenterologists should lead to prompt treatment and favorable outcome.

Anastomotic occlusive web following double-stapled anterior resection and fecal diversion. Presentation and endoscopic management.

Picon AI. Guillem JG.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
The incidence of occlusive web following stapled anastomosis for curative resection of rectal cancer is unknown and the management of this entity not well defined. A 73-year-old patient underwent a double-stapled anterior resection with a temporary loop ileostomy for a T3,N1 rectal cancer. He received postoperative chemoradiation adjuvant therapy. Prior to ileostomy closure, sigmoidoscopy revealed an anastomotic occlusive web at 10-12 cm from the anal verge. Under monitored sedation, a flexible sigmoidoscope was inserted per anus and advanced to the level of the occlusive web. Utilizing hydrostatic balloon dilatation, the occlusive web was broken and the bowel lumen was restored. The procedure was performed expeditiously and without complications. Subsequently the patient underwent ileostomy closure and experienced normal bowel movements. Although occlusive webs are uncommon after colorectal anastomosis, this case report describes a safe, effective, and uncomplicated endoscopic procedure that can be performed in patients with anastomotic occlusive web developing after prolonged fecal diversion.

Laparoscopy-assisted jejunal resection for bleeding leiomyoma.

Chung RS.
Department of Surgery, Meridia Huron Hospital, East Cleveland, OH 44112-4308, USA.
We report a case of successful resection of a jejunal leiomyoma using a minimally invasive technique. By combining the procedures of push enteroscopy and laparoscopy, jejunal resection can be performed expeditiously without laparotomy.

Microwave applications in clinical medicine.

Lantis JC 2nd. Carr KL. Grabowy R. Connolly RJ. Schwaitzberg SD.
Department of Surgery, New England Medical Center, Boston, MA 02111, USA.
Over the last fifty years, energy has been applied to various human tissues for both the diagnosis and therapy of numerous diseases. However, in general, the medical community remains uninformed about the many potential applications of this energy source. We review the many areas in which microwave energy has shown clinical utility.

One-trocar appendectomy in pediatric surgery.

Esposito C.
Division of Pediatric Surgery, Federico II University of Naples, Italy.
Laparoscopic appendectomy is a safe alternative to open appendectomy to treat appendicitis. The author reports his experience in performing laparoscopic appendectomy with the use of only one trocar in pediatric patients. Between 1 January 1994 and 30 October 1995 at the Department of General and Pediatric Surgery, Division of Pediatric Surgery of the "Federico II" University of Naples, we performed 51 laparoscopic appendectomies. Patient age varied from 4 to 16 years with a mean age of 7 years. In the last 25 patients of our series we performed the one-trocar appendectomy, positioning only one trocar infraumbilically with the use of a 10-mm operative telescope. The appendix is identified, dissected when necessary, grasped laparoscopically with a 450-mm operative atraumatic instrument introduced through the operative channel of the laparoscope, and then exteriorized through the umbilical cannula. The appendectomy was performed using traditional method outside the abdominal cavity. We had no intra- or perioperative mortality or morbidity. The mean overall hospitalization time was 2 days (1-4 days). At a maximal follow-up of 20 months the children have no clinical problems nor any visible scar related to the laparoscopic appendectomy. In conclusion, the author considers the one-trocar appendectomy an appropriate alternative procedure to other techniques of laparoscopic appendectomy.

Guidelines for surgical treatment of gastroesophageal reflux disease (GERD). Society of American Gastrointestinal Endoscopic Surgeons (SAGES).

No information.
Gastroesophageal reflux disease (GERD) is a significant health concern. Medical management is expensive and may be necessary lifelong. Effective surgical therapy is available and, if performed by experienced surgeons, is successful in greater than 90% of patients. Laparoscopic techniques which reproduce their "open" counterpart are also available. When performed by appropriately trained surgeons, these laparoscopic approaches appear to hasten the patient's recovery and return to normal function.

Efficacy of routine laparoscopy for the acute abdomen.

Year 1998
Chung RS. Diaz JJ. Chari V.
Department of Surgery, Meridia Huron Hospital, 13951 Terrace Road, East Cleveland, OH 44112-4308, USA.
BACKGROUND: Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen. METHODS: After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls. RESULTS: The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest. CONCLUSIONS: Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time.

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain. Its time has come.

Year 1998
Greason KL. Rappold JF. Liberman MA.
Department of General Surgery and Clinical Investigation, Naval Medical Center, 34800 Bob Wilson Drive, San Diego, CA 92134-5000, USA.
BACKGROUND: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. METHODS: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). RESULTS: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p = 0.49) or morbidity (DL = 11%, ILA = 5%, p = 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. CONCLUSIONS: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option.

Causes of recurrence after laparoscopic hernioplasty. A multicenter study.

Year 1998
Felix E. Scott S. Crafton B. Geis P. Duncan T. Sewell R. McKernan B.
Center for Hernia Repair, 6191 N. Fresno St., Fresno, CA 93710, USA.
BACKGROUND: To determine if there are common factors beyond the learning curve that lead to recurrence after laparoscopic hernioplasty, we analyzed failures seen in seven centers specializing in laparoscopic hernia repair. METHOD: We performed a retrospective review of patients who had a laparoscopic hernioplasty (Tapp or Tep) between 1990 and 1996 at centers specializing in laparoscopic repairs (>500 repairs at each center). RESULTS: In all, 7661 patients had 10,053 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach; they were followed for 1 month to 6 years. In patients followed for >/=6 months with a median follow-up of 36 months, 35 repairs failed (0.4%), and all but one of these patients underwent a remedial operation. Twenty-nine had a laparoscopic repair, four had a combined laparoscopic and anterior repair, and one had an anterior repair alone. The cause of failure was determined in all 34 patients. The mechanism of recurrence was inadequate lateral fixation of the mesh in 11 cases, inadequate lateral fixation compounded by too small a mesh in three cases, missed lipoma of the cord in four cases, inadequate fixation of the mesh medially to Cooper's ligament in eight cases (seven of which were associated with too small a mesh), a missed hernia in four cases, and a hernia through a keyhole in the mesh in five cases. As surgeons gained experience, the incidence of recurrence due to missed hernias or too small a mesh decreased. CONCLUSIONS: This large multicenter study demonstrated that the incidence of recurrence after laparoscopic hernioplasty performed by experienced surgeons was extremely low and that some causes could be corrected by experience, whereas others will require changes in technique or equipment.

Changing management of gallstone disease during pregnancy.

Year 1998
Glasgow RE. Visser BC. Harris HW. Patti MG. Kilpatrick SJ. Mulvihill SJ.
Department of Surgery, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
BACKGROUND: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. METHODS: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. RESULTS: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6-10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. CONCLUSIONS: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients.

Patient response to marketing minimally invasive surgery for heartburn.

Year 1998
de Vos Shoop M. Peters JH. DeMeester TR. Crookes PF. Kline MM.
Department of Surgery, University of Southern California, School of Medicine, 1510 San Pablo Street, Sutie 514, Los Angeles, CA 90033-4612, USA.
BACKGROUND: Over 40% of Americans suffer from "heartburn" at least once a month. This and other manifestations of gastroesophageal reflux (GERD) are often treated with neglect by both patients and their primary care physicians. Diagnostic evaluation is all too often sought only in late stages of the disease. We studied the response to a media campaign promoting minimally invasive surgery as a cure for longstanding heartburn. METHODS: The information was publicized on 14 TV and six radio stations over 4 weeks. Patients were referred to an 800-number and data on the following topics were obtained using a standardized questionnaire: demographics, reflux symptoms, previous specialist referral, diagnostic evaluation and treatment, insurance information, and reasons for and expectations in calling. All questionnaires were screened for likelihood of GERD (high, medium, low). A return call was placed to triage patients (surgical or medical appointment, information only, no contact). RESULTS: We received calls from 1,389 potential patients. Based on symptoms, medical therapy, and previous evaluation, 891 (64%) were judged to likely have GERD and assigned high-priority status. Of the patients providing insurance information, 32% were enrolled in an HMO; 29% commercial; 16% Medicare; 14% employer based; and 9% had no insurance. Six hundred ninety-eight high-priority patients were contacted. Of these, 402 (58%) wanted information only; 228 (33%) desired surgical and 68 (%) medical appointments. Two hundred fifteen patients (16% of callers) were seen by a surgical or medical consultant. One hundred thirty-five underwent diagnostic studies, of which 77 (57%) had pathologic esophageal acid exposure. Eighty-three patients have undergone surgery to date-60 laparoscopic and 14 open antireflux procedures; nine had other surgical procedures. CONCLUSIONS: Surprisingly, 64% of patients responding to a marketing campaign for heartburn have typical symptoms of GERD, have consulted one or more physicians and/or received medical treatment. More than half the patients tested (77/135) were found to have a positive 24-h pH study, and 78% (60/77) of these elected antireflux surgery to control their reflux symptoms.

Evaluating results of laparoscopic surgery for esophageal achalasia.

Year 1998
Rosati R. Fumagalli U. Bona S. Bonavina L. Pagani M. Peracchia A.
Department of General and Minimally Invasive Surgery, Istituto Clinico Humanitas, Via Manzoni, 56, 20089, Rozzano, Milano, Italy.
BACKGROUND: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure of choice to treat stage I-III esophageal achalasia. METHODS: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients underwent laparoscopic Heller-Dor for stage I-III achalasia. Conversion to laparotomy was done in three cases. All procedures were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative treatment). RESULTS: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year. After a mean follow-up (F.U.) of 21 months (1-62), clinical results range from excellent to good in 98.2%. One patient (1.7%) complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure reduced from 30.3 +/- 12.4 to 10.7 +/- 3.5 mmHg (basal) and from 14. 8 +/- 9.3 to 2.9 +/- 2.1 mmHg (residual). CONCLUSIONS: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous endoscopic dilations.

Autostrangulation of the vermiform appendix. An unusual mechanism of acute appendicitis.

Year 1998
Frank JL. Sabol J. Drinkwater D. Nash S.
Department of Surgery, Baystate Medical Center, Springfield, MA 01199, USA.
A 23-year-old woman presented with acute appendicitis. At laparoscopy the appendix appeared to be strangulating itself. The pathologic evaluation demonstrated mucosal coagulation necrosis, confirming the early ischemic changes of the infarctive process visualized laparoscopically.

Hepatic-portal venous gas in acute colonic diverticulitis.

Year 1998
Zielke A. Hasse C. Nies C. Rothmund M.
Department of Surgery, Philipps-University of Marburg, Baldinger Strasse, Post Office Box 100, 35043 Marburg, Germany.
The diagnosis and assessment of severity of acute colonic diverticulitis may be difficult. A case is presented, in which the delayed diagnosis of diverticulitis resulted in the development of a diverticular mesocolic abscess complicated by hepatic-portal venous gas (HPVG). The utility of ultrasound as a rapid, noninvasive tool to diagnose this distinctly rare condition is outlined. The literature on HPVG associated with acute colonic diverticulitis is reviewed, and the therapeutic options are discussed.

Coincidental finding of hepatic carcinoid micrometastases during routine laparoscopic cholecystectomy.

Year 1998
Rixen D. K inverted question markhler L. Troidl H.
II Department of Surgery, University of Cologne, Klinikum Merheim, Ostmerheimerstrasse 200, 51109 Cologne, Germany.
A case of a coincidental finding of hepatic carcinoid micrometastases, barely visible to the eye, during routine laparoscopic cholecystectomy is reported. The micrometastases were possibly recognized as a result of a beneficial aspect of laparoscopic surgery, namely the >10x enlargement of tissue/pathologic structures.

Laparoscopic endobiliary stenting as an adjunct to common bile duct exploration.

Year 1998
Gersin KS. Fanelli RD.
Department of Surgery, Berkshire Medical Center, Pittsfield, MA 01201, USA.
BACKGROUND: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. METHODS: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. RESULTS: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. CONCLUSIONS: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.

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

Year 1998
Schafer M. Suter C. Klaiber C. Wehrli H. Frei E. Krahenbuhl L.
Department of Visceral and Transplantation Surgery, Inselspital University of Berne, Switzerland.
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.

Laparoscopic liver surgery. A report on 28 patients.

Year 1998
Marks J. Mouiel J. Katkhouda N. Gugenheim J. Fabiani P.
Department of Surgery, Allegheny University of the Health Sciences, Hahnemann Division, Philadelphia, PA 19102-1192, USA.
BACKGROUND: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. METHODS: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). RESULTS: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1-67 months with one asymptomatic recurrence. CONCLUSIONS: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the "four-hands technique" for simultaneous dissection and control of bleeding and bile ducts during resections.

Endoluminal stenting for benign colonic obstruction.

Year 1998
Davidson R. Sweeney WB.
University of Massachusetts Medical Center, Department of Surgery, Worcester 01655, USA.
We report a case of complete descending colon obstruction due to diverticular disease that was initially managed by endoscopic stent placement followed by single-stage left colectomy with primary anastomosis. Traditional management of complete large bowel obstruction, whether due to benign or malignant disease, most often requires a temporary colostomy because of unprepared colon. In this case, preparation of the colon was accomplished by successful stenting of the benign colonic obstruction. We believe that endoscopic colonic stenting is an effective way of avoiding a temporary colostomy in patients with complete large bowel obstruction.

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy.

Year 1998
Barthel JS. Chowdhury T. Miedema BW.
Division of Gastroenterology, Department of Medicine, MA-421, University of Missouri School of Medicine, Columbia, MO 65212, USA.
BACKGROUND: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. METHODS: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. RESULTS: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. CONCLUSIONS: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted.

Endoscopic electrohydraulic lithotripsy in the management of pancreatobiliary lithiasis.

Year 1998
Craigie JE. Adams DB. Byme TK. Tagge EP. Tarnasky PR. Cunningham JT. Hawes RH.
Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA.
BACKGROUND: Clinical evaluation of intraoperative endoscopy with electrohydraulic lithotripsy (EHL) in the management of 13 patients with pancreatobiliary lithiasis was undertaken. METHODS: Ten patients with chronic pancreatitis with intraductal lithiasis in the head and three with biliary lithiasis (one choledochal, one cystic, one right intrahepatic) underwent intraoperative endoscopy with EHL. Shock waves were applied by visual contact with a 3-Fr gauge EHL probe until all stones were fragmented and irrigated free. All pancreatitis patients had failed ERCP attempts to stent their pancreatic ducts secondary to ductal lithiasis. Patients with pancreatic stones underwent lateral pancreatojejunostomy. Biliary stone patients underwent laparoscopic cholecystectomy with common duct exploration (two cases) and open cholecystectomy with choledochoduodenostomy (one case). RESULTS: Intraductal stone eradication was successful in all patients. Transampullary visualization of the duodenum was achieved in eight cases. Average EHL time was 65 min. There was no evidence of postoperative pancreatitis, cholangitis, or retained common duct stones. CONCLUSION: Intraoperative pancreatobiliary endoscopy with EHL is safe and effective in the eradication of pancreatic and bile duct stones. This novel technique represents a valuable adjunct in the management of chronic fibrocalcific pancreatitis with ductal lithiasis in the head region and in the open and laparoscopic management of intra- and extrahepatic bile duct stones.

Esophageal and lower esophageal sphincter pressure profiles 6 and 24 months after laparoscopic fundoplication and their association with postoperative dysphagia.

Year 1998
Anvari M. Allen C.
Department of Surgery, Saint Joseph's Hospital, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario, Canada, L8N 4A6.
BACKGROUND: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced postoperative dysphagia. METHODS: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients before (n = 381), at 6 months (n = 260), and at 24 months (n = 97) after laparoscopic fundoplication. RESULTS: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF. An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other patients. CONCLUSIONS: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of the wrap during swallowing may be a determinant of long-term dysphagia.

Unusual intraoperative complication in laparoscopic sigmoidectomy.

Year 1998
Lacy AM. Garcia-Valdecasas JC. Delgado S. Sabater L. Grande L. Fuster J. Visa J.
Department of Surgery, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
The authors report a case of complete rotation of the left colon after laparoscopic sigmoidectomy. Such an uncommon complication in open colectomies has not been previously described with the laparoscopic approach. During the performance of laparoscopic-assisted colectomies the proximal segment of the colon can be rotated when removing the specimen through a small incision. Therefore we recommend inspecting the position of the colon before the stapler is fired.

Anaphylactic shock complicating laparoscopic treatment of hydatid cysts of the liver.

Year 1998
Khoury G. Jabbour-Khoury S. Soueidi A. Nabbout G. Baraka A.
Department of Surgery, American University of Beirut Medical Center, PO Box 113-6044, Beirut, Lebanon.
Hydatid cysts of the liver have been treated surgically for many years by several surgical techniques including evacuation, marsupialization, and filling the cyst with saline after evacuation of the endocyst. We have previously reported laparoscopic treatment of hydatid cysts using the same hydatid asepsis and surgical techniques as in open surgery, with comparable results. Spillage of hydatid fluid during open surgery has been shown to result in serious anaphylactic reaction. The present report describes the first case report of such a reaction during laparoscopic treatment of hydatid cyst of the liver.

Late rejection of the mesh after laparoscopic hernia repair.

Year 1998
Foschi D. Corsi F. Cellerino P. Trabucchi A. Trabucchi E.
Second Department of Surgery, Institute of Biomedical Science H. San Paolo, University of Milan, via A.di Rudini 8, 20142 Milan, Italy.
We report the first case of late rejection of a mesh after laparoscopic hernia repair. It occurred in a 48-year-old man who had had a laparoscopic hernia repair by transabdominal preperitoneal approach 3 years earlier. The most characteristic finding was the slow development of a firm mass in the right groin, without pain or fistula. At admission 3 months later, US and CT scans demonstrated a necrotic mass extending into both iliac fossa. The mass was approached through a midline incision. Pus was taken for microscopic examination (negative), and the mesh was removed, along with several staples. Ultramicroscopic examination of the mesh showed breakdown of the fibers, collagen reduction, and no chronic inflammatory cells. No infectious cause of inflammation was identified.

Is laparoscopic pyloromyotomy superior to open surgery?

Year 1998
Sitsen E. Bax NM. van der Zee DC.
Department of Pediatric Surgery, University Children's Hospital Wilhelmina, P.O. Box 18009, 3501 CA Utrecht, The Netherlands.
BACKGROUND: We set out to determine whether laparoscopic pyloromyotomy (LPM) is superior to open pyloromyotomy (OPM) in babies with hypertrophic pyloric stenosis (HPS). METHODS: We performed a retrospective study of 36 LPM and 36 OPM. Both groups were comparable in terms of sex, age and weight on admission, and blood pH on admission and prior to surgery. In the LPM group, three trocars were used; in the OPM group, a small right upper quadrant transverse muscle-cutting laparotomy was carried out. RESULTS: LPM produces a better cosmetic result, seems to produce less postoperative discomfort, and results in the absence of conversion in a shorter hospital stay. However, the duration of the operation was significantly longer (32 versus 18 min). Moreover, LPM clearly entailed more complications (three mucosal perforations against two, and two reoperations against none in the open group). CONCLUSIONS: The actual series does not favor the laparoscopic approach over the open one, in view of the relatively high complication rate. Babies who are operated laparoscopically, however, seem to have less postoperative discomfort, a shorter hospital stay, and a better cosmetic result. As we are confident that the complication rate and duration of the operation will drop with further experience, we will continue to do LPM. LPM is not easy and should only be carried out when substantial experience has been gained in the field of pediatric laparoscopic surgery.

Laparoscopic cholecystectomy. Risk of missed pathology of other organs.

Year 1998
Gal I. Szivos J. Jaberansari MT. Szabo Z.
Department of Surgery, Bugat Pal Hospital, Dozsa Gy. u. 20-22, H-3201 Gyongyos, Hungary.
BACKGROUND: The wide acceptance of laparoscopic cholecystectomy (LC) has resulted in increased rates of cholecystectomy. However, the increased rate of LC bears the possibility of concomitantly missing other intra-abdominal pathologic states that exist concurrently with this procedure. The purpose of this report was to evaluate data on LC with regard to missed pathologies of other organs in a clinical prospective follow-up. METHODS: The clinical prospective follow-up of 676 patients treated laparoscopically for gallstone disease at our unit since January 1993, was studied. Converted procedures were excluded from the follow-up study. RESULTS: Among 676 patients who underwent LC, 4 patients (0.6%) required readmission for missed pathology of another organ. The diagnostic delay ranged from 2 weeks to 7 months. The readmissions were due to colonic cancer (2 cases), carcinoma of the stomach (1 case), and fibrosis of the mesenterium of small bowel causing ileus (1 case), which are demonstrated in detail. According to retrospective analysis of the symptoms, none of the patients had typical biliary pain at the time of laparoscopic procedure. CONCLUSIONS: The demand for LC from patients and practitioners is becoming increasingly more frequent, as all become aware of its benefits. However, on the basis of data from the literature and this study, the authors would like to emphasize the need for careful history-taking, thorough investigation, and comparison with gallstone symptoms before LC is performed. It is emphasized, however, that surgeons using laparoscopic approaches should learn techniques of full diagnostic laparoscopy, which should be performed at the beginning of every procedure.

Benefit of prophylactic endoscopic sclerotherapy of esophageal varices. A retrospective analysis.

Year 1998
Svoboda P. Kantorova I. Ochmann J. Kozumplik L.
Urazova nemocnice, Research Center for Surgery and Traumatology of the Czech Ministry of Health, Ponavka 6, 662 50 Brno, Moravia, Czech Republic.
BACKGROUND: The therapeutic schedule in bleeding esophageal varices is today established: emergency endoscopy with sclerotherapy or ligation combined with somatostatin and decreasing portal pressure drug followed by repetitive sclerotherapy or ligation. But the approach to varices that do not bleed is not clear. METHODS: The authors submit the results of a 6-year sclerotherapeutic program. Since January 1989 they have treated 421 patients with varices and have together performed 4,115 endoscopic sclerotherapeutic procedures. Among the 421 patients 95 were treated during acute bleeding and 254 were treated after first bleeding; in 72 patients prophylactic sclerotherapy (PSG) was performed. RESULTS: The procedure was indicated, when grade III or IV varices or high-risk signs and/or hepatic venous pressure gradient (HVPG) > 15 in grade II varices were observed. Prophylactic therapy (not-treated group-NTG) refused next 31 selected patients. The mean follow-up time was 32 months in the PS group and 28 months in NTG (n.s.). Fifteen PSG patients died (21%), while the mortality among the NTG patients (13 = 42% patients) was significantly higher (P < 0.02). CONCLUSIONS: We recommend prophylactic sclerotherapy with 1% polidocanol in patients with advanced varices in liver cirrhosis of varied etiology. We emphasize the need to perform these procedures in a department with adequate experience, where at least 100-200 sclerotherapies per year are performed.

How useful is colonoscopy in locating colorectal lesions?

Year 1998
Lam DT. Kwong KH. Lam CW. Leong HT. Kwok SP.
Department of Surgery, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong.
BACKGROUND: It is important to establish the precise location of a colorectal lesion preoperatively. We used a model based on colorectal cancer to assess the efficacy of colonoscopy in locating these lesions. METHODS: We retrospectively analyzed all consecutive new colorectal cancer cases at the Department of Surgery, United Christian Hospital, Hong Kong, in 1995. RESULTS: Of the 123 cases reviewed by us, 84 cases satisfied the analysis criteria. The overall accuracy was 81%. It was especially high in the rectosigmoid region (93%) and descending colon (100%). The overall predictive power was 83%. It was especially high in the right-sided colon (100%) and the rectosigmoid region (93%). CONCLUSIONS: We conclude that colonoscopy is an accurate means for locating lesions in the upper rectum and sigmoid colon. It is also very predictive of lesions in the upper rectum, sigmoid colon, and right-sided colon.

Laparoscopic vs open inguinal hernia repair. A randomized, controlled trial.

Year 1998
Tanphiphat C. Tanprayoon T. Sangsubhan C. Chatamra K.
Department of Surgery, Faculty of Medicine, Chulalongkorn Hospital, Chulalongkorn University, Rama IV Road, Bangkok 10330, Thailand.
BACKGROUND: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. METHODS: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. RESULTS: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p = 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p = 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5-14) days vs 14 (8-19) days (p = 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17-60) days vs 35 (20-56) days (p = 0.25). The return to work was not significantly different, median 14 (8-25) days after laparoscopic repair and 15 (11-21) days after open repair (p = 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. CONCLUSIONS: Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly.

A population-based survey of biliary surgery in Norway. Relationship between patient volume and quality of surgical treatment.

Year 1998
Buanes T. Mjaland O. Waage A. Langeggen H. Holmboe J.
Surgical Department, Ullevaal Hospital, University of Oslo, Kirkeveien 166, N-0407 Oslo, Norway.
BACKGROUND: A registry was initiated in order to establish national standards for the quality of surgical treatment of gallstones, and to provide feedback to all hospitals about serious complications, in order to reduce their future incidence. METHODS: Prospective registration of complications was performed at all hospitals and collected in the National Norwegian Cholecystectomy Registry (NNCR) over a period of 33 months. RESULTS: Open cholecystectomy (OC) was performed in 1011 patients, and laparoscopic cholecystectomy (LC) in 4332 patients. These figures represent 68% of all procedures performed nationally. The frequency of bile duct (BD) injury was 0. 8% for LC versus 0.7% for OC (ns); mortality was 0.1% versus 2.1%, respectively (p < 0.05). The frequency of BD injury and mortality were added; the sum comprised the Severe Complication Index (SCI). A linear relationship was found between SCI and patient volume (correlation coefficient, r22 = 0.78). CONCLUSIONS: SCI was found to be the best indicator of surgical success. We have proposed its use as a parameter for a future prospective quality assurance program, along with patient volume.

Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.).

Year 1998

Surgical Clinic Merheim, II Department of Surgery, University of Cologne, Ostmerheimer Str. 200, 51109 Cologne, Germany.
BACKGROUND: Common bile duct stones (CBDS) are a frequent problem (10-15%) in patients with symptomatic cholecystolithiasis. Over the last decade, new diagnostic and surgical techniques have expanded the options for their management. This report of the Consensus Development Conference is intended to summarize the current state of the art, including principal guidelines and an extensive review of the literature. METHODS: An international panel of 12 experts met under the auspices of the European Association of Endoscopic Surgery (EAES) to investigate the diagnostic and therapeutic alternatives for gallstone disease. Prior to the conference, all the experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The preconsensus document compiled out of this correspondence was altered following a discussion of the external evidence made available by the panel members and presented at the public conference session. The personal experiences of the participants and other aspects of individualized therapy were also considered. RESULTS: Our panel of experts agreed that the presence of common bile duct stones should be investigated in all patients with symptomatic cholecystolithiasis. Based on preoperative noninvasive diagnostics, either endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiography should be employed for detecting CBDS. Eight of the 12 panelists recommended treating any diagnosed CBDS. For patients with no other extenuating circumstances, several treatment options exist. Stones can be extracted during ERCP, or either before or (in exceptional cases) after laparoscopic or open surgery. Bile duct clearance should always be combined with cholecystectomy. Evidence for further special aspects of CBDS treatment is equivocal and drawn from nonrandomized trials only. CONCLUSIONS: The management of common bile duct stones is currently undergoing some major changes. Many diagnostic and therapeutic strategies need further study.

Laparoscopic cholecystectomy after pancreatic debridement.

Year 1998
Vezakis A. Dexter SP. Martin IG. Larvin M. McMahon MJ.
Leeds Institute for Minimally Invasive Therapy, The Centre for Digestive Diseases, The General Infirmary at Leeds and the Division of Surgery, Great George Street, Leeds LS1 3EX, England.
BACKGROUND: Pancreatic debridement is a lifesaving operation in patients with severe acute pancreatitis and pancreatic or peripancreatic necrosis. Even in the presence of gallstones, cholecystectomy may be avoided during the procedure, but definitive treatment of the stones is needed at a later stage. METHODS: Five patients (median age 58 years) underwent laparoscopic cholecystectomy, at a median time interval of 15 months, after pancreatic debridement via a dome-shaped upper abdominal incision for severe acute pancreatitis. The use of alternative methods for primary access, additional cannulae to enable division of adhesions, the harmonic scalpel, and the fundus first technique made the laparoscopic approach possible and safe. RESULTS: The median operating time was 130 min. Four patients were discharged home the first or second postoperative day. One patient required a "mini-laparotomy" for drainage of a periumbilical hematoma and was discharged on the 13th day. CONCLUSIONS: Laparoscopic cholecystectomy can be considered an effective and safe approach for the treatment of gallstones in patients who have undergone pancreatic debridement.

Pancreatic carcinoma. Diagnostic and prognostic implications of a normal pancreatogram.

Year 1998
Hewitt PM. Beningfield SJ. Bornman PC. Krige JE. van Wyk ME. Terblanche J.
Surgical Gastroenterology and Department of Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
BACKGROUND: The aim of this study was to establish the implications of a normal pancreatogram in patients with pancreatic cancer. METHODS: We reviewed all ERCP done at our institution for the period 1983-92 and studied 62 of 727 patients who had a diagnosis of pancreatic (n = 416) or biliary (n = 311) cancer but a normal pancreatic duct. RESULTS: Thirty of the 62 patients had pancreatic cancer. In 15 cases, the ERCP diagnosis was incorrect, and in 19 cases, Santorini's duct was not visualized. Other imaging revealed a pancreatic head mass in 25 patients (2.5->7 cm). Only three patients had resectable tumors; another eight underwent laparotomy. Five had bypass surgery, 10 required biliary stenting, and nine had no treatment. Four patients died in hospital, and eight were lost to follow-up. In the remaining 18 patients, median survival was 7 months (range, 1-30 months). CONCLUSION: A normal pancreatogram does not exclude the diagnosis of pancreatic cancer, nor does it confer a better prognosis.

Laparoscopic gastrostomy according to Janeway.

Year 1998
Ritz JP. Germer CT. Buhr HJ.
Department of General, Vascular and Thoracic Surgery, University Hospital Benjamin Franklin, Free University of Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.
Percutaneous endoscopic gastrostomy is not suitable for all patients requiring gastrostomies. Patients with endoscopically impassable tumors require a safe and effective alternative procedure for paraesophageal alimentation. We present the surgical technique and results of the laparoscopic gastrostomy according to Janeway. Using an endoscopic stapling device a gastric tube is created from a stomach fold, led out through the trocar site, and fixed to the skin in the left upper quadrant. Via an inserted catheter enteral alimentation can be performed intermittently since the gastrostoma is continent. Between July 1995 and November 1996 laparoscopic gastrostomy was performed in 15 patients (10 male, five female) with tumors in the pharynx or esophagus. Mean operation time was 35 min. One stoma necrosis developed; the other postoperative courses were complication-free. All gastrostomies were continent. Laparoscopic gastrostomy is easy to perform and involves minimal discomfort and complications for the patient.

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes.

Year 1998
Salky BA. Edye MB.
Mount Sinai Medical Center, Fifth Avenue at 100th Street, New York, NY 10029, USA.
BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.

Diagnostic laparoscopy in patients with an acute abdomen of uncertain etiology.

Year 1998
Cuesta MA. Eijsbouts QA. Gordijn RV. Borgstein PJ. de Jong D.
Department of Surgery, Vrije Universiteit Hospital, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
BACKGROUND: There are acute abdominal conditions in which it is difficult to establish an indicative diagnosis before laparotomy. A diagnosis is important in planning the right abdominal incision or to avoid an unnecessary laparotomy. Diagnostic noninvasive procedures such as X-ray studies do not always appear conclusive. Diagnostic laparoscopy is the only technique which can visualize the abdomen and, by establishing an adequate diagnosis, permits the surgeon to plan the right abdominal approach. METHODS: In a prospective study, 65 patients with a generalized acute abdomen (no intestinal obstruction or perforation) underwent a diagnostic laparoscopy under general anesthesia previous to the planned median laparotomy. RESULTS: In 46 patients (70%) diagnostic laparoscopy permitted the establishment of an adequate diagnosis, whereas in seven patients (10%) no cause for the acute abdomen could be found and an explorative laparotomy was avoided. In another 12 patients (20%) insufficient information was obtained during laparoscopy and an explorative laparotomy was performed. CONCLUSIONS: A conclusive diagnosis was established in 53 patients. This information led to a change in the surgical approach in 38 patients (e.g., limited, well-placed approach, laparoscopically, or avoidance of an unnecessary laparotomy). Diagnostic laparoscopy in this category of patients is a useful technique with important therapeutic consequences.

Laparoscopic evaluation of patients with suspected acute appendicitis.

Year 1998
Tytgat SH. Bakker XR. Butzelaar RM.
Department of General Surgery, St. Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands.
BACKGROUND: High error rates are reported in the clinical diagnosis of acute appendicitis. This study was undertaken to discover what additional value laparoscopy has in the diagnosis of suspected acute appendicitis. METHODS: From April 1995 to November 1996, a diagnostic laparoscopy, before open appendicectomy, was performed in 100 consecutive patients with suspected acute appendicitis. Appendicectomy was performed only if the appendix showed signs of inflammation at laparoscopy or if the appendix could not be visualized. RESULTS: Twenty-four patients were spared an appendicectomy, and in half of them a new diagnosis was established during laparoscopy. The rate of misdiagnosis was 41% in female patients of reproductive age and 8% in male patients. There were no cases of missed appendicitis in this trial, and all removed appendices showed signs of inflammation at histology. CONCLUSIONS: It is safe to rely on the diagnosis made at laparoscopy. Its use for establishing diagnosis before appendicectomy in women of reproductive age is recommended.

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer.

Year 1998
Hunerbein M. Rau B. Hohenberger P. Schlag PM.
Department of Surgery and Surgical Oncology, Robert Rossle Hospital and Tumor Institute, Lindenbergerweg 80, Humboldt University, 13122 Berlin, Germany.
BACKGROUND: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. METHODS: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). RESULTS: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases-i. e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. CONCLUSIONS: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy.

Laparoscopic common bile duct exploration by choledochotomy. An effective and efficient method of treatment of choledocholithiasis.

Year 1998
Dorman JP. Franklin ME Jr. Glass JL.
Southeast Baptist Hospital, 4242 East Southcross Boulevard, Suite 1, San Antonio, TX 78222, USA.
BACKGROUND: Management of cholelithiasis and choledocholithiasis usually requires two separate teams-the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. METHODS: In 1990-1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. RESULTS: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). CONCLUSIONS: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease.

A comparison of laparoscopic ultrasound with digital fluorocholangiography for detecting choledocholithiasis during laparoscopic cholecystectomy.

Year 1998
Thompson DM. Arregui ME. Tetik C. Madden MT. Wegener M.
Saint Vincent Hospital and Health Care Center, 2001 West 86th Street, Indianapolis, IN 46260, USA.
BACKGROUND: Laparoscopic ultrasound is an alternative to operative cholangiogram for evaluation of the common bile duct (CBD) during laparoscopic cholecystectomy. It is a safe, fast, and reliable method for detecting choledocholithiasis. METHODS: We prospectively evaluated the sensitivity and specificity of laparoscopic ultrasound (LUS) and digital fluorocholangiogram (DFCG) in a three-phase study of 360 consecutive patients. RESULTS: In phase I, 140 patients undergoing laparoscopic cholecystectomy had LUS performed first, followed by DFCG. Thirteen patients had CBD calculi identified on LUS. Four patients with confirmed (two cases) or presumed (two cases) CBD calculi on DFCG were not identified on LUS. Thus, the specificity of LUS was 100%, whereas the sensitivity was 76.5%. DFCG had four false positives, for a sensitivity of 100% with a specificity of 96.7%. LUS was performed, on average, in 6.6 min, whereas DFCG required 10.9 min to perform. In phase II, the infusion of saline through a cystic duct catheter was performed in instances where the distal CBD could not be well seen. This maneuver distended the intrapancreatic portion of the CBD, allowing better visualization. Nine stones were identified on LUS in 78 patients, increasing the sensitivity to 100%. One false positive DCFG was encountered, resulting in a sensitivity of 100% and a specificity of 98.6%. In phase III, we performed routine LUS and used DFCG only in select cases. The sensitivity and specificity for LUS were 95.7% and 100%, respectively, whereas DFCG had a sensitivity of 95.2% and a specificity of 100%. One patient in phase III has returned 11 months post-op with a CBD stone. This was initially missed on LUS, DFCG, and postoperative ERCP. The sensitivity and specificity in all 360 patients were 90% and 100% for LUS and 98.1% and 98.1% for DFCG, respectively. A total of five CBD stones were missed by LUS, four early in the study (phase I). One missed on LUS in phase III was also missed by DFCG and ERCP. CONCLUSIONS: LUS is a reliable alternative to DFCG during laparoscopic cholecystectomy (LC). With experience, it is as sensitive as DFCG and more specific. It is more rapidly performed than cholangiography.

Results of the routine use of a modified endoprosthesis to drain the common bile duct after laparoscopic choledochotomy.

Year 1998
DePaula AL. Hashiba K. Bafutto M. Machado C. Ferrari A. Machado MM.
Department of Surgery, Hospital Samaritano, Praca Walter Santos, 01, Setor Coimbra, Goiania, Go, Brazil.
BACKGROUND: One hundred eighty-one patients were submitted to laparoscopic common bile duct exploration. METHODS: A transcystic approach was used in 147 patients, choledochotomy in 14, and both in 20. The indications to perform a choledochotomy included stones larger than 20 mm, stones proximal to the cystic duct entrance, and cases in which the transcystic duct approach proved impossible or unsuccessful. RESULTS: The common bile duct was drained by a T-tube in four patients, by laparoscopic sphincterotomy in one, by laparoscopic choledochoduodenostomy in one, and by a 10 Fr endoprosthesis in 28. The stent placement was technically feasible in all patients but one. The biliary drainage was adequate. Mean hospital stay was 2.1 days. Complication was limited to one umbilical infection and one self-limited biliary leak. CONCLUSIONS: The procedure proved to be technically simple, safe, and efficient, and resulted in a low morbidity rate and short hospital stay.

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis.

Year 1998
Johnson AB. Peetz ME.
Department of Surgery, Emory University School of Medicine, H124C, 1364 Clifton Rd, Northeast, Atlanta, GA 30322, USA.
BACKGROUND: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. METHODS: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p = ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. CONCLUSIONS: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results.

Year 1998
Toy FK. Bailey RW. Carey S. Chappuis CW. Gagner M. Josephs LG. Mangiante EC. Park AE. Pomp A. Smoot RT Jr. Uddo JF Jr. Voeller GR.
Community Medical Center, 1800 Mulberry Street, Scranton, PA 18510, USA.
BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair.

Year 1998
Paganini AM. Lezoche E. Carle F. Carlei F. Favretti F. Feliciotti F. Gesuita R. Guerrieri M. Lomanto D. Nardovino M. Panti M. Ribichini P. Sarli L. Sottili M. Tamburini A. Taschieri A.
Istituto di Scienze Chirurgiche, Universita di Ancona, Ospedale Umberto I degrees, Piazza Cappelli 1, 60121 Ancona, Italy.
BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.

Eosinophilic enteritis. A case for diagnostic laparoscopy.

Year 1998
Edelman DS.
The Gallbladder and Laparoscopic Surgery Center of Miami, Baptist Hospital, 8720 North Kendall Drive, Suite 204, Miami, FL 33176, USA.
Eosinophilic enteritis is rare. This report of a single case involving the distal ileum demonstrates the importance of laparoscopy in the diagnosis of this disease. An adequate biopsied segment of intestine can be obtained using complete intracorporeal techniques and three portals. Histiopathologic confirmation will insure proper treatment. The effectiveness of laparoscopy as a diagnostic tool cannot be understated. Surgeons should continue to encourage its use in similar patients with ill-defined abdominal pain, nonspecific laboratory results, and radiographic findings that are inconclusive and do not allow one to initiate appropriate therapy.

An unusual case of endometrial trocar site implantation.

Year 1998
Martinez-Serna T. Stalter KD. Filipi CJ. Tomonaga T.
Department of Surgery, Creighton University, 601 North 30th St. Omaha, NE 68131, USA.
We present the case of a 35-year-old woman with a history of apparent bilateral hernia who had a surgical intervention that included a diagnostic laparoscopy converted to open laparotomy. The patient experienced endometrial implants exclusively at trocar sites. This case is cited as validation of the pneumoperitoneum-induced free cell implantation theory, or the so-called aerosolization theory.