Surg Laparosc Endosc

Lesser sac endoscopy in gastric carcinoma: operability assessment.

Charukhchyan SA.
Department of Endoscopy, Oncological Research Center Ministry of Health of the Georgia Republic, Tbilisi.
Since 1983, endoscopic evaluation of the lesser sac has been used in assessing operability in patients with gastric carcinoma. In this prospective study, the results of lesser sac endoscopy application in 200 patients divided into two groups are analyzed. Serosal layer invasion of the posterior gastric wall was found in 89 patients. Direct retroperitoneal invasion and metastases were found in 97 and 42 patients, respectively, and confirmed histopathologically in 24. The reproducibility of the applied method was 96.15 and 99%, the sensitivity of the diagnosis of inoperability was 88.23 and 93.44%, and the sensitivity of the diagnosis of tumor spread was 98 and 98.5%, respectively, in patients of Groups 1 and 2. The use of lesser sac endoscopy, permitting accurate assessment for metastases and visceral and retroperitoneal invasion, was found to allow better staging than laparoscopy alone and thereby reduced by 5.8 times the number of exploratory laparotomies performed in patients with gastric carcinoma.

Laparoscopic extraperitoneal repair of inguinal hernias.

Cohen RV. Morrel AC. Mendes JM. Alvarez G. Garcia ME. Kawahara NT. Margarido NF. Rodrigues AJ Jr.
Department of Surgery, University of Sao Paulo and Casa de Saude Santa Rita, Brazil.
The world of surgical laparoscopy is evolving. Laparoscopic prosthetic inguinal hernia repair is gaining rapid and wide acceptance. This experience consisted of 144 hernia repairs in 105 patients (40 bilateral, 31 recurrent, and 33 unilateral nonrecurrent hernias), treated through an extraperitoneal laparoscopic repair. When compared with transabdominal repair, operative time and postoperative recovery were similar, with some advantages related to the avoidance of intraabdominal manipulation and potential related complications. In spite of a relatively short follow-up (up to 40 months), there were no recurrences in this series. Morbidity rate was acceptable (16.1%), mainly reported as minor complications. Anatomical and technical skills to perform the operation are required and achieved through training. Extraperitoneal hernia repair with synthetic mesh is safe and feasible, with the advantages of being associated with less pain, rapid return to full activities, and the already proven milder systemic responses following interventional laparoscopy.

The role of laparoscopy in the management of intussusception in the Peutz-Jeghers syndrome: case report and review of the literature.

Cunningham JD. Vine AJ. Karch L. Aisenberg J.
Department of Surgery, The Mount Sinai Medical Center, New York, New York, USA.
A 15-year-old girl with known Peutz-Jeghers syndrome and with nausea and vomiting of all ingested food was transferred from an outside institution. Physical examination revealed a palpable upper abdominal mobile mass. Upper gastrointestinal series revealed a stacked coin appearance consistent with small bowel intussusception. An abdominal computed tomographic scan showed a left upper quadrant sausage-shaped mass with invagination of bowel into bowel suggestive of small bowel intussusception. The patient was taken to the operating room for a combined upper endoscopy and laparoscopy. Laparoscopy confirmed the radiologic findings and a jejuno-jejunal intussusception was identified and reduced laparoscopically. The endoscope could not be passed to the level of the polyp, thus, this loop of small bowel was resected laparoscopically. The final pathologic diagnosis was multiple hamartomas. We conclude that laparoscopy is a safe and effective method of managing intussusception in the Peutz-Jegher syndrome because the pathologic lead point is a benign hamartoma. A combined endoscopic and laparoscopic approach can be used to treat proximal small bowel intussusception and this could possibly eliminate the need for laparotomy and reduce the post-operative complications associated with multiple reoperations in this patient population.

Laparoscopy in the management of an adult case of small bowel intussusception.

El-Sherif OF.
Department of General and Minimally Invasive Surgery, Al-Mouwasat Hospital, Dammam, Kingdom of Saudi Arabia.
Small bowel obstruction is slowly coming to be treated by laparoscopic surgery. There is no doubt that laparoscopic surgery will dramatically change the management of small bowel obstruction. I report an adult case of small bowel intussusception causing relapsing small bowel obstruction in which exploratory laparoscopy made an impressive change in the management and outcome.

Laparoscopic cholecystectomy alleviates pain in patients with acalculous biliary disease.

Frassinelli P. Werner M. Reed JF 3rd. Scagliotti C.
Department of Surgery, Lehigh Valley Hospital, Allentown, PA 18105-1556, USA.
Our goal was to determine whether laparoscopic cholecystectomy is a safe and effective means of treatment for patients with acalculous cholecystitis. We reviewed the charts of 243 patients diagnosed with acalculous cholecystitis or biliary dyskinesia. Follow-up telephone interviews to measure degree of patient satisfaction and relief of preoperative symptoms were conducted. Hepatobiliary scanning results and postoperative symptom resolution were compared. One hundred seventy-one patients (94.5%) reported complete or partial resolution of symptoms postoperatively. Although 99 patients had symptoms reproduced with cholecystokinin injection during scanning, there was no significant correlation between these findings and alleviation of pain with cholecystectomy. There was no significant correlation between pain resolution after cholecystectomy and abnormal pathologic findings. Patients who suffered symptoms for a longer period of time preoperatively were more likely to be satisfied with the result of laparoscopic cholecystectomy. Laparoscopic cholecystectomy alleviates symptoms in many patients with acute or chronic acalculous cholecystitis or biliary dyskinesia with minimal morbidity.

Expandable metallic esophageal stents in benign disease: a cause for concern.

Hramiec JE. O'Shea MA. Quinlan RM.
Department of Surgery, Providence Hospital and Medical Center, Southfield, Mich. USA.
Over a 2-year period at our institution, 6 patients underwent metallic stent treatment, 5 for malignant conditions and 1 for a benign condition of the esophagus. The use of expandable metallic stents for benign strictures has paralleled malignant indications but is limited and less understood from a clinical standpoint. A review of current literature in the treatment of benign strictures is presented. Treatment of benign strictures is associated with high morbidity and mortality as demonstrated by the cumulative experience of 21 patients. Migration, hyperplastic tissue obstruction at the terminal ends, reflux, and complications of perforation occur at a prohibitive rate. We conclude that expandable metallic stents should be reserved for palliative treatment of esophageal malignant obstructions and tracheoesophageal fistulas. Pharmacological management, necessary dilatations and operative corrections (antireflux procedures, esophagectomy) are recommended treatments for benign strictures.

Definitive treatment of Hirschsprungs disease with a laparoscopic Duhamel pull-through procedure in childhood.

de Lagausie P. Bruneau B. Besnard M. Jaby O. Aigrain Y.
Service de chirurgie pediatrique, hopital Robert Debre, Paris XIX, France.
The Duhamel abdominoperineal pull-through is the authors' preferred treatment for children with Hirschsprung's disease (HD). Advances in instrumentation and technique now make laparoscopic correction possible. This procedure was successfully performed in six children aged 5 weeks to 6 years. No colostomy was performed before or after the Duhamel procedure. The technique and its potential role in the treatment of HD are discussed.

Early intraperitoneal dissemination after radical resection of unsuspected gallbladder carcinoma following laparoscopic cholecystectomy.

Ohtani T. Takano Y. Shirai Y. Hatakeyama K.
Department of Surgery, Niigata University School of Medicine, Niigata City, Japan.
We describe a case of early intraperitoneal dissemination after a radical second operation following laparoscopic cholecystectomy for unsuspected locally advanced carcinoma of the gallbladder. A radical procedure including wedge resection of the gallbladder bed, resection of the extrahepatic bile ducts, and dissection of the regional nodes and interaortocaval nodes was performed 17 days after laparoscopic cholecystectomy in a 60-year-old woman. The final histologic examination revealed a moderately differentiated adenocarcinoma invading perimuscular connective tissue with one positive pericholedochal node (pT2, pN1, pM0). Despite the absence of intraperitoneal dissemination at reexploration, the patient had intraperitoneal dissemination 5 months after the second operation. Insidious intraperitoneal dissemination may decrease the survival rate of locally advanced carcinoma of the gallbladder after laparoscopic cholecystectomy compared with open cholecystectomy. Surgeons should search for unsuspected carcinoma of the gallbladder intraoperatively to avoid implantation metastasis.

Mirizzi syndrome: choice of surgical procedure in the laparoscopic era.

Sare M. Gurer S. Taskin V. Aladag M. Hilmioglu F. Gurel M.
Department of General Surgery, Inonu University, Faculty of Medicine, Malatya, Turkey.
Impaction of a calculus in gallbladder neck or cystic duct or even in its remnant may produce common hepatic duct stricture by direct mechanical impression or associated inflammation. This clinical entity is referred to as Mirizzi syndrome. Four patients were operated on for Mirizzi syndrome. This represents 0.9% of the 444 patients who underwent laparoscopic cholecystectomy in our clinic. Two cases with Mirizzi syndrome type I, one of which had a stone in a gallbladder remnant, were successfully treated by laparoscopic cholecystectomy without any complications. One patient developed a bile leakage; fistulography via a sump drain revealed bile leakage from the laceration site of the stone, and the patient was reoperated on to perform a Roux-en-Y hepaticojejunostomy. The patient was lost due to cardiopulmonary arrest originating from septic shock. In another case diagnosed as Mirizzi type II, the operation was converted to an open procedure due to intense inflammation and fibrosis around the area of the Calot's triangle. Subtotal cholecystectomy was done and the defect on the common hepatic duct repaired by means of a gallbladder flap over the T tube.

Incarcerated obturator hernia successfully treated by laparoscopy.

Cueto-Garcia J. Rodriguez-Diaz M. Elizalde-Di Martino A. Weber-Sanchez A.
Department of General Surgery, American British Cowdray Hospital, Mexico City, Mexico.
Obturator hernia is extremely rare and represents a therapeutic and diagnostic challenge. The diagnosis is infrequently made preoperatively because of the nonspecific clinical and radiologic signs that in turn delay the surgical treatment, which is responsible for the known increase in morbidity and mortality. Herein a case is presented of a patient with an incarcerated obturator hernia that was diagnosed and successfully treated using laparoscopic surgery.

An acute scrotum following a laparoscopic appendectomy.

Figueroa AJ. Stein JP. Dunn MD. Skinner DG.
Department of Urology, University of Southern California, Los Angeles 90033, USA.
We report a case of a 13-year-old boy who developed an acute left hemiscrotum following a laparoscopic appendectomy for a perforated appendicitis. Laparoscopic techniques have provided surgeons and their patients with effective and less invasive methods to treat illness that previously required open surgery. However, complications can occur with these new surgical modalities. It is incumbent upon the surgeon to carefully document and evaluate these complications, facilitating preventive measures, and allow for a proper and timely diagnosis and treatment plan in the future. Herein, we present a previously unreported urologic complication of an acute scrotum following a laparoscopic appendectomy for a perforated appendicitis.

Late complication after laparoscopic fenestration of a liver cyst.

Klingler PJ. Bodner E. Schwelberger HG.
Second Department of Surgery, University of Innsbruck, Austria.
We report the case of a serious complication resulting from laparoscopic fenestration of a hepatic cyst. Seven months after the procedure had been performed, the cyst had recurred and ruptured, leading to massive bleeding. Bleeding control and enucleation of the cyst were carried out successfully by conventional surgery. The patient recovered rapidly after an uneventful postoperative period, and no recurrence of the liver cyst was found 20 months after our intervention. This case emphasizes the importance of a strict follow-up and determination of the outcome for this new application of laparoscopic surgery.

Laparoscopic mesh repair of a reducible obturator hernia using an extraperitoneal approach.

Yokoyama T. Munakata Y. Ogiwara M. Kawasaki S.
Department of Surgery, Toyoshina Red Cross Hospital, Japan.
We present a case of an 84-year-old woman with nonstrangulated, reducible obturator hernia treated with laparoscopic total extraperitoneal prosthetic hernia repair. Preoperative diagnosis was made based on the clinical findings. The patient's postoperative recovery has been uneventful, without complications. When a nonstrangulated obturator hernia is diagnosed preoperatively, this procedure is likely to be successful.

Evaluation of the biliary tree during laparoscopic cholecystectomy: laparoscopic ultrasound versus intraoperative cholangiography: a prospective study of 150 cases.

Year 1998
Catheline JM. Turner R. Rizk N. Barrat C. Buenos P. Champault G.
Department of Digestive Surgery, Paris University Hospital, Hopital Jean Verdier, Bondy, France.
From November 1994 to March 1996, 150 patients treated by laparoscopic cholecystectomy were included in a prospective study, to compare intraoperative cholangiography (IOC) and laparoscopic ultrasonography (LU). The biliary tree was successively explored by these two methods in the routine detection of common bile duct stones. The feasibility of LU was 100%. Cholangiography was performed only in 125 cases (83%). The time taken for LU was significantly shorter (11.6 vs. 17.6 minutes, p = 0.0001). In this study, common bile duct stones were found in 14 cases (9%). For their detection, results were comparable to LU and IOC. For LU, sensitivity was 80% and specificity 99%; and for IOC, 78 and 97%, respectively. Both examinations combined had a 100% sensitivity and specificity. Laparoscopic ultrasonography failed to recognize the intrapancreatic part of the common bile duct in 25 cases (17%) and did not show anatomic abnormalities detected by IOC. It did, however, detect other unsuspected intraabdominal abnormalities. Although LU is safe, repeatable, and noninvasive, a considerable learning curve is necessary to optimize its efficacy. Comparison of relative cost must be undertaken.

Open versus laparoscopic gastrojejunostomy for palliation in advanced pancreatic cancer.

Year 1998
Bergamaschi R. Marvik R. Thoresen JE. Ystgaard B. Johnsen G. Myrvold HE.
Department of Surgery, and National Center for Advanced Laparoscopic Surgery, University Hospital of Trondheim, Norway.
To assess short-term outcome of open (OGJ) versus laparoscopic (LGJ) gastrojejunostomy in palliation of gastric outlet obstruction (GOO) caused by advanced pancreatic cancer, 22 OGJ patients were compared with 9 diagnosis-matched LGJ controls operated on at the same hospital between 1991 and 1996. Patients undergoing OGJ and LGJ were comparable for age, gender, weight, American Society of Anesthesiologists grading, and previous extensive abdominal surgery, but not for gastroenterostomy performed as a prophylactic procedure (9 vs. 0, respectively). Mortality (5 vs. 1, p = 1.5), overall morbidity (9 vs. 3, p = 0.42), operating time (113.6 +/- 24.5 minutes vs. 125 +/- 15.2 minutes, p < 0.5), time to oral solid food intake (7.2 +/- 0.9 days vs. 5.3 +/- 1.3 days, p < 0.5), nonsteroidal anti-inflammatory drug consumption (7,563.6 +/- 3,381.3 mg vs. 2,044 +/- 673 mg, p < 0.5), opioid consumption (688.5 +/- 258.6 mg vs. 2,910.5 +/- 2,659.9 mg, p < 0.5), delayed-return gastric emptying (5 vs. 1, p = 0.12), postoperative hospital stay (14.6 +/- 1.9 days vs. 10.1 +/- 1.8 days, p < 0.5), survival (5.7 +/- 0.8 months vs. 4.6 +/- 0.6 months, p < 0.5), and further hospital stay before death (9.8 +/- 3.3 days vs. 11.6 +/- 3.4 days, p > 0.5) were not significantly different in 22 OGJ and 9 LGJ patients, respectively. Estimated blood loss was significantly lower in LGJ patients (270.2 +/- 45.8 ml vs. 66 +/- 15.7 ml, p < 0.01). When 13 of 22 patients undergoing OGJ for treatment were compared with 9 LGJ patients, only estimated blood loss (p < 0.01) and hospital stay (p < 0.05) were significantly reduced in LGJ patients. Recurrent GOO before death occurred in one patient (1 of 22, 4.5%) 9 months after OGJ. LGJ for palliative treatment of GOO in advanced pancreatic cancer offered (in spite of the learning curve) reduced estimated blood loss and hospital stay when compared with OGJ.

Resistance to venous outflow during laparoscopic cholecystectomy and laparoscopic herniorrhaphy.

Year 1998
Bais JE. Schiereck J. Banga JD. van Vroonhoven TJ.
Department of Surgery, University Hospital Utrecht, The Netherlands.
The effects of pneumoperitoneum on peak venous flow velocity in the common femoral vein and the vena cava have already been studied. The results suggested that venous stasis occurs during surgical pneumoperitoneum. This study determines the effects of pneumoperitoneum on the overall venous outflow resistance of the lower limbs. Venous outflow resistance was measured during surgical procedures by impedance plethysmography in 12 patients undergoing laparoscopic cholecystectomy, 4 patients undergoing laparoscopic herniorrhaphy, 4 patients undergoing conventional cholecystectomy, and 2 patients undergoing conventional herniorrhaphy. Venous outflow resistance did not change significantly during laparoscopic cholecystectomy or herniorrhaphy. No difference in venous outflow resistance between laparoscopic cholecystectomy and herniorrhaphy was found. During pneumoperitoneum, no obstruction to total lower limb venous outflow could be demonstrated, indicating that venous stasis in the limbs did not occur, and consequently, flow in the iliac and inferior caval veins was not compromised. Hypothetically, active vasodilatation resulting from mild compression may explain this. In our view, no special measures to prevent deep venous thrombosis have to be taken during laparoscopic procedures.

Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?

Year 1998
Gurleyik E. Gurleyik G. Yucel O. Unalmiser S.
Department of Surgery, Haydarpasa Numune Hospital, Istanbul, Turkey.
Perforation and spillage of gallstones is a common occurrence in laparoscopic cholecystectomies. The long-term complications of these stones remains controversial. Experimental studies have been carried out to elucidate the outcome of intraperitoneal gallstones, but the chemical composition of these stones has not been considered in previous studies. In this study, we investigated the local effects of intraperitoneal gallstones in rats with respect to their chemical composition. Bile and gallstones were taken from human cholecystectomy specimens, and sent for bacteriologic and chemical analysis. Twenty cholesterol and 10 pigment stones were placed in the abdominal cavity of rats. Long-term local effects of gallstones were determined at the end of 3 months with macroscopic and microscopic examination. The fragments of two pigment stones were infected by Staphylococcus aureus. Five (17%) cholesterol stones were found free in the abdominal cavity, and 25 stones (83%) were wrapped with adjacent structures. Granuloma formation was found around 4 pigment stones (13% of all stones, 40% of pigment stones; p = 0.0077). We observed large granulomas and cutaneous fistula formation in two rats with infected pigment stones placed in the abdominal cavity. Histhopathologic examination also showed significantly severe inflammatory reactions secondary to pigment stones (p

Rectal expander-assisted transanal endoscopic microsurgery in rectal tumors.

Year 1998
Kakizoe S. Kakizoe K. Kakizoe Y. Kakizoe H. Kakizoe T. Kakizoe S.
Department of Surgery, Kakizoe Hospital, Hirado, Nagasaki, Japan.
Rectal expander-assisted transanal endoscopic microsurgery (RE-TEM) was performed for two cases of early rectal cancer and a case of villous tumor under saddle block anesthesia. RE-TEM is the new technique for local excision of rectal tumors with a rectal expander that we developed. The rectal expander expands the rectum after insertion through the anus and provides adequate vision for microsurgery with standard video monitors. Tumors were located 8, 8, and 5 cm from the anal verge, and all of them were excised completely with no difficulty. Minor bleeding was noted in all cases and was controlled by electric coagulation and/or sutures. Average operative time for the three cases was 105 min. We conclude that RE-TEM is useful for rectal tumors and/or early rectal cancer that cannot be removed by endoscopy.

A prospective review of laparoscopic cholecystectomy in Brunei.

Year 1998
Kok KY. Mathew VV. Tan KK. Yapp SK.
Surgical Unit, RIPAS Hospital, Bandar Seri Begawan, Brunei.
Brunei has a small population and a unique medical setup: The number of laparoscopic cholecystectomies (LCs) performed in our institution represents the total number of cases performed in this country. A prospective analysis of all the LCs performed in Brunei is presented. All 220 LCs performed between February 1, 1992, and November 30, 1996, were prospectively recorded on a detailed protocol. Analyses were made with respect to preoperative patient demography, intraoperative complications, and postoperative morbidity and mortality. Symptomatic gallstone disease was found to be common among the ethnic Nepalese population. In this series, nine patients required conversion to open surgery (4%). Acute cholecystitis comprised 21% of cases, and the mean operating time was longer in these cases (144.1 min) than in elective cases (101.2 min; P = 0.002). The overall morbidity was 5% with one ductal injury (0.5%). The mortality rate in this series was 0.5%. Our results of LC are favorable and comparable with those of published series. We conclude that LC has been successfully introduced into our institution. This study also represents an unofficial audit of the state of development of LC in Brunei.

Intraoperative endoscopy during colorectal surgery.

Year 1998
Martinez SA. Hellinger MD. Martini M. Hartmann RF.
Department of Surgery, University of Miami/Jackson Memorial Hospital and the Veterans Administration Medical Center, Florida 33136, USA.
In cases where preoperative studies may have been inadequate or could not be performed, intraoperative endoscopy (IOE) becomes an essential investigative tool for identification of synchronous lesions, of nonpalpable lesions, of sources of bleeding, and localization of lesions during laparoscopic colonic surgery. We report our experience with IOE, and describe our techniques of transabdominal colonoscopy. A review of the IOE performed in hospitals affiliated with the University of Miami was done. Fifty-eight patients received IOE from July 1994 to August 1996. There were 47 colonoscopies (38 transanal and 9 transabdominal), and 11 flexible sigmoidoscopies. Colorectal cancer, diverticulitis, inflammatory bowel disease, and lower gastrointestinal bleeding represented 83% of cases. In 10% of cases IOE changed the extent of the surgical procedure. There were no complications related to IOE. We conclude that in selected patients undergoing colorectal procedures, IOE is an essential tool. It can be performed safely, effectively, and rapidly.

Laparoscopic vagotomy and open pyloroplasty for bleeding duodenal ulcer not controlled endoscopically.

Year 1998
Ng JW. Yeung GH.
Department of Surgery, Yan Chai Hospital, Tsuen Wan, Hong Kong.
The majority of our patients with bleeding duodenal ulcer responded to endoscopic injection treatment. However, in six patients admitted during a 2 1/2-year period, we were forced to do emergency surgery to control the hemorrhage (three with failed injection and persisting exsanguination from a brisk bleeder and three rebled soon after apparent initial hemostasis). We performed an innovative procedure: pyloroplasty was done after oversewing the arterial bleeder in the duodenum through a small transverse wound in the right upper quadrant. The wound was then closed around a 10-mm trocar sheath. With the addition of three more ports, a truncal vagotomy was completed laparoscopically. Recovery was rapid and uneventful in all six cases; postoperative pain was minimal. The mean operative time was 85 minutes. We believe that, in a selected group of patients, laparoscopic vagotomy and open pyloroplasty through an essentially extended port wound (as described in detail) is an expedient and effective procedure in the emergency setting.

Value of peritoneal lavage cytology during laparoscopic staging of patients with gastric carcinoma.

Year 1998
Ribeiro U Jr. Gama-Rodrigues JJ. Bitelman B. Ibrahim RE. Safatle-Ribeiro AV. Laudanna AA. Pinotti HW.
Department of Gastroenterology, University of Sao Paulo, Brazil.
Forty-nine consecutive patients with advanced gastric carcinoma underwent preoperative staging by laparoscopy between June 1991 and June 1992. Peritoneal lavage with cytologic examination was performed when ascites was not present. In eight cases (16.3%), laparoscopy revealed carcinomatosis and/or multiple hepatic metastases, so laparotomy was not performed. Intraperitoneal free cancer cells (IFCCs) were detected in 41% of patients (65% in patients with ascites and 28% by peritoneal lavage). In the absence of macroscopic peritoneal dissemination, IFCCs were encountered in 29% of patients. IFCCs were present only when invasion of the gastric serosa was >3 cm2 or when adjacent organs and structures were already invaded. Mucinous adenocarcinoma, Borrmann class IV tumors, and Stage IV patients had higher incidence of IFCCs. Cytologic results were similar at laparoscopy and laparotomy (p > 0.05). Therefore, cytologic evaluation of peritoneal lavage added sensitivity to laparoscopy in assessing patients with advanced gastric carcinoma and may alter their therapeutic approach.

Videolaparoscopic treatment of Spigelian hernias.

Year 1998
Amendolara M.
U.O.A. Independent General Surgery Hospital, Department of Este (PD), Conselve-Este. Monselice-Montagnana (PD) Veneto Region, Italy.
Because treatment for Spigelian hernia is rarely discussed in the literature, this report presents two cases observed in a recent 6-month period by the U.O.A. Independent General Surgery Department, Hospital of Este. Both patients had laparoscopic treatment using a polypropylene prosthesis, which confirms the technological validity of the surgical method. The described cases are emblematic, because the intervention permitted a resolution of associated pathologies (gallbladder gallstones and umbilical hernia), which confirms both the efficacy of the surgical technique and of the high diagnostic precision of laparoscopy, as it is described by several sources. The validity of the technique is also confirmed by the quick recovery of patients and by the reduced hospitalization time, especially in elderly patients and in precarious general conditions.

Comparison of N2O and CO2 pneumoperitoneums during laparoscopic cholecystectomy with special reference to postoperative pain.

Year 1998
Aitola P. Airo I. Kaukinen S. Ylitalo P.
Department of Surgery, Tampere University Hospital and Medical School, University of Tampere, Finland.
To study the possible benefits of N2O pneumoperitoneum, 40 patients scheduled for laparoscopic cholecystectomy for symptomatic cholelithiasis were randomized into either CO2-induced (n = 20) or N2O-induced (n = 20) pneumoperitoneum groups. The intensity of postoperative pain was assessed by the patients themselves using an visual analogue pain score scale. CO2 insufflation caused respiratory acidosis. The total amount of anesthetic enflurane needed was lower in the N2O than in the CO2 group (p < 0.041). The N2O group experienced less pain 1 hour (p < 0.040) and 6 hours (p < 0.017) postoperatively and the next morning. Serum cortisol and plasma adrenaline concentrations in the N2O group did not differ from those in the CO2 group. Patients with N2O pneumoperitoneum seem to have less pain without the side effects caused by CO2. The N2O pneumoperitoneum is a good alternative to the CO2 pneumoperitoneum, especially for prolonged laparoscopic operations in patients with chronic cardiopulmonary diseases.

Video-assisted thoracoscopic resection of an epiphrenic diverticulum with esophagomyotomy and partial fundoplication.

Year 1998
Saw EC. McDonald TP. Kam NT.
Department of Surgery, Kaiser Permanente Medical Center, Hayward, California 94545-4297, USA.
Videothoracoscopic stapled diverticulectomy with distal esophageal myotomy and partial fundoplasty was successfully done for a 65-year-old woman who had a large, symptomatic epiphrenic diverticulum associated with achalasia. This minimally invasive approach resulted in good symptomatic relief of dysphagia, minimal postoperative pain, a 1-day hospital stay, and early return to normal activity.

A minimally invasive technique of appendectomy using a minimal skin incision and laparoscopic instruments.

Year 1998
Suh HH.
Department of Surgery, Namkwang General Hospital, College of Medicine, Seonam University, Kwangju, Korea.
To take advantage of the laparoscopic procedure, a new minimally invasive technique of appendectomy for nonobese and uncomplicated appendicitis is presented. Initially, diagnostic laparoscopy is performed through a minimal skin incision (microceliotomy) 1.5-2.0 cm in length in the right lower abdomen to rule out other disease. Then an appendectomy is performed using conventional surgical instruments under direct vision through the previous skin incision. There were 18 women and 12 men in this series. The mean age was 22.6 years. Pathologic findings of the appendix were: 2 normal, 13 catarrhal, 10 suppurative, and 5 gangrenous type. The mean operation time was 30.7 min. The mean frequency of postoperative analgesic requirement (nalbuphine 0.2 mg/kg) was 0.9 times. The mean hospital stay was 4.1 days (range, 2-7 days), and the duration until return to full activity was 7.6 days (range, 5-14 days). There was no mortality or morbidity. This appendectomy technique is a useful method for minimizing the postoperative pain and operative scar, thus allowing the patient an early return to full activity.

Laparoscopic repair for perforation of duodenal ulcer with omental patch: report of initial six cases.

Year 1998
Takeuchi H. Kawano T. Toda T. Minamisono Y. Nagasaki S. Sugimachi K.
Institute of Gastroenterology of Hofu, Yamaguchi, Japan.
We report our initial experience with perforated duodenal ulcer treated by laparoscopic repair with omental patch in six patients, and the results are compared with those of other procedures retrospectively. The average operative time was 85.0 min, and the estimated blood loss was 13.7 ml. The estimated blood loss of laparoscopic repair was significantly less than that of gastrectomy (p < 0.01). However, although all patients with gastrectomy or open omental patch needed administration of analgesia, only half of patients require analgesia in laparoscopic repair. No postoperative complication was encountered, and the recurrence of ulcer was not recognized in a mean follow-up of 10 months. We recognized this procedure to be safe and feasible. Although a larger number of patients with longer follow-up is needed, this procedure may become one of the treatments for perforated duodenal ulcer.