Respiratory mechanics during laparoscopic cholecystectomy: the effects of the abdominal wall lift

The abdominal wall lift (AWL) has been proposed for laparoscopic cholecystectomy to reduce hemodynamic effects caused by carbon dioxide (CO2) and high intraabdominal pressures (IAP). Data concerning effects of AWL on respiratory mechanics are scant. We therefore used a noninvasive method to evaluate whether the AWL could offset these effects. The PETCO2, airflow, and airway pressure were continuously measured in nine patients undergoing laparoscopic cholecystectomy using an AWL with minimal CO2 insufflation. We used a least-squares method to calculate maximal airway pressure (Pmax), elastance (Ers), and resistances (Rrs) of the respiratory system. After CO2 insufflation, the initiation of AWL resulted in a significantly decreased IAP (from 13 to 6 mm Hg; P < 0.001) and Rrs (from 20.6 to 17.8 cm H2O.L(-1).s(-1); P = 0.029), whereas Ers was partly modified (34.0 to 33.3 cm H2O/L; not significantly different). With AWL, we hypothesized that the diaphragm remained flat and stiff, outweighing the beneficial effect of the decrease of IAP on Ers. PETCO2 significantly increased after AWL and at the end of the procedure. We conclude that AWL partly reverses the impairment of the respiratory mechanics induced by CO2 insufflation during laparoscopic surgery. IMPLICATIONS: The abdominal wall lift (AWL), acting on the abdominal chest wall, had some benefits during laparoscopic surgery by limiting CO2 peritoneal insufflation and several side effects, such as hemodynamics. We examined the consequences of this technique on respiratory mechanics in nine patients undergoing laparoscopic cholecystectomy. Our findings suggest that the AWL decreases intraabdominal pressure and respiratory resistances without a significant effect on respiratory elastance.     

Laparoscopic cholecystectomy in a patient with mitochondrial myopathy

The authors report a 27-year-old woman with mitochondrial myopathy and respiratory failure requiring nasal-CPAP administration who successfully underwent laparoscopic cholecystectomy for chronic cholecystitis. The hypothesis that minimally invasive surgery results in less operative stress is truly substantiated by the experience with laparoscopy in such patients with high risk of perioperative and postoperative complications.     

Apropos of a case of gas gangrene of the abdominal wall after cholecystectomy

The authors report a new case of gas gangrene following cholecystectomy with a fatal outcome. Mode of infection and principles of diagnosis and therapy are discussed together with a review of the literature.     

Laparoscopic cholecystectomy using ultrasonically activated coagulating shears

A 4-year-old girl with bilateral striatal oedema in association with an echovirus type 21 infection is reported. In the course of a prolonged upper respiratory-tract infection, the patient developed muscular hypotonia, resting tremor, ataxia, sleepiness, hyperaesthesia, and indistinct speech. T2-weighted cranial MRI revealed bilateral oedema of the basal ganglia and the cerebellar peduncles. At follow-up after 3 months MRI changes and clinical symptoms had fully resolved.     

Laparoscopic cholecystectomy in pregnancy

Several recent literature reviews have shown that Laparoscopic cholecystectomy can be performed safely in pregnant females with symptomatic gallbladder disease. We have performed a retrospective analysis of all patients who underwent a cholecystectomy (6,080 patients) from January 1, 1990 until December 31, 1996 at San Pablo Medical Center. Lapa-cholecystecomy was performed in 4,252 (64%) and in the remaining 1,828 (36%) patients, an open cholecystectomy performed. Of the Laparoscopic cases, 5(0.1%) were performed in pregnant females with complicated gallbladder disease(GBD). The diagnosis of GBD was done with an abdominal sonogram. Four of the 5 patients had suffered from gallstones pancreatitis and one acute cholecystitis, prior to the operation. The records of patients were reviewed to secure the following variables, age, pre and post operative course and outcome. Intraoperative cholangiogram performed in 1 patient. No complications were seen in the mother or in the fetus in any of the five cases. Literature was reviewed to assess our reports. Conclusions: Pregnant females with complicated gallbladder disease can be safely managed with Laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy in pregnancy

Acute calculus cholecystitis during pregnancy can be a difficult management problem. Two pregnant patients with cholecystitis refractory to conservative management underwent laparoscopic cholecystectomy at a community hospital. One patient was treated under epidural anesthesia. Pregnancy should not be an absolute contraindication to laparoscopic cholecystectomy, and epidural anesthesia should be considered.     

Laparoscopic cholecystectomy in the geriatric population

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community. SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas. METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion. RESULTS: Eighty-two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty-two percent of this group suffered acute cholecystitis with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population. CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency.     

The abdominal lift: is there any advantage for the critically ill patient?

The use of carbon dioxide to create a cavity for the operation of laparoscopic cholecystectomy leads to serious complications of the cardiovascular system; consequently, patients with ischaemic heart disease can be put at greater risk. For example, on reaching an intra-abdominal pressure of 15mmHg, a fall of about 35% of the static compliance was observed. Upon using the Laparolift, these influences on the respiratory system were not detected, and the rise in systemic vascular resistance usually seen with the CO2-pneumoperitoneum did not occur. From the anaesthetist's viewpoint the Laparolift was helpful in the treatment of patients with serious limitations of cardiac function.     

Laparoscopic hepatic resection: a new and safe procedure by abdominal wall lifting method

HCC is well known for its high incidence of intrahepatic tumor recurrence and many patients suffering from them, usually undergo further treatments, such as PEI, TAE, MCNT or hepatic resection. However, conventional hepatic resection by large skin incision causes severe intraabdominal adhesions, which disturb US examination and further treatments. The aim of the laparoscopic procedure is to prevent intraabdominal adhesions. This is a study of the feasibility of laparoscopic hepatic resection without CO2 pneumoperitoneum, which is not yet popular, as a safe and effective procedure. The patient in this study had a solitary HCC in the lateral segment. Mobilization of the lateral segment, dissections of the left hepatic artery and portal venous branches, i.e. P2 and P3, were performed under CO2 gas insufflation. However, to avoid CO2 gas embolism, further procedures, including parenchymal compression and hepatic venous dissection, were performed using the abdominal wall lifting method without pneumoperitoneum. The patient could eat on the second postoperative day and had an uneventful postoperative recovery and was discharged from the hospital 13 days after surgery. Hospital stay was shorter than conventional hepatic resections with large skin incisions. The importance of this procedure lies in that it is not only a minimally invasive procedure, but also provides us with the possibilities of further treatments, including PEI and re-hepatic resection.     

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.     

Laparoscopic cholecystectomy in The Netherlands

Laparoscopic cholecystectomy was introduced into the Netherlands in the Spring of 1990. The aim of this study was to evaluate the results of the procedure in Dutch hospitals over the first 2 years to obtain some insight into its safety and efficacy in general surgical practice. A written questionnaire was sent to all 138 Dutch surgical institutions enquiring about conversion rate, complications (with emphasis on mortality rate and common bile duct injuries), operating time and hospital stay. The surgeons' opinions were also sought on possible contraindications such as previous operation, bile duct stones and cholecystitis, as were their estimations of the percentage of patients in their practice eligible for laparoscopic cholecystectomy. Data were obtained for 6076 laparoscopic cholecystectomies; the response rate was 100 per cent. Conversion to open cholecystectomy was necessary in 413 patients (6.8 per cent), mostly because of adhesions, cholecystitis, haemorrhage and unclear anatomy. Postoperative complications were reported in 260 patients (4.3 per cent). There were seven deaths (0.12 per cent) and 52 (0.86 per cent) bile duct injuries, of which 20 were recognized during laparoscopy. The mean operating time for the ten most recent patients in each institute was 70 (range 30-180) min and the mean hospital stay 4.5 (range 2-8) days. Previous lower abdominal operations were not considered to be a contraindication by 96 per cent of surgeons, whereas previous upper abdominal procedures were regarded as a contraindication by 66 per cent. After successful clearance of the bile duct at endoscopic retrograde cholangiopancreatography, only 12 per cent would perform an open procedure. Moderate cholecystitis was not considered a contraindication to laparoscopic cholecystectomy by 71 per cent of surgeons, but severe cholecystitis was a reason for open cholecystectomy for 83 per cent. In most surgical practices 70-80 per cent of patients were considered to be eligible for the laparoscopic procedure. In conclusion, laparoscopic cholecystectomy has gained rapid acceptance in the Netherlands. Although the number of bile duct injuries is high, the findings of this general survey are similar to those from highly specialized centres and match the overall results of conventional cholecystectomy.     

Laparoscopic cholecystectomy in acute cholecystitis

Laparoscopic cholecystectomy was fulfilled in 108 patients admitted to the clinic with acute cholecystitis. Operations were made on 73% of them during the first four days from the beginning of the disease, 18.5% were operated upon within 5-7 days, 8.5% - 8 days later. Endoscopic papillotomy with removing the stones from the choledochus was performed in 10% of the patients before operation. Serious problems during taking the gallbladder from the inflammatory infiltration were observed in 29% of the patients. Technical problems took place more often if the patients were operated upon 5 days after the beginning of the disease. Change for open laparoscopy and standard cholecystectomy were necessary in 9 patients (8.3%). There were no lethal outcomes after laparoscopic cholecystectomy. Complications were observed in 12 patients (11.1%). The average period of staying at the hospital was (5.2 +/- 2.1) days. Laparoscopic cholecystectomy can be successfully performed in patients with acute cholecystitis by a sufficiently experienced surgeon.     

Laparoscopic cholecystectomy in the densely scarred abdomen

Extensive intra-abdominal adhesions are a possible contraindication to laparoscopic cholecystectomy and are known to occur after peritonitis because of perforated hollow viscus or multiple abdominal operations. Four such patients, who had undergone three or more previous abdominal operations, and had additional complicating factors, were successfully treated by laparoscopic cholecystectomy. An initial subxiphoid incision with blunt finger dissection was used to place the primary port. This approach achieves greater success and is safer than the traditional open umbilical dissection, because it avoids extensive lysis of small bowel and transverse colon adhesions from the anterior abdominal wall.     

Laparoscopic cholecystectomy in pancreas transplant recipients

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Since its introduction in 1987, this procedure has been employed with increasing frequency as its safety has been documented in numerous studies. Absolute contraindications to laparoscopic cholecystectomy have become relative contraindications, and patients previously felt to be at excessive risk for laparoscopic cholecystectomy are viewed as patients who may benefit from laparoscopic cholecystectomy. The use of this procedure in patients with comorbid medical conditions has the potential to decrease patient morbidity. Patients who have previously undergone solid organ transplantation and require immunosuppressive therapy are a group of patients who may benefit from laparoscopic cholecystectomy. We report four patients who have previously undergone combined renal and pancreas transplantation who underwent successful laparoscopic cholecystectomy.     

Dermatolipectomy of the abdominal wall

The authors describe clinical cases of dermatolipectmy of the abdominal wall performed during the last 15 years: a group of six female patients with excess skin after rapid and excessive reduction of adipose tissue, a second group of 42 patients with cumulation of subcutaneous fat in the region of the hypogastrium with formation of massive skinfolds, the so-called clinical picture of "venter pendulus". The third group of 122 patients with excessive adipose tissue and skin combined with diastasis of the rectus abdominis muscles or even prolapse of the abdominal organs. Transverse puboinguinal dermatolipectomy was performed. In 56 patients, high transverse resection is not used by the authors. Vertical lipectomy in the median line was performed in three patients and combined transverse-vertical lipectomy in 104 patients. From the total number of 170, operations satisfactory from the aspect of the surgeon and in particular the patient, were achieved in 122 (71.7%) cases, good results in 43 (25.4%) and satisfactory results in 5 (2.9%).     

Laparoscopic cholecystectomy in cirrhotic patients: expanding indications

Cirrhosis, portal hypertension, and bleeding disorders are being considered as relative or absolute contraindications to laparoscopic cholecystectomy (LC). This report describes four cirrhotic patients with clinical portal hypertension in three and mild to severe bleeding tendency in all. Laparoscopic cholecystectomy was uniformly successful in these patients with no complications. If the surgeon exercises extreme caution in securing hemostasis and does not overlook some details concerning patient management, LC can be efficiently and safely performed in cirrhotic patients. Compared with open cholecystectomy, LC may be even more advantageous concerning the virtual elimination of incision-related complications. Our preliminary experience is encouraging and suggests more liberal use of LC in cirrhosis-portal hypertension-bleeding tendency disease complex.