Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair

BACKGROUND: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies. METHODS: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery. RESULTS: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients. CONCLUSIONS: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.     

Elective laparoscopic splenectomy for hematologic disorders

Laparoscopic splenectomy has been reported to be the procedure of choice in selected patients with hematologic disorders. The purpose of this study is to review our experience with laparoscopic splenectomy in this patient population. The charts of all patients with hematologic disorders who presented for laparoscopic splenectomy over a 17-month period were reviewed. Fifteen patients, nine males and six females, aged 12 to 80 years (mean, 49 years) presented for laparoscopic splenectomy. Surgical indications included 13 cases of idiopathic thrombocytopenic purpura and one each of hemolytic anemia and Hodgkin's disease. Splenectomy was performed utilizing a four- or five-puncture laparoscopic technique. For completed laparoscopic splenectomies, the mean operative time was 129 minutes, and the mean estimated blood loss was 232 cc. Mean splenic weight was 210 g. There were no operative deaths. There was a single intraoperative complication, a 1700-cc hemorrhage, and two postoperative complications: pneumonitis and deep venous thrombosis. Overall morbidity was 20 per cent. A single patient (7%) required conversion to laparotomy for completion due to hemorrhage. For patients completed laparoscopically, the mean hospitalization was 1.5 days, and none required parenteral narcotics for pain control after the first 36 hours. Laparoscopic splenectomy for patients with hematologic disorders is a safe and technically feasible procedure. Decreased hospitalization and discomfort are the primary benefits. This technique should be added to the repertoire of surgeons treating patients with hematologic disorders.     

Intermittent sequential compression of the lower limbs prevents venous stasis in laparoscopic and conventional colorectal surgery

PURPOSE: This study was designed to evaluate the influence of intraoperative intermittent sequential compression (ISC) on venous blood return from the lower limbs during laparoscopic and conventional colorectal colectomy. METHODS: Fifty patients undergoing laparoscopic (n = 25) or conventional (n = 25) colorectal surgery were included in a prospective study. Peak venous flow (PFV) and the cross-sectional area (CSA) of the femoral vein were assessed by Doppler ultrasound examination intraoperatively. RESULTS: Age, gender, and body mass index were comparable between both groups. Baseline PFV was 21 +/- 6.6 cm/s in the conventional and 18.4 +/- 6.4 cm/s in the laparoscopic group (P = 0.2). ISC increased PFV to 156 +/- 29 percent of the baseline value in the conventional group and to 161 +/- 29 percent in the laparoscopic group. PFV decreased after abdominal insufflation to 127 +/- 19 percent of the baseline value in the laparoscopic group and after laparotomy to 134 +/- 27 percent in the conventional group (P = 0.3). PFV decreased slightly in both groups during surgery but remained well above the baseline value. Baseline CSA was 1.02 +/- 0.17 cm2 in the conventional group and 1 +/- 0.23 cm2 in the laparoscopic group. ISC decreased CSA to 0.91 +/- 0.18 cm2 (conventional) and 0.85 +/- 0.18 cm2 (laparoscopic) after initiation of ISC. CSA was 0.92 +/- 0.18 cm2 after abdominal insufflation in the laparoscopic group, and it was 0.93 +/- 0.18 cm2 after laparotomy in the conventional group (P = 0.4). During surgery, there were no differences in absolute CSA or CSA changes compared with the baseline value in both groups. Postoperative circumference of the calf and thigh were not different between both groups. Postoperative thromboembolic complications did not occur. CONCLUSION: ISC effectively increases venous blood flow from the lower limbs during conventional and laparoscopic colorectal resections and may decrease the risk of postoperative deep vein thrombosis. Therefore, ISC is strongly recommended in every prolonged laparoscopic procedure.     

Anesthesia in laparoscopic surgery

The use of laparoscopic techniques in general surgery is increasing in popularity. The anesthesiologist's goals during laparoscopic surgery are hemodynamic and respiratory stability, appropriate muscle relaxation, control of diaphragmatic excursion, intraoperative and postoperative patient analgesia. The implications are that the anesthesiologist must use a technique that not only allows for optimal surgical conditions but also provides intraoperative patient comfort and safety and a rapid postoperative anesthetic recovery. Laparoscopy is not a benign procedure. It is associated with major and minor surgical and non surgical complications, including death. Therefore, it is imperative that the anesthesiologist and surgeon thoroughly understand the physiopathology and immediate treatment of these potential complications and communicate effectively about their management.     

Port site fascia closure in laparoscopic assisted colectomy: a simple technique

The importance of port site fascia closure after laparoscopic procedures has been recently recognized as an increasing number of port site hernias have been reported. We present a simple technique of port site closure after laparoscopic-assisted colon resections.     

Elective appendectomy with abdominal and pelvic surgery

A series is presented of 830 patients in whom elective appendectomy was performed at the time of laparotomy for other intraabdominal disease. Special emphasis is given to 490 such procedures among 1042 patients with abdominal hysterectomy, an incidence of 47%. This increases to 57% by exclusion of patients with previous appendectomy. The contraindications to elective appendectomy are discussed, as well as its morbidity, mortality, and complications. The author concludes that an elective appendectomy should be performed with abdominal and pelvic surgery whenever the opportunity is presented, provided that the procedure is not prohibited by the contraindications discussed.     

Robot arm in laparoscopic surgery

Currently laparoscopic surgery is limited by several factors. One of them is the precise handling of optics. Up to now, in our hospital 52 laparoscopic operations have been done with a voice-controlled robot arm to handle the optics in gallbladder, stomach, large bowel and hernia operations. The visual field is determined by the surgeon. In all cases handling of the robot arm was precise and the voice response exact and without technical problems. Twenty-nine operations were done by one operator as "solo surgeries". In 20 further cases there was one assistant. A robot arm can be used successfully without problems by any laparoscopic surgeon in any operating theater.     

Measurements in emergency laparoscopic surgery

The paper deals with the advantages of the techniques of abdominal surgical interventions by using a laparoscope. It suggests that the diagnostic feasibilities of laparoscopy should be expanded by inserting the transducers that yield reliable data on the status of the viscera.     

Exposure of the operative field in laparoscopic surgery

Endoscopic surgery, as a result of over 90 years of investigation, has now become the most innovative part of general surgery; every procedure in the thoracic and abdominopelvic cavity, intraperitoneal or extraperitoneal, has been reviewed for feasibility. The basic principles in the management of surgical patients, however, have not changed: adequate exposure and good lighting remain important and may become more important with endoscopic techniques. Historical review shows the dependence of advances in laparoscopy upon technical development in the field of intraabdominal exposure as the result of two objectives: namely abdominal wall displacement and bowel retraction.     

Complications of laparoscopic surgery

The potential complications of a laparoscopic procedure include those related to laparoscopy and those related to the specific operative procedure. The majority of these complications occur during the early learning phase for laparoscopy. They also may occur, however, during procedures performed by surgeons who have considerable laparoscopic experience. As new applications for laparoscopy continue to emerge, it is important for the surgeon to be familiar with the possible complications associated with the various laparoscopic procedures. Only through an appreciation of the potential complications of a procedure can their overall incidence be reduced to a minimum.     

A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report

BACKGROUND: Uncontrolled studies using laparoscopic techniques in colorectal surgery have not demonstrated clear advantages to these procedures compared with conventional ones, and surgeons are concerned about unusual early recurrences reported after laparoscopic colorectal cancer surgery. STUDY DESIGN: We conducted a prospective, randomized trial in one surgical department comparing laparoscopic (LAP) and conventional (CON) techniques in 109 patients undergoing bowel resection for colorectal cancers or polyps. Postoperatively, all patients underwent measurement of pulmonary function tests every 12 hours, and were treated identically on a highly controlled protocol with regard to analgesic administration, feeding, and postoperative care. RESULTS: Of the 55 patients assigned to LAP and 54 to the CON group, there were 42 and 38 with cancer, respectively (the other patients had large adenomas). Overall recovery of 80% of forced expiratory volume in 1 second and forced vital capacity was a median of 3 days for LAP and 6.0 days for CON (p = 0.01). LAP patients used significantly less morphine than CON patients up to the second day after surgery (0.78 +/- 0.32 versus 0.92 +/- 0.34 mg/kg per day, p = 0.02). Flatus returned a median of 3.0 days after LAP versus 4.0 days after CON surgery (p = 0.006). Tumor margins were clear in all patients. After a median followup of 1.5 years (LAP) and 1.7 years (CON), there were no port site recurrences in the LAP group. Seven cancer-related deaths have occurred (three in the LAP group, four in the CON group). CONCLUSIONS: Within this prospective, randomized trial, laparoscopic techniques were as safe as conventional surgical techniques and offered a faster recovery of pulmonary and gastrointestinal function compared with conventional surgery for selected patients undergoing large bowel resection for cancer or polyps. There were no apparent shortterm oncologic disadvantages. Longer followup is needed to fully assess oncologic outcomes.