n-3 fatty acid-enriched eggs, lipids, and Western diet: time for change

Laparoscopic cholecystectomy is an integral part of the general surgery operative inventory. The conventional approach may need to be modified to fit different clinical situations. We present the first reported case of a laparoscopic cholecystectomy combined with a ventral hernia repair.     

Laparoscopic-assisted bowel resections in inflammatory bowel disease: state of the art

The objectives of this paper are to review the rational, the present results and future of laparoscopic-assisted bowel surgery in patients with inflammatory bowel disease (IBD). Only a few centres in the world report on laparoscopic bowel resection in IBD that include stoma surgery, ileocolic resection, left, right and (sub)total colectomy for Crohn's disease, and subtotal or restorative total proctocolectomy (ileal pouch anal procedures). The combined series report conversion rates between 2.5% and 22.2%. Ileocolic resection, stoma creation, stricturoplasty and segmental small bowel resection are associated with an acceptable length of surgery, but laparoscopic(-assisted) total colectomy or restorative proctocolectomy still demand up to 4-6 hours of operative time. The few randomised studies addressing laparoscopic-assisted (segmental) bowel surgery versus conventional surgery demonstrated significantly less pain, a quicker return to self-care and a shorter hospital stay. The results of the series reporting on laparoscopic-assisted (ileo)colectomy in IBD are similar to those from these randomised studies. Laparoscopic-assisted subtotal colectomy and restorative proctocolectomy have no benefit compared with conventional surgery other than superior cosmesis. Morbidity of laparoscopic (ileo)colectomy in IBD is low, that of laparoscopic-assisted subtotal colectomy and restorative proctocolectomy remains to be seen. The various laparoscopic bowel resections done in IBD are all feasible. The first series describing laparoscopic surgery for IBD indicate that laparoscopic-assisted segmental (ileo)colectomy is safe and is the preferred approach provided it is done in a centre specialised in the treatment of IBD and by skilled laparoscopic surgeons beyond the learning curve. Until now, laparoscopic-assisted subtotal colectomy and restorative proctocolectomy do not have the same short-term benefits as seen in other laparoscopic colorectal procedures. Patients with inflammatory bowel disease (IBD) have a high life-time risk of having abdominal surgery and reoperations. The proposed advantages of laparoscopic surgery in this group of young patients might be higher than in patients with other colorectal diseases. Minimal physiologic insult in patients who already are under significant physiologic stress, less adhesion formation and superior cosmesis are important benefits over time. In a time where patient's demands will increase, the future of laparoscopic colonic surgery in IBD looks assured.     

Simultaneous laparoscopic therapy of cholecysto- and choledocholithiasis. An analysis of results

INTRODUCTION: With the advent of laparoscopic cholecystectomy, ERCP has gained importance in the treatment of choledocholithiasis. Laparoscopic cholecystectomy with intraoperative cholangiography and common bile duct surgery allows diagnosis and treatment of cholecystolithiasis and choledocholithiasis in a single procedure. PATIENTS AND METHODS: Laparoscopic treatment of choledocholithiasis was evaluated in 99 consecutive patients with choledocholithiasis. 28 patients underwent successful preoperative ERCP. Of the patients with intraoperative confirmation of choledocholithiasis, removal was attempted by a transcystic approach in 36 and 23 underwent choledochotomy. 24 patients with a high operative risk underwent postoperative ERCP. RESULTS: The transcystic approach was successful in 72.2%. Choledochotomy was successful in 91.3%, yielding a combined success rate of 80%, 3.4% had local complications and 8.4% had other complications (complication rate 11.8%), 20.3% of the patients underwent ERCP after failed laparoscopic procedures. One patient had a laparoscopic redo. There was no mortality and no conversion to open surgery. CONCLUSION: ERCP and laparoscopic common bile duct surgery are complementary, efficient and safe modalities of treatment for choledocholithiasis. Choice of procedure is influenced by the surgeon's experience and institutional infrastructure, and the individual patient.     

Development of the cribriform plate and of the lamina mediana

From September 1992 to November 1996, 28 patients underwent laparoscopic adrenalectomy at Osaka University Medical Hospital. They were compared with 25 instances of conventional open surgery performed between May 1990 and April 1996 at the same institution. Laparoscopic adrenalectomy was performed via either a transperitoneal or a retroperitoneal approach. The mean operative time of 375 minutes for laparoscopic adrenalectomy was significantly longer than that of 133 minutes for open surgery. The average hospital stay for laparoscopic surgery was significantly shorter than that of conventional open adrenalectomy. The convalescent period was also significantly shorter in the patients who had laparoscopic adrenalectomy. There was no statistical difference in blood loss during the operation or the number of doses of analgesics administered after operation in the two groups. We conclude that laparoscopic adrenalectomy is one of the options to be selected in surgically managing adrenal tumors. Laparoscopic adrenalectomy could become a standard operative procedure as instruments and techniques of laparoscopy improve significantly.     

Laparoscopy in AIDS

Surgical problems in the patient with HIV and AIDS are becoming more commonplace as the incidence of HIV seropositivity increases and patients with AIDS are living longer. Laparoscopic surgery is being applied more frequently in the diagnosis and therapy of these patients' problems as more surgeons become familiar with the techniques. Although no prospectively randomized trials exist, the benefits of the laparoscopic approach clearly have had an impact on the morbidity associated with surgery. The decreased perioperative immune depression may benefit these patients, and risks to the operative teams probably are lessened if basic tenets of laparoscopic surgery are observed.     

Laparoscopic cholecystectomy for gallbladder stones

The authors describe the technique for the treatment of gallbladder stones using a laparoscopic approach and discuss the diagnostic and operative flow chart stressing complications and ways to avoid them. A total of 2517 non-selected patients underwent surgery since october 1990 up to september 1995. 252 were affected by acute cholecystitis (10%); 172 underwent emergency laparoscopic cholecystectomy. ERCP was performed in 278 patients (11.04%): 177 underwent endoscopic sphincterotomy and laparoscopic cholecystectomy, 21 underwent laparoscopic cholecystectomy before sphincterotomy, 8 laparoscopic cholecystectomy and ESWL. Laparoscopic cholecystectomy was converted into laparotomy in 37 patients (1.4%); surgery was abandoned in 3 patients following to onset of intense bradycardia. Major complications were observed in 0.63%; bile duct injury occurred in four patients (0.15%). One patient died following a massive intraoperative myocardial infarction. Average operative time was 21 minutes. Only 22.8% of patients required mild analgesia on the first day after surgery. The average hospital postoperative stay was 2.6 days. Return to work took place in 98% of non complicated patients within one week of being discharged from hospital.     

Eicosanoids and fat emulsions in acute respiratory distress syndrome patients

Laparoscopic splenectomy has been accepted as a feasible extension of minimally invasive surgery, which has undergone dramatic improvements in both technology and instrumentation. We performed a laparoscopic splenectomy in a 7-year-old girl with hereditary spherocytosis. The patient recovered rapidly and returned to unrestricted activities quickly. The appropriate positioning of each laparoscopic port is essential for a good operative view and smooth access. It is also important to dissect the hilum of the spleen meticulously. Laparoscopic splenectomy in the pediatric age group appears to be another promising extension of laparoscopic surgery.     

Treatment of adnexal torsion using operative laparoscopy

The aim of this work was to clarify the value and application of operative laparoscopic treatment for adnexal torsion. We included in our study all patients (n = 27) who presented with an intra-operative diagnosis of torsion of the adnexa between January 1989 and May 1995. A total of 28 adnexal torsions were treated. Treatment was carried out by laparoscopic surgery in 75% of cases (21 torsions): in one-half of the cases (14 torsions) it was possible to achieve conservative laparoscopic treatment. The nature of the lesions and the experience of the surgeons are two factors which closely govern the outcome of surgical treatment. For those patients presenting a benign pathology, laparoscopic surgery was used to treat 84% of cases in the series. All the patients presenting a benign pathology and operated upon since 1993 have received laparoscopic surgical treatment. No major complications (peritonitis, thrombotic emboli, coagulation problems) were observed after conservative laparoscopic surgery. These results demonstrate that, provided the surgeons are sufficiently experienced, treatment by conservative laparoscopic surgery for adnexal torsion is both safe and reliable. In the years to come more work must be done to assess the vitality of the adnexa so that as many patients as possible can benefit from conservative treatment.     

Perspectives of minimal invasive surgery

The rapid and often uncritical introduction of complex minimal invasive procedures in clinical routine has been increasingly criticized. Even established minimal invasive techniques as for instance laparoscopic cholecystectomy are discussed controversial. Causes hereof are the lack of basic research and the unstructured development of new operative techniques. The possibilities of physiology adjusted basic research in minimal invasive surgery and stepwise a structured testing of new operative techniques are demonstrated. The changing conditions of the next century demand critical evaluation of the effectiveness of video-endoscopic surgery in prospective randomized trials, if it will keep or expand its present clinical importance.     

Voice-controlled robot: a new surgical aide? Thoughts of a user

The learning curve for utilization of the voice-controlled AESOP Robot security apparatus for laparoscopic procedures is short. A short experience and the first trials suggest that this security apparatus could allow better intra operative ergonomics, the practice of solosurgery or telementoring. The high cost requires a homogeneous and dense practice in laparoscopic surgery.     

Adrenal and renal surgery by the laparoscopic and/or retroperitoneoscopic approach

Since its introduction 6 years ago, almost all abdominal procedures have been attempted laparoscopically. Despite their retroperitoneal location, kidneys and adrenals have also been reached by the blitz of endoscopic surgery since 1992. We present here the techniques, indications, advantages or disadvantages of the videoscopic approach-either laparoscopic or retroperitoneoscopic- of those solid retroperitoneal organs. Preliminary results of the international literature are presented, while objectively comparing currently available data about the efficacy and cost of endoscopic versus open procedure. Despite the time-consuming nature and high operative cost of the endoscopic approach, decreased convalescence and better patient comfort are evident. Furthermore videoendoscopic adrenal surgery performed, even sporadically, by surgeons experienced in laparoscopic surgery is as safe as the open approach, provided that those surgeons are also familiar with the rules and potential drawbacks of adrenal surgery for endocrine disorders.     

Laparoscopic adrenalectomy. A new standard of care

OBJECTIVE: The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. BACKGROUND: Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional "open" surgery. METHODS: Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. RESULTS: None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing either laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.     

The spiritual and psychological explanations for loss experience

OBJECTIVE: To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. MATERIALS AND METHODS: A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. RESULTS: The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes. CONCLUSIONS: Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.     

Spatial accuracy of primary and secondary memory-guided saccades in schizophrenic patients

A reusable cone suitable for use with existing laparoscopy cannulas was designed to provide means for sealing and stabilizing the operative site throughout the procedure, and for repairing the surgical site after the surgery is completed. The device consists of a moveable laparoscopic cannula cone fitted with suture holders. The cone contains tunnels terminating at its distal end that serve as passages for sutures loaded on a special needle to traverse the abdominal wall. When sutures are pulled into suture holders they stabilize the cannula and seal the puncture site. When sutures are tied at the end of the procedure, they achieve full-thickness closure of the operative site. The laparoscopic cannula cone stabilizes the cannula on the abdominal wall, maintains an air-tight seal, controls potential hemorrhage from the cannula puncture site, and achieves satisfactory closure of the surgical defect. Preliminary experience with the instrument and method has been most satisfactory.     

Telesurgical consultation

PURPOSE: We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. MATERIALS AND METHODS: Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. RESULTS: In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or post-operative complications. CONCLUSIONS: Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.     

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.     

Laparoscopy for chronic abdominal pain

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.     

Results of laparoscopic Nissen fundoplication

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.     

Altercation of generations: genetic conflicts of pregnancy

Laparoscopy has followed the typical phases in the development of any new operative technique. We have now begun to realize its limitation and are beginning to standardize the procedures and specify their indications. Since laparoscopy predominantly reduces the trauma of access, the development of a total operative trauma score has assisted us in determining the impact of specific laparoscopic procedures compared to their open alternatives. Laparoscopy is responsible for less blood loss, less postoperative pain, a shorter hospital stay and a very small scar, all of which accounts for its popularity among patients. A rational combination of laparoscopy, endoscopy and open surgery to treat urological diseases should be developed in the future.     

Mitral valve surgery using combined superior-transseptal approach to the left atrium

We performed mitral valve surgery in 5 patients using the combined superior-transseptal approach to the left atrium. Exposure of the mitral valve was excellent, and postoperative arrhythmias related to the operative procedures were not seen in all patients. The operative technique and indications are discussed in this paper.