A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

A case controlled comparison of open and laparoscopic splenectomy in children

BACKGROUND: This case controlled study compares the efficacy, safety, and cost of laparoscopic splenectomy (LS) and open splenectomy (OS) for hematologic disorders in children. METHODS: The records of 82 consecutive children and adolescents undergoing splenectomy for hematologic disorders between August 1994 and September 1997 were reviewed retrospectively. RESULTS: Fifty patients underwent LS by a lateral approach and 32 underwent OS through a left subcostal incision. Mean age was 7.76 years for LS and 6.9 years for OS. Patient weights were similar: (LS, mean 30.5 kg; OS, mean 27.6 kg). Hematologic indications included hereditary spherocytosis in 43 children (LS 26, OS 17), sickle cell anemia with sequestration in 13 (LS 7, OS 6), immune thrombocytopenic purpura in 14 (LS 8, OS 6), and 12 with other disorders (LS 9, OS 3). Concomitant cholecystectomy was performed in 10 of 50 LS and 6 of 32 OS cases. Accessory spleens were identified in 8 of 32 (25%) OS and 9 of 50 (18%) LS cases (P = .578). No LS procedures required conversion to OS. The mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (P = .233). LS required a longer operative time (115 vs 83 minutes, P = .002), less need for postoperative intravenous narcotic (51% vs 100%, P < .0001), lower total narcotic doses (0.239 vs 0.480 mg/kg morphine, P = .006), shorter length of hospital stay (1.4 +/- 0.97 vs 2.5 +/- 1.43 days, P = .0001), and lower average total hospital charges ($5713 vs $6564) than OS. There were no deaths or major complications in either group. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay, and lower total hospital charge.     

Laparoscopic splenectomy in children. Preliminary results and comparison with the open technique

To determine the safety and efficacy of laparoscopic splenectomy (LS) in children, a retrospective review of our preliminary experience using LS was compared to results in patients who previously underwent open splenectomy (OS). From July 1993 to January 1995, we performed eight LS procedures in six children with hereditary spherocytosis (HS) and two with immune thrombocytopenic purpura (ITP). Laparoscopic cholecystectomy was simultaneously done in one case with HS. There were 4 males and 4 females who ranged in age from 5 to 15 years--an average age of 8.8 years. Two cases in the early series required a counterincision because of bleeding. Eleven patients who previously underwent OS in our department were used to compare demographics, operative courses, and surgical outcomes. The ages, genders, diseases, body weights, and spleen weights were comparable between LS group and OS groups. The operative time for the LS group was statistically longer than for the OS group (226 +/- 24 min vs 101 +/- 8 min, P < 0.001). The estimated blood loss in the LS group was similar to that of the OS group (100 +/- 39 ml vs 73 +/- 11 ml. P = 0.97). There were no peri- or postoperative complications in two groups. The postoperative hospital stay of LS group was statistically shorter than that of the OS (6.8 +/- 0.6 days vs 10.4 +/- .05 days, P < 0.0001). LS provided better cosmesis and minimized trauma in children over OS. LS appears to be a safe and effective procedure in children, and is useful in the management of pediatric patients with HS or ITP.     

Laparoscopy improves outcomes for pediatric splenectomy

BACKGROUND: Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method. METHODS: A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital. RESULTS: The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05). CONCLUSIONS: Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.     

Laparoscopic splenectomy as an alternative to open surgery in the treatment of autoimmune thrombocytopenia

BACKGROUND: Several studies have shown the potential advantages laparoscopic splenectomy (LS) over open surgery. The aim of this study has been to evaluate the advantages of LS over open surgery in the treatment of autoimmune thrombocytopenia. PATIENTS AND METHODS: 54 consecutive patients splenectomized for the treatment of idiopathic thrombocytopenic purpura (ITP) or HIV-related thrombocytopenia were analyzed. Operative features (operative time, conversion to open surgery, accessory spleens), immediate (stay, analgesia and blood transfusion requirements) and late postoperative features (platelet count), as well as splenectomy-related complications in both surgical procedures were compared. RESULTS: Between February 1990 and February 1997, 54 splenctomies were performed for the treatment of autoimmune thrombocytopenia (ITP, n = 47, and HIV-related thrombocytopenia, n = 7). Eighteen were performed through an open approach, and 36 by laparoscopy. Both groups were comparable with regard to age, sex, platelet count, disease duration and body mass index. LS was completed in 34 cases (conversion to open surgery: 5.5%). The incidence of accessory spleens was 11% in the LS group and 5.5% in the open surgery group. Postoperative morbidity (16% vs 28%) and blood requirements (25% vs 33%) were lower after LS, but the differences did not reach statistical significance. Analgesia requirements (7 [SD 3] vs 11 [6]; p < 0.01) and postoperative stay (3.8 [2.6] vs 7.4 [3] days; p < 0.01) were significantly shorter after LS. Following splenectomy, the platelet counts became normal in 72% of patients submitted to LS and 78% of patients in the open surgery group. After 20 and 63 months mean follow-up, one patient in each group developed late complications. CONCLUSION: As compared to open surgery, LS offers a better immediate clinical outcome, with similar long-term results.     

Laparoscopic splenectomy in adults and children: experience with 31 patients

BACKGROUND: Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported. METHODS: Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included idiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm. RESULTS: Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 8% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2. CONCLUSIONS: Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura. A 1-year follow-up study

BACKGROUND: Laparoscopic splenectomy is a novel approach for the treatment of idiopathic thrombocytopenic purpura (ITP) in patients requiring surgical intervention. This technique was used for treatment in 16 consecutive patients. Follow-up was initiated at a median of 13.5 months after surgery to determine whether or not laparoscopic splenectomy is a safe and successful procedure that should be used in all patients requiring splenectomy for ITP. METHODS: Sixteen patients underwent laparoscopic splenectomy for ITP between May 1994 and September 1996. They were evaluated prospectively prior to surgery, immediately following surgery, at discharge, and at 13.5 months following surgery (n = 14) to determine the short- and long-term results of the procedure. RESULTS: Mean operation time was 123.4 +/- 12.1 min, and there were no significant intra- or postoperative complications. Mean intraoperative blood loss was 437.5 +/- 73.5 ml. Autologous blood transfusion was necessary in one patient (6.3%). Mean organ weight was 202.2 +/- 47.3 g. Mean postoperative hospital stay was 4.6 +/- 0. 4 days. Before discharge, mean platelet count rose by 100.7%. At follow-up (13.5 months postoperatively), it was 77.7% above preoperative values. No additional surgery was necessary in any of the patients undergoing laparoscopic splenectomy, and hematologic success was achieved in 12 patients (85.7%). CONCLUSIONS: Our results clearly indicate that laparoscopic splenectomy is a safe and successful procedure in patients suffering from ITP. It offers the well-known advantages of minimal invasive surgery as well as the surgical effectiveness of the open approach. This surgical technique should therefore be considered in all patients requiring splenectomy for the treatment of ITP.     

Posterolateral approach. An alternative strategy in laparoscopic splenectomy

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.     

Trends in rates of occupational fatal injuries in the United States (1983-92)

Recent advancements in laparoscopic surgery have made laparoscopic splenectomy possible. We retrospectively compared the outcomes of laparoscopic versus open splenectomy in patients with idiopathic thrombocytopenic purpura (ITP) or beta-thalassemia. From July 1993 to July 1997, 52 patients (ITP, 43 cases; beta-thalassemia, 9 cases) underwent either laparoscopic (30 patients, 9 men, 21 women; average age, 36.9 years) or conventional open splenectomy (22 patients, 5 men, 17 women; average age, 34.3 years). The two groups were similar in terms of sex, age, diagnosis, duration of disease, preoperative platelet count, and spleen size. The mean surgical time, estimated amount of blood loss, duration of postoperative recovery, analgesic usage, and complications were compared between the two groups. Laparoscopic splenectomy was successful in 29 (97%) of the 30 patients. The mean surgical time in the laparoscopy group was longer than in the open splenectomy group (190.6 vs 113.9 minutes, p < 0.01). The laparoscopy group had earlier postoperative oral intake (15.2 vs 52.6 hours, p < 0.01), less usage of analgesics (meperidine 50 mg/unit, 1.1 vs 2.8 units, p < 0.01) and a shorter postoperative hospital stay (4.1 vs 6.8 days, p < 0.01). The estimated blood loss, incidence of accessory spleen, surgical complication rate, and recurrence rate of thrombocytopenia were similar in the two groups. Our findings show that laparoscopic splenectomy in patients with ITP or beta-thalassemia is as safe as the open approach. While laparoscopy required a longer surgical time, the recovery period was shorter, analgesic use was less, and physical discomfort was less severe.     

Abdominal wound tumor recurrence after open and laparoscopic-assisted splenectomy in a murine model

PURPOSE: The cause of abdominal wall tumor recurrences after laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that poor surgical technique (i.e., crushing of the tumor) and not the CO2 pneumoperitoneum is responsible for port wound tumors. However, in that experiment no actual laparoscopic procedure or manipulation was performed. The purpose of the current study was to determine the rate of abdominal wound tumors after laparoscopic-assisted splenectomy performed via a CO2 pneumoperitoneum vs. open splenectomy using the mouse splenic tumor model. METHODS: To establish splenic tumors, female BALB/c mice (N=72) were given subcapsular splenic injections of a 0.1-ml suspension containing 10(5) C-26 colon adenocarcinoma cells via a left flank incision at the initial procedure. Eight days later, animals were randomized into one of two groups: 1) laparoscopic-assisted splenectomy, or 2) open splenectomy. Laparoscopic-assisted splenectomy animals had three laparoscopic ports placed and then underwent laparoscopic mobilization of the spleen under a CO2 pneumoperitoneum followed by extracorporeal splenectomy via a subcostal incision. Group 2 animals underwent open splenectomy via a subcostal incision after three port incisions were made in the same locations as for laparoscopic-assisted splenectomy mice. The incision was closed after 20 minutes in both groups. Ten days later, the mice were killed and inspected for abdominal wall tumor implants. The experiment was performed via two separate trials. RESULTS: When results of the two trials were combined, there was no significant difference in the incidence of animals in each group with at least 1 port tumor (open, 21 percent; laparoscopic-assisted splenectomy, 33 percent; P=0.14). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic-assisted splenectomy group than in the open group (20 vs. 7 percent; P=0.01). The subcostal incisional tumor recurrence rate was also higher in the laparoscopic-assisted splenectomy group (50 vs. 21 percent; P=0.02). as was the perioperative mortality rate (21 vs. 7 percent; P=0.08). Results of the two individual trials were also considered separately. The incidence of port wound tumors decreased significantly from the first to the second laparoscopic-assisted splenectomy trial (36 vs. 9 percent; P=0.003), although the incidence of tumors at the subcostal incision and the mortality rate for the two laparoscopic-assisted splenectomy group trials were not significantly different. The open group tumor incidences did not change from trial to trial. CONCLUSIONS: Overall, significantly more port and incisional tumors were noted in the laparoscopic-assisted group. Although not statistically significant, mortality rate of the laparoscopic-assisted group was higher than the open group. The reasons for these findings are unclear. Laparoscopic mobilization was quite difficult and required excessive splenic manipulation, which may have liberated tumor cells from the primary tumor and facilitated port tumor formation. With increased experience, less manipulation was required to complete mobilization. Of note, the incidence of port tumors in the laparoscopic-assisted splenectomy group decreased significantly from the first to the second trials; therefore, it is possible that surgical technique is a factor in port tumor formation. However, the persistently high tumor incidence at the subcostal incision site argues against the hypothesis that the second trial's laparoscopic mobilizations were less traumatic. The CO2 pneumoperitoneum may also be a factor. Further studies are warranted to clarify these issues.     

Anesthesia case of the month. Dystocia, cesarean section and acupuncture resuscitation of newborn kittens

OBJECTIVE: To assess the results of laparoscopic splenectomy as a treatment for immune thrombocytopenic purpura (ITP). MATERIAL AND METHODS: We conducted a retrospective study of all patients who underwent laparoscopic splenectomy for ITP at our institution between August 1992 and May 1997. RESULTS: Of 27 patients who underwent attempted laparoscopic splenectomy for ITP at our institution during the study period, 26 had completion of the procedure without conversion to an open splenectomy. The median postoperative hospital stay was 1.5 days, and no postoperative deaths occurred. In one patient, pancreatitis developed postoperatively. In four patients, splenectomy failed--two initially and two subsequently--and reinstitution of medical therapy was necessary. The other patients have remained free of medication, and 19 patients have platelet counts greater than 100 x 10(9)/L. The 3-year actuarial success rate was 81.5%. Response to corticosteroid therapy preoperatively may be an indicator of success of splenectomy. CONCLUSION: Laparoscopic splenectomy is safe and allows prompt recovery. Long-term response rates are similar to those achieved with open splenectomy.     

Pediatric laparoscopic splenectomy using the lateral approach

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.     

Optimizing laparoscopic splenectomy. Technical details and experience in 59 patients

BACKGROUND: Laparoscopic splenectomy (LS), like other advanced laparoscopic procedures, is still an evolving procedure. The indications for surgery, criteria for patient selection, and operative technique are not yet well defined. We have therefore modified the standard technique for performing LS in an attempt to optimize the procedure. METHODS: Over the past 2 years, we have performed LS in 59 patients. The last 43 patients were operated using a standardized technique that we believe to be optimal. It includes the routine use of the right lateral position, operating through three trocars, the mass transection of the splenic vasculature with a vascular endoscopic stapler, and the use of a self-retaining retrieval bag. RESULTS: The average operating time was 79 min. Average blood loss was 95 cc, and average postoperative hospitalization was 2.3 days. There was one intraoperative complication and one postoperative complication. These results are superior to those we achieved earlier in our own experience, as well as to similar series that have been published recently. CONCLUSIONS: In our experience, the use of this new technique resulted in relatively short procedures with low morbidity. We believe that these results justify the use of LS as the procedure of choice for elective splenectomy in patients with normal or moderately enlarged spleens.     

Laparoscopic splenectomy after arterial embolisation

Laparoscopic splenectomy remains a challenging procedure, as haemorrhage causes the most complications. In order to reduce this risk, preoperative selective embolisation of the splicing artery has been performed in a series of six successful laparoscopic splenectomies in one male and five female patients with a mean age of 34.6 years (range 17-53 yrs). Indications for surgery were immune thrombocytopenic purpura (ITP)(n = 3), non-Hodgkin lymphoma with secondary haemolytic anaemia (n = 1), autoimmune haemolytic anaemia (n = 1) and congenital spherocytosis (n = 1). The mean splenic length was 12.3 cm (range 9-16 cm) and no accessory spleens were identified. Mean operative time was 96.7 min (range 90-150 min). There were no deaths nor haemorrhagic or septic complications. Recovery after surgery was excellent with a mean hospital stay of 5.2 days (range 2-10 days). We conclude that selective embolisation of the splenic artery, just prior to laparoscopic splenectomy adds to the safety, and operating time may be shortened.     

Laparoscopic splenectomy. Technique and results in a series of 27 cases

Between early 1992 and December 1994, laparoscopic splenectomy was performed in 27 patients with idiopathic thrombocytopenia (ITP), hairy-cell leucemia, HIV, or Hodgkin's disease. In all cases medical treatment, especially cortisone therapy, failed. In Hodgkin's disease the splenectomy was combined with liver biopsies and dissection of parailiacal, paraaortic, and mesenteric lymph nodes for abdominal staging. The operation was performed using four trocars; the splenic vessels were divided by a linear stapler. In general the spleen was removed in a bag through a slightly enlarged trocar incision or after morcellation. Three patients needed a small laparotomy for the removal (laparoscopic assisted). In a recent case of Hodgkin's disease the intact spleen was removed via posterior colpotomy. In 22 of 27 cases (81%) the operation was finished laparoscopically. Five times a conversion to conventional laparotomy was necessary because of bleeding of enlarged lymph nodes at the hilum. Wound infections occurred in two cases. In one patient with ITP the platelet count did not improve and continuous blood loss led to relaparotomy at the 1st postoperative day. No surgical bleeding was found. All patients tolerated a fluid diet at the 1st postoperative day and hospitalization time was 4.4 days (range 3-14). Regarding the low complication rate and the advantages of a smaller abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy and laparoscopic abdominal staging has a substantial benefit for the patients.     

Open compared with laparoscopic approach to Burch colposuspension: a cost analysis

OBJECTIVE: To compare postoperative course and hospital charges of an open versus laparoscopic approach to Burch colposuspension for the treatment of genuine stress urinary incontinence. METHODS: A retrospective chart review was performed to identify all patients undergoing open or laparoscopic Burch colposuspension by the same surgeon over a 2-year period. Patients undergoing additional surgical procedures at the time of colposuspension were excluded from the study. Twenty-one patients underwent open Burch colposuspension and 17 patients underwent laparoscopic colposuspension. Demographic data including age, parity, height, and weight were collected for each group. Both groups also were compared with regard to operative time, operating room charges, estimated blood loss, intraoperative complications, change in postoperative hematocrit, time required to resume normal voiding, length of hospital stay, and total hospital charges. RESULTS: The laparoscopic colposuspension group had significantly longer operative times (110 versus 66 minutes, P < .01) and increased operating room charges ($3479 versus $2138, P < .001). There was no statistical difference in estimated blood loss or change in postoperative hematocrit between the two groups. No major intraoperative complications occurred in either group. Mean length of hospital stay was 1.3 days for the laparoscopic group and 2.1 days for the open group (P < .005). However, total hospital charges for the laparoscopic group were significantly higher ($4960 versus $4079, P < .01). CONCLUSION: Laparoscopic colposuspension has been described as a minimally invasive, cost-effective technique for the surgical correction of stress urinary incontinence. Although the laparoscopic approach was found to be associated with a reduction in length of hospital stay, it had significantly higher total hospital charges than the traditional open approach because of expenses associated with increased operative time and use of laparoscopic equipment.     

Laparoscopic pancreatic resection: Is it worthwhile?

A series of 23 patients who had undergone an attempted laparoscopic Whipple (n = 10) or laparoscopic distal pancreatectomy (n = 9) or laparoscopic enucleation (n = 4) since January 1992 were retrospectively reviewed. In the laparoscopic Whipple group (6 women and 4 men; mean age 71 [range 33 to 82] years), eight had malignant periampullary tumors and two had chronic pancreatitis. The rate of conversion to an open procedure was 40%, and complications were seen in the nonconverted group. The average operative time was 8.5 hours, and the hospital stay was 22.3 days. However, in the laparoscopic distal pancreatectomy and enucleation groups, there were seven women and six men (mean age 46.5 [range 27 to 75] years). Of these, nine patients had a planned laparoscopic distal pancreatectomy (8 for islet cell tumors and 1 for chronic pancreatitis) and four had a planned laparoscopic enucleation (all 4 for islet cell tumors). The conversion rate for these patients was 36%, and the mean operative time was 4.5 hours for laparoscopic distal pancreatectomy and 3 hours for laparoscopic enucleation. The hospital stay was 5 days and 4 days, respectively. Although this series was small, no benefit seemed to be derived from the use of a complete laparoscopic Whipple procedure. Laparoscopic distal pancreatectomy and enucleation were technically easier to perform and seemed to benefit patients by shortening their hospital stay with no recurrence of disease.     

Laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis: report of 11 cases

Pyloromyotomy remains the standard of care for the treatment of infantile hypertrophic pyloric stenosis. Open pyloromyotomy is effective and is the gold-standard technique. The authors report on the techniques of laparoscopic pyloromyotomy. The clinical courses of the first 11 infants treated with laparoscopic pyloromyotomy we with the courses of 14 infants treated recently with open pyloromyotomy. The average surgical time for the laparoscopic group was 25.4 minutes. The average time (postoperatively) until full feedings was 19.0 hours. In the open pyloromyotomy group the average surgical time was 26.1 minutes, and the time until full feedings was 23.2 hours. These results are not significantly different. When compared with open pyloromyotomy, the laparoscopic approach appears to be equally safe and effective, with superior cosmetic results. The authors believe that laparoscopic pyloromyotomy is an excellent alternative procedure for the management of hypertrophic pyloric stenosis.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.