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.     

Laparoscopic cholecystectomy

Traditional cholecystectomy has been the standard surgical treatment of the gallstone disease for more than 100 years. The technical development led to a new surgical procedure and its rapid acceptance. This is laparoscopic cholecystectomy. Its application is becoming widespread in therapy too. But most of the surgeons are lack of technical experiences in this field. Currently it restricts the indications those are anyway the same of standard cholecystectomy. Besides its many advantages, laparoscopic cholecystectomy has its own disadvantages and being an invasive procedure, there are possibilities of complications. The latest can be reduced by the adequate choice of patients, the careful learning of the operative technic and by turning to open surgery (conversion) when it is necessary. Its morbidity is nearly equal to complications of standard cholecystectomy, but mortality rate is lower (0.05-0.2%). Our morbidity of performed 300 laparoscopic cholecystectomies was 6.4%. We had no death. The hospitalization became as short as 4 days. Our early clinical results (90%) are the same of traditional cholecystectomy. Laparoscopic cholecystectomy as a new surgical procedure involves the efficiency of the standard cholecystectomy and the noninvasive endoscopic technic. Laparoscopic cholecystectomy performed by well trained surgeons is a safe surgical procedure, its early results are excellent and makes the choice of surgical treatment, used in bile surgery richer.     

Guidelines to determine the route of oophorectomy with hysterectomy

OBJECTIVES: Our purpose was to determine whether there is adequate visibility and access for transvaginal oophorectomy in most patients and the success rate of the transvaginal approach. The final goal was to establish objective guidelines for choosing the route of oophorectomy with hysterectomy. STUDY DESIGN: Patients underwent laparoscopy-assisted vaginal hysterectomy (n = 91) or vaginal hysterectomy (n = 875). Ovarian removal, either unilateral (n = 97) or bilateral (n = 187), was carried out for clinical or prophylactic reasons. The accessibility of the ovaries for transvaginal removal was assessed by stretching the infundibulopelvic ligament and grading the position of the ovaries from 0 (no descent) to III (descent past the hymenal ring with traction). RESULTS: In 158 patients transvaginal bilateral oophorectomy was performed without laparoscopic assistance. In another 29 patients bilateral transvaginal oophorectomy was performed with laparoscopy-assisted vaginal hysterectomy, and prophylactic bilateral oophorectomy by the transvaginal route was successful in all but 1 of 143 patients with ovaries of grade I or higher. In 20 patients laparoscopic lysis of adhesions was necessary to permit transvaginal oophorectomy. Ninety-seven patients underwent transvaginal unilateral oophorectomy, 74 with conventional vaginal hysterectomy and 23 with laparoscopy-assisted vaginal hysterectomy. Among the patients not having oophorectomy, all ovaries had sufficient mobility to have been removed transvaginally. CONCLUSION: Good surgical practice dictates that visibility and accessibility be the primary criteria for selecting the route of oophorectomy with hysterectomy. In most patients the ovaries are visible and accessible to transvaginal removal.     

Carcinoid of the gallbladder. A report of a clinical case treated by video laparoscopic cholecystectomy

The authors report a clinical case of the gallbladder carcinoid tumour treated with laparoscopic cholecystectomy. After a short analysis of the classification, the malignant potentiality and the symptoms of gallbladder carcinoids, they conclude that it is possible to treat carcinoids with laparoscopic cholecystectomy, but only in some selected cases, that is to say in the absence of factors indicative of local invasion and that in the other cases it is preferable the classic surgical treatment of laparotomic resection.     

Laparoscopically extended hysterectomy for cervix cancer: technique, indications and results. Apropos of a series of 41 cases in Clermont

We report a study of 41 radical hysterectomies performed through laparoscopic approach for carcinoma of the cervix uteri. According to the FIGO staging, the tumors were classified as 12 stages Ia2, 24 stages Ib, 4 stages IIa and 1 stage IIb. 17 patients were treated by exclusive surgical procedure. 24 patients received a combination of radiation therapy and surgery 2 patients had a tumor of the cervical stump after subtotal hysterectomy. The mean duration of the procedure was 270 minutes. The post-op stay was 6.5 days. There was no major operative and postoperative complication. Only one patient required a blood transfusion. The intravenous pyelogram control was correct in all cases. At this time, with a 4 to 76 months follow-up, no recurrence was observed. This experience suggests the faisability of the laparoscopic radical hysterectomy. This approach seems to be convenient in young and non obese women with a tumor less than 4 cm in the greatest diameter.     

Laparoscopic repair and groin hernia surgery

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.     

Endometrial ablation. A review of the technics and results

The authors make a careful examination of a very new surgical hysteroscopic technique, endometrial ablation, which is proposed as an alternative to hysterectomy in cases of persistent uterine bleeding not supported by endometrial atypia or adenocarcinoma. In addition to examining the indications for this type of surgery the authors also assess the state of the art of two techniques currently used: the laser technique and the method based on electroresection. The risks, benefits, collateral effects and results are evaluated for each method.     

An ultrasonic scalpel for laparoscopic gynecologic surgery

In order to obtain good results in laparoscopic surgery the surgeon should be well trained and experienced and the equipment perfect. The recent innovation in laparoscopic surgery is the ultrasonically activated scalpel. Scissors make the working part of scalpel with one hand vibrating 55,000 Hz in a second. The effect reflects in braking hydrogen links and denaturation of proteins in instant haemostasis and coagulation in blood vessels, and there is no need of tying them up. Practically, there is no damaging of the surrounding tissues. The technique is easy to use. When performing laparoscopic vaginal hysterectomy and adnexectomy the ligamentum infundibulopelvicum and ligamentum rotundum are cut, and there the blood vessels are not thicker than 3 millimeters. As these ligaments are easy to reach with ultrasonically activated scalpel, we can say that this instrument is the ideal option for laparoscopic vaginal hysterectomy.     

Is laparoscopic hysterectomy a waste of time?

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.     

A new uterine manipulator for operative laparoscopic hysterectomy

A new, reusable uterine manipulator was developed to facilitate pelviscopic surgery and laparoscopic hysterectomy. The device is weighted to hold the uterus in an anteverted position and allow easy access to the cul-de-sac. It is spring loaded to create a tight seal for tubal insufflation. The instrument is calibrated in centimeters and has a sliding cervical plug that allows it to be inserted into the fundus to a depth of 15 cm for uterine manipulation during laparoscopic hysterectomy. The spring-loading mechanism holds the device firmly to the cervical tenaculum regardless of the depth of penetration, and rotates 180 degrees for use in the retroverted uterus.     

A technique for laparoscopic completion of vaginal hysterectomy

Recently, the use of laparoscopic assistance in vaginal hysterectomy has become popular, although its role in gynecologic surgery has not been well established. A way to define this role is to start the hysterectomy vaginally and use laparoscopic assistance only if it becomes necessary. We present a new technique in which vaginal hysterectomy proceeds to the opening of the peritoneal reflections and ligature of uterine vessels and uterosacral ligaments. If laparoscopic assistance becomes necessary at this point, a uterine manipulator with an adapted inflatable balloon is inserted vaginally, allowing completion of the procedure laparoscopically while maintaining a pneumoperitoneum. Eight operations were performed successfully in our institution using this new technique. Operative time was less than with conventional laparoscopically assisted vaginal hysterectomy. The technique also simplified the management of the uterine vessels and detachment of the bladder.     

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.     

Treatment of intraosseous high flow arteriovenous malformation of the mandible by temporary segmental ostectomy for extracorporal tumour resection: a case report

The laparoscopic approach of the postoperative adhesions represents not only a way of diagnosing the pathogenic adhesions but also a superior alternative to the surgery of classical dissection of adhesions by laparotomy because of its obvious advantages: the evolution is simple, the bowel activity is quickly restored, the brief period of hospitalization, the reduced risk of recurrence. The authors present their experience derived from the 29 laparoscopic adhesiolysis; 3 urgent cases with subocclusions, 6 when rhe surgical intervention was programmed, with a painful postoperative suffering, and 20 with laparoscopic cholecystectomy. From among these cases, a conversion and a postoperative complication were recorded. The result after a period of time are satisfactory.     

Three major coronary artery-to-left ventricular shunts: report of three cases and review of literature

The gallbladder is perforated and stones are spilled more frequently during laparoscopic cholecystectomy than during open cholecystectomy. Recent reports have implicated spilled gallstones as a source of infrequent but serious complications of laparoscopic of laparoscopic cholecystectomy. They can cause serious morbidity, and in most cases the patient will require open surgery for management of these complications. The authors report the case of a patient who was ill for 14 months after laparoscopic cholecystectomy when spilled stones formed a nidus for intra-abdominal abscess and colocutaneous fistula. Every effort must be made to prevent gallbladder perforation. When it does occur, all stones should be retrieved. Attempts at repairing gallbladder perforations are often unsatisfactory. A simple solution to this potential problem is to retrieve all stones immediately, place them in an intraperitoneal specimen bag, and "park" the bag on the liver. As soon as the gallbladder is dissected off the liver it should be placed in the specimen bag with the stones and removed through the umbilical port opening.     

Surgery for gynecologic cancer

Surgery is an integral part of staging procedures for ovarian, endometrial, and vulvar cancers, with a move toward surgicopathologic rather than clinical staging in cervical cancer. Morbidity can be reduced without compromising patient cure by individualizing surgery for patients with early vulvar cancer, and reproductive potential can be maintained in some women with early ovarian cancer. The place of prophylactic oophorectomy and primary and secondary surgery in ovarian cancer remain controversial and await prospective study. Recent developments in laparoscopic techniques have been applied to a number of problems in gynecologic cancer surgery, and the feasibility of laparoscopic lymphadenectomy and radical pelvic surgery has been demonstrated. Care must be taken, however, to ensure that the tenets of surgical oncology are not sacrificed in order to offer minimal-access surgery to women with gynecologic cancer.     

Detection of codon 72 polymorphism of p53 gene from blood and loss of heterozygosity in brain tumors using polymerase chain reaction

We evaluated the efficacy of a new laparoscopic ultrasonic aspirator and applied it in gynecologic endoscopy. Two procedures were selected for preliminary evaluation of the instrument; ultrasonic aspiration for selective presacral neurectomies and total laparoscopic hysterectomy (TLH). The aspirator worked successfully in evacuating soft tissue and in adequately exposing the presacral plexus. In TLH we were able to skeletonize the broad ligament adventitia all the way to the level of the uterine arteries bilaterally, including exposure of the ureters. The time required for the procedures varied from case to case, and strongly depended on tissue type and on instruments used to dissect and improve visualization of the operative field. The aspirator may prove useful as an adjunctive in the surgical management of endometriosis, in laparoscopic lymphadenectomy, and in treating complex adhesions after further evaluation is completed.     

The postpubertal change in the playful defense of male rats depends upon neonatal exposure to gonadal hormones

Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.     

Urinary complications of the resectable cancers of the cervix uteri (author's transl)

The authors studied the urinary complications following 721 operations performed between 1960 and 1974 for cervix uterin carcinoma. The surgical method was the one used at the Fondation Curie according to the protocol of treatment. They have noted that: --first, the surgical act as primary treatment (672 cases) was innocuous, as this series showed only 0,6% of the severe complications; in contrast, when the surgery is performed for a recurrence after a total dose irradiation, the severe complications raised to 8%; --secondly, the uretero-hydronephroses following this type of surgery are relatively frequent on the systematic urograms, but most of them are quite asymptomatic and without later sequelae only 0,3% of them required a surgical treatment. The authors analyse the factors influencing the ureteral stenoses, especially the extent of lymphadenectomy and the associated external irradiation. They studied too the ureteral stenoses due to a local recurrence.     

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.