Endoscopic variceal ligation in the management of gastroesophageal varices in postoperative biliary atresia

BACKGROUND/PURPOSE: Gastroesophageal variceal bleeding is a serious and difficult problem in the long-term management of biliary atresia (BA). Recently, endoscopic approaches have been attempted to manage this problem. The authors have attempted endoscopic variceal ligation (EVL), a less invasive procedure than endoscopic sclerotherapy. METHODS: In the past 5 years, 66 EVL procedures using standard flexible endoscope with a diameter of 9 mm (type p-30, XQ200, or XQ240; Olympus, Tokyo, Japan) were performed in 30 separate sessions on 11 postoperative BA patients. The mean age of the children was 7.8 (range, 3 to 15) years. The EVL device was a small elastic O-ring or a loop ligator. RESULTS: EVL was performed for emergency hemostasis in two patients and prophylaxis for impending rupture in nine with large, blue varices, or with red spots on the variceal surface. During the initial procedure, all varices were ligated successfully, and reduction in size was noted. Of eight patients who were examined 7 to 14 days after treatment, seven (87.5%) had improved. Eight of 11 patients (72.7%) were finally cured or at least had improved after one to seven sessions of EVL. However, three patients did not show improvement after four to seven sessions because of the reappearance of the varices, development of distal lesions such as gastric varices, and acute gastric mucosal lesions. A technical complication encountered was a slippage of the O-ring in one patient. A technical difficulty was seen in ligating the giant gastric varix in one patient. There was no deterioration of liver function induced by EVL in this entire series. CONCLUSIONS: EVL is an effective and feasible treatment of gastroesophageal varices in postoperative BA patients. However, reappearance or reactivation of the varices or emergence of the more distal lesions is likely to occur even after repeated EVL.     

The Saeed Six-Shooter: a prospective study of a new endoscopic multiple rubber-band ligator for the treatment of varices

BACKGROUND AND STUDY AIMS: Rubber-band ligation is superior to sclerotherapy, and is considered to be the endoscopic treatment of choice for bleeding varices. The single-shot mechanism of the ligation device generally used is inherently inefficient, and makes the procedure tedious. It also requires overtube placement, associated with discomfort and complications. This study describes the Saeed Six-Shooter, a multiple ligation device. PATIENTS AND METHODS: Twenty-seven consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 7-10 days. The parameters studied were the ease of use, the ability to control active bleeding and eradicate varices, survival, and complications. RESULTS: Active bleeding was controlled in all seven (100%) patients. Esophageal varices were eradicated in 70% (3.2 +/- 1.2 sessions), and gastric varices in 88% of patients (2 +/- 1.2 sessions). Five patients re-bled, two from esophageal varices, two from gastric varices, and one from treatment-induced ulcer. There were four deaths, none due to exsanguination. A single complication, esophageal stricture, resolved with balloon dilation. Intubation was no more difficult with the endoscope loaded with the Six-Shooter than with the endoscope alone (P > 0.3). Six ligations were performed in 39% of cases within 60 seconds, and in 74% of cases within 90 seconds. For gastric varices, the device was effectively used with the endoscope retroflexed. CONCLUSIONS: The Saeed Six-Shooter is a safe and efficient instrument for the endoscopic ligation of varices, and has overcome the limitations of the single-shot ligator.     

Alteration of serotonergic innervation in the suprachiasmatic nucleus of the rat following removal of input fibers from retina and lateral geniculate nucleus

We report the results of sclerotherapy in 20 patients with bleeding gastric varices due to hepatic schistosomiasis. In an endemic area, patients with hepatic schistosomiasis, and bleeding gastric varices seen on endoscopy to be inferior extension of esophageal varices, were treated with emergency endoscopic injection just proximal to the cardia. Hemostasis was achieved in 17. Obliteration of varices was achieved in all patients with sclerotherapy, combined with surgery. Thirteen patients who had not been operated on in the past and consented to surgery underwent esophagogastric devascularization with splenectomy. Surgery was carried out as an emergency in the three patients who did not respond to sclerotherapy and electively in 10 patients after control of bleeding. After surgery, sclerotherapy was required for remnant varices. One patient with Child-Pugh grade C cirrhosis died of hepatic encephalopathy after control of the bleed. During a median follow-up of 9 months (range, 1-25 months), recurrence of bleeding in one patient and recurrent varices in two others were controlled with sclerotherapy. One patient had a fatal hemorrhage at home. We conclude that sclerotherapy effectively controls acutely bleeding type 1 gastric varices. Combined with esophagogastric devascularization and splenectomy, long-term results may be encouraging in patients with hepatic schistosomiasis.     

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.     

The effect of Gynostemma pentaphyllum mak (GP) on carcinogenesis of the golden hamster cheek pouch induced by DMBA]

AIM: of this study is to compare two similar groups presenting inguinal herniae, one group having laparoscopic herniography and the other having a Bassini or Fruchaud repair. METHOD: Since September 1994, in our department, patients presenting with symptoms of unilateral or bilateral inguinal herniae to our practice were offered the transperitoneal or preperitoneal approach as an alternative of open surgical repair. We considered the first 50 patients operated by laparoscopic technic (35 M and 15 F), age between 22-72 years (group A), and similar group operated by Bassini or Fruchaud technic (group B). All the patients had general anesthesia and perioperative antibiotics. In the group A we used Prolene, Mercilene or Plastex mesh. The following parameters were assessed: 1) operative time from incision to closure: 2) amount and type of analgesia required postoperatively; 3) morbidity related to the procedure; 4) interval before returning to full activity; 5) early recurrence rate; 6) hospital cost. RESULTS: The mean operative time for unilateral herniae in group A was 70 +/- 10 minutes versus 40 +/- 12 minutes in group B. Group A required to return to work was significantly shorter for the patients in group A (7 +/- 3 days) compared with group B patients (25 +/- 10 days). Although no recurrent herniae have yet been found in patients from either group; follow-up was only 2-18 months in the two groups. The cost of hospital care of group A patients exceeded that of group B by approximately 1.7 more. IN CONCLUSION: was consider that although is more expensive, the laparoscopic procedure in treatment of inguinal herniae, has more benefits for the patients.     

Cervical spinal cord compression caused by ossification of the posterior vertebral ligament. Apropos of a case

In eight Japanese patients, three different laparoscopic procedures were used to excise an early gastric carcinoma; partial resection in four, intragastric resection of the gastric mucosa in two, and laparoscopic-assisted distal partial gastrectomy with the abdominal wall-elevating method in two patients. Histological examinations revealed that the lesions were completely resected, and there was no evidence of lymphatic metastasis. The operation time ranged from 2 to 4 h. These forms of laparoscopic gastric surgery for patients with early gastric carcinomas may be useful from the standpoint of minimal access, rapid recovery, less pain, and good cosmesis.     

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.     

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.     

Sex and test verification bias. Impact on the diagnostic value of exercise echocardiography

This trial represents the Egyptian experience in cyanoacrylate injection for hemostasis of bleeding gastric varices. One hundred patients with portal hypertension due to schistosomal hepatic fibrosis and/or posthepatitic liver cirrhosis were included. All patients presented with bleeding from gastric varices either fundal (80 patients) or inferior extension of esophageal varices (20 patients) were enrolled. Injection therapy was administered as the first active measure. No tamponade or drugs were used. Cyanoacrylate was mixed with lipid and injected through a hand-made probe. A mean of 3 (range 1-9) ampoules of cyanoacrylate were used per injection session. Bleeding stopped at the end of all sessions. Ten patients (12.5%) with fundal varices had rebleeding during the first 24 hours. Reinjection could control bleeding in 6 patients with a total success rate of 95%. Four patients were managed surgically. Fatal pulmonary embolism developed in one patient (1.25%) with fundal varix. Five more patients (6.25%) died from bleeding-related liver failure. In conclusion, injection of cyanoacrylate is highly satisfactory in controlling bleeding from both types of gastric varices.     

Treatment of hemorrhages by rupture of cardio-tuberous varices with transjugular intrahepatic portasystemic shunt

Twelve consecutive patients admitted for bleeding from ruptured gastric varices were treated with transjugular intrahepatic portosystemic shunts and followed for a mean of 6 +/- 3 months (range: 8-293 days). The shunt was performed successfully in all 12 patients. The shunt occluded in 3 patients (respectively 19, 101 and 103 days after insertion) of whom one remained asymptomatic and two experienced rebleeding. Four patients presented with acute encephalopathy, spontaneously in two and after rebleeding in two. Three patients died, two after rebleeding and one of septic shock secondary to pneumonia. Overall, 9 patients survived a mean of 211 +/- 92 days with no rebleeding, 8 of whom have not yet experienced any complications. These results suggest that transjugular intrahepatic portosystemic shunts could be useful in treating hemorrhages from ruptured gastric varices and in preventing their recurrence.     

Laparoscopic adjustable gastric banding

We introduced open adjustable silicone gastric banding (ASGB) for treatment of morbid obesity in our institution in 1991. It was done in a prospective study comparing ASGB with vertical banded gastroplasty (VBG) with regard to weight loss. After 200 cases of open ASGB and 210 VBG procedures and the encouraging weight loss results, we started laparoscopic placement of the adjustable silicone band. The initial work was done in an animal laboratory program where a new surgical protocol has been established. Details of the laparoscopic dissection around the stomach in a deep operative field and fatty atmosphere have been developed, and a laparoscopically implantable version of the adjustable silicone band (LAGB) has been devised. The first human laparoscopic ASGB procedure was performed in our institution on September 1, 1993. Altogether 350 patients had undergone adjustable silicone gastric banding (LASGB) procedures by May 1997 (277 women, 73 men). All the patients were morbidly obese, with an average preoperative weight of 118 kg (92-200 kg). The mean BMI was 43 kg/m2 (36-65 kg/m2). The conversion rate to laparotomy has been low (1.4%). Early complications have been rare, and pouch dilatation and stomach slippage have been the only significant late complications. The rate of these complications has been considerably improved by reducing the pouch volume and using more gastrogastric sutures. Evaluation of postoperative weight loss of LASGB patients compared with our VBG and ASGB (open) patients showed a similar curve.     

Assessing children''s emotional stress in scores from the total pneumographic data

Laparoscopic assisted vaginal hysterectomy (LAVH) is a rather new operative procedure in Denmark. During the period 1.12.1992-28.02.1993 we performed ten LAVH. The procedure is described. The operations were performed with bipolar coagulation and subsequent cutting with scissors. The average operating time was two hours. The average uterine weight was 130 g and total average hospital stay was two 2.8 days. In one patient laparotomy had to be performed due to arterial bleeding close to the right ureter. One patient developed a postoperative haematoma with temporary stasis of the right ureter. Both patients recovered. Adequate laparoscopic training in humans and animals is mandatory before LAVH is performed. In the learning phase it is advisable that the uterine size does not exceed 200 g.     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).     

Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding

BACKGROUND: Operation is required for patients with portal hypertension who have failed to respond to emergency sclerotherapy for control of acute variceal bleeding. This study evaluates the role of transabdominal extensive oesophagogastric devascularization combined with gastro-oesophageal stapling for control of acute variceal bleeding in patients with portal hypertension of different aetiologies. METHODS: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling was performed in 65 patients (28 with cirrhosis, 17 with non-cirrhotic portal fibrosis and 20 with extrahepatic portal venous obstruction) in whom emergency endoscopic sclerotherapy, and/or pharmacotherapy and balloon tamponade had failed. The Sugiura procedure was modified to minimize operating time and to reduce the operative difficulties due to oesophageal wall necrosis after sclerotherapy. RESULTS: The operative mortality rate was higher in patients with cirrhosis (P = 0.0003); sepsis was the leading cause of death (in nine of 18). A high mortality rate (12 of 15) was seen in patients with Child grade C cirrhosis. Control of bleeding was achieved in all patients. The procedure-related complication rate was 17 per cent with a 6 per cent oesophageal leak rate; four of 47 surviving patients developed oesophageal stricture. During a mean follow-up of 33 months, residual varices, recurrent varices and rebleeding were seen in three, two and three of 47 survivors. CONCLUSION: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling is an effective and safe procedure for control of acute variceal haemorrhage with satisfactory long-term control, especially in patients without cirrhosis and low-risk patients with cirrhosis.     

MR imaging in the evaluation of the therapeutic effect of B-RTO for gastric varices

BACKGROUNDS/AIMS: Balloon-occluded retrograde transvenous obliteration (B-RTO) has become a new treatment option for gastric varices. In the present study, mid-term follow-up data after B-RTO were presented, and the role of magnetic resonance imaging (MRI) and MR-portography in the assessment of therapeutic effect was evaluated. METHODOLOGY: Twelve patients with gastric varices were treated with up to three sessions of B-RTO. The patients were followed up with MRI, MR-portography, and endoscopy for a mean of 12.3 months. RESULTS: In ten patients, one (n = 8) or two (n = 2) sessions of B-RTO were effective to produce immediate (< 2 weeks) variceal obliteration on MRI and MR-portography. Endoscopic confirmation of variceal eradication was obtained within three (n = 9) or six (n = 1) months after B-RTO in these patients. The remaining two patients who underwent three sessions of B-RTO showed only a significant reduction in variceal size immediately after B-RTO, but variceal obliteration was observed within three months with subsequent variceal eradication. There were no signs of exacerbation of gastric varices on MRI and endoscopy in any patient during the follow-up period. CONCLUSIONS: The results suggest that B-RTO is effective for the treatment of gastric varices. MRI and MR-portography may provide accurate assessment of therapeutic effect.     

Laparoscopic adrenalectomy

Between June and September 1993, laparoscopic adrenalectomy was indicated in five patients (three women, two men; aged 25-50 years). Three had a phaeochromocytoma, two had an adenoma (Conn's syndrome). Four of the five tumours were localized to the right adrenal gland, one to the left. Tumour diameter ranged from 3 to 5 cm. The laparoscopic procedure was successful in four of the patients (three right, one left). In the fifth case the operations had to be completed by conventional surgery, because of non-controllable haemorrhage. Duration of operation ranged between 165 and 360 min for right adrenalectomy and was 135 min for the left one. Rapid convalescence, lower dose of pain-killing drug required, short hospital stay and good cosmetic results characterized the postoperative course after the laparoscopic procedure. This technique thus opens up new perspectives for adrenal surgery.     

Transthoraco-phrenic esophageal transection with paraesophago-gastric devascularization and splenectomy using a stapler

BACKGROUND/AIMS: Surgery remains the most reliable treatment for bleeding esophageal varices. The aim of this study was to introduce the operative technique of transthoraco-phrenic esophageal transection with paraesophagogastric devascularization using a stapler and to evaluate surgical results. METHODS: Forty-five patients underwent the procedure; an elective procedure was performed in 22 patients (bleeders) and a prophylactic procedure in 23 patients (nonbleeders). Twenty-nine patients were classified as Child's A, 15 as B and 1 as C. Previous sclerotherapy had been performed in 5 patients. RESULTS: No hospital deaths occurred. No patients developed postoperative anastomotic leakage, encephalopathy, or any complications related to phrenicotomy. Three patients bled postoperatively from recurrent esophageal varices. Cumulative 5-year bleeding rates were 5.0% in bleeders and 6.6% in non-bleeders. Two patients died due to bleeding varices. Cumulative 5-year survival rates were 72.1% and 78.8% in patients classified as Child's A and Child's B, respectively. CONCLUSIONS: This procedure may be indicated for a majority of Child's A or B patients. Although the advantages of this procedure must be evaluated further, it may be an alternative when injection sclerotherapy and endoscopic ligation fail.     

Mesocaval H shunt using an external iliac graft in the treatment of portal hypertension in children

The authors reported four cases of mesocaval interposition shunt in children with autogenous vein graft. In three cases, external iliac vein was used as the graft because its appropriate size in diameter and length; for local reasons, jugular graft was used in last case. Post-operative controls by angiography in all patients except the one recent case showed a patent anastomosis; esophago gastric endoscopy three month post operatively in the last case showed regression of varices. External iliac vein is convenient to this shunt. Edema of the lower limb is minimal and well tolerated. The control of hypersplenism and esophogastric varices is progressive with time.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Comparative experience of a simple technique for laparoscopic chronic ambulatory peritoneal dialysis catheter placement

BACKGROUND: Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. METHODS: A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. RESULTS: Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P = 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P = 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient's death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). CONCLUSIONS: This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.