Laparoscopy in the treatment of intussusception in children

PURPOSE: The technique and outcome of minimally invasive laparoscopic treatment of various forms of intussusception in children after ineffective attempt at conservative treatment are described. METHODS: Ninety-eight patients from 2 months to 11 years of age were analyzed. RESULTS: Suggested scheme of surgical treatment using laparoscopic technique was successful in 64 patients (65.3%), and conversion to open procedure occurred in 34 (34.7%). There was no mortality or intraoperative complications in our series. CONCLUSION: Practically every form of intussusception without bowel necrosis, including the most complex forms, can be reduced now using modern videolaparoscopic equipment and atraumatic instruments.     

Laparoscopic biopsy for suspected abdominal lymphoma

This study retrospectively reviewed the findings in laparoscopic biopsy specimens from 51 consecutive patients with suspected abdominal lymphoproliferative disorders. Histologic evaluation was supplemented (as necessary) by paraffin-section or frozen-section immunohistochemical analysis or by Southern blot hybridization. The laparoscopic procedure was diagnostic of a lymphoproliferative disorder in 24 patients (47%), of other neoplasms in 5 patients (10%), and of reactive tissue in 11 patients (22%); no tissue could be obtained for technical reasons (adhesions and inaccessible lesions) in 11 patients (22%). The 24 patients with lymphoproliferative disorders diagnosed by laparoscopic techniques included 14 patients with a new diagnosis of lymphoma and 10 patients with recurrent disease; pathologic findings were diagnostic of diffuse large cell lymphoma (11 patients), follicular lymphoma (11 patients), chronic lymphocytic leukemia (1 patient), and lymphocyte-predominant Hodgkin's disease (1 patient). Previous abdominal cytologic or core-needle biopsy specimens from 11 lymphoma patients did not yield an unequivocal diagnosis or subtype of lymphoma. The 11 patients (22%) in whom laparoscopic techniques did not produce a tissue sample needed laparotomy (10 patients) or femoral lymph node biopsy (1 patient) to document the diagnosis of large cell lymphoma (2 patients), follicular lymphoma (5 patients), composite lymphoma (1 patient), myeloma (1 patient), neurofibroma (1 patient), and reactive lymph nodes (1 patient). In the majority of patients with suspected abdominal lymphoma, laparoscopic techniques provide sufficient tissue for the diagnosis and classification of lymphoma and for the diagnosis of other causes of abdominal lymphadenopathy.     

Laparoscopic rectum surgery in carcinoma]

Rectal cancer requires a special training in laparoscopic colorectal surgery because of its high requests in managing the operation. From August 1993 to March 1997, we performed 61 laparoscopic operations for rectal cancer in our hospital, 53 patients underwent a continence preserving resection and 8 patients a laparoscopic assisted abdominoperineal rectal exstirpation. 50 cases were curatively operated. In 11 patients only a palliative operation was feasible. The perioperative mortality was zero. Intra- and postoperative complications were seen in 7 cases (11.5%). Late complications were observed in another 6 patients (9.8%). 4 of the palliatively operated patients died in a median follow up of 17.5 months. After curative operation a tumor progression occurred in 6 patients (12%), 3 of them (6%) died within the follow up period. Our study demonstrates the feasibility of laparoscopic rectal cancer operations in any localization and with the same oncologic results as achieved with conventional approach.     

Management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy

The development of laparoscopic cholecystectomy has rekindled the issue of management of choledocholithiasis. A number of options exist including pre or postoperative endoscopic sphincterotomy (ERCP-ES), laparoscopic common duct exploration or open common duct exploration. We present here our experience with the management of choledocholithiasis in patients treated with laparoscopic cholecystectomy. From January 1991 to January 1995, 900 patients underwent laparoscopic cholecystectomy. 71 ERCP were carried out in 71 patients with suspicion or evidence of choledocholithiasis. Common duct stones were detected in 44 patients. Preoperative ERCP was done in 56 patients, with suspicion of choledocholithiasis, based on clinical, laboratory or ultrasonographic findings. 29 of these patients (51.7%) had common duct stones, that were successfully removed by endoscopic sphincterotomy. One patient suffered mild pancreatitis and a second one had transient hyperamylasemia. Postoperative ERCP was performed in 15 patients. Indications for ERCP were the evidence of common duct stones in intraoperative cholangiography in 7 cases, and clinical or laboratory suspicion of choledocholithiasis, 3 months to 3 years after laparoscopic cholecystectomy. Stones were detected in 100% of the patients. In 11 patients (73.3%), the stones were extracted by endoscopic sphincterotomy and 4 patients underwent open common duct exploration. Two patients had transient hyperamylasemia. ERCP is a safe and effective method for detection and treatment of common duct stones. ERCP prior to laparoscopic cholecystectomy in patients suspected of having choledocholithiasis, is safe and offers with good results. Rutinary intraoperative cholangiography is recommended, for the detection of unsuspected choledocholithiasis and as an effective treatment (postoperative-ERCP, open or laparoscopic common duct exploration) can be chosen depending on surgeon's skills and patient's characteristics.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Sudden hearing loss and uveitis as a form of presentation of neurosarcoidosis

BACKGROUND: The pathologies and size of adrenal lesions removed through the open posterior and laparoscopic routes share remarkable similarities. This study aims at comparing the relative merits of these two approaches. METHODS: Patients with adrenal tumors operated on by posterior approach (n = 56) and transabdominal laparoscopic approach (n = 12) between January 1981 and May 1997 were retrospectively reviewed. RESULTS: The two groups were comparable in terms of age, and the position, size, and weight of the tumor. The operative time of posterior adrenalectomy was significantly shorter than that of laparoscopic adrenalectomy (median 120 minutes versus 160 minutes), whereas laparoscopic adrenalectomy was associated with less parenteral analgesic requirement (median 0 mg versus 225 mg), a shorter hospital stay (median 3 days versus 5 days), and a shorter duration off work (median 11 days versus 26 days). The estimated blood loss was also significantly reduced in the laparoscopic group (median 50 mL versus 150 mL). CONCLUSIONS: Laparoscopic adrenalectomy is replacing posterior adrenalectomy to become the procedure of choice for the majority of patients undergoing adrenalectomy.     

Laparoscopic fundoplication in infants and children

BACKGROUND: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. METHODS: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. RESULTS: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). CONCLUSION: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication.     

Is laparoscopic surgical practice "factual" (evidence based)? Results of a prospective regional survey

OBJECTIVE: Evidence-based medicine is a growing paradigm in health care. We conducted a prospective study to determine whether laparoscopic surgery is truly evidence-based in everyday practice. METHODS: A prospective regional survey was performed in 11 French hospitals (one university and 10 district hospitals) to ascertain how general laparoscopic surgery was conducted during the last 3 months of 1997. We also searched the electronic databases for original articles on laparoscopic procedures. The methodology of randomized trials was analyzed and procedures were classed by level of evidence. We assumed that an evidence-based procedure was which had been validated by well-designed randomized controlled or prospective trials giving homogeneous results. RESULTS: One half of the procedures performed had been evaluated by randomized controlled trials. Among the 428 laparoscopic procedures, 334 (78%) were found to be evidence-based (CI 74.1-81.9%). Twelve of the 18 indications for laparoscopy (67%) were evidence based (CI: 62.5%-71.5). There was no difference between university teaching hospitals and general district hospitals. CONCLUSION: Contrary to initial criticisms, the practice of laparoscopic surgery appears to be truly evidence-based in the majority of cases.     

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.     

Effects of carbon dioxide pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy on body weight and tumor growth

BACKGROUND: The oncologic consequences of intraperitoneal carbon dioxide (CO2) insufflation during the laparoscopic resection of cancer are under debate. The effect of other insufflating gases or gasless laparoscopy on cancer requires study. OBJECTIVE: To study body weight and tumor growth in rats after CO2 pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy. METHODS: On day 1, an 8-mg bolus of ROS-1 tumor was placed under the renal capsule of both kidneys in rats. In experiment A, rats had either CO2 insufflation (n=10) or a gasless laparoscopic bowel resection (n=10) on day 3 and were humanely killed after 7 days. In experiment B, rats had either a laparoscopic bowel resection with CO2 insufflation (n=11) or insufflation with air (n=11) on day 3 and were killed after 7 days. In both experiments, postoperative weight loss and tumor growth were measured, and the differences were tested with an analysis of covariance. RESULTS: Renal subcapsular tumor growth in the group having gasless laparoscopy was less than that in the group having CO2 pneumoperitoneum (P=.04). Postoperative weight loss in these groups showed no differences (P=.55). No differences in tumor growth or weight loss were found between rats having insufflation with CO2 and those having insufflation with air (P=.61 and P=.68, respectively). CONCLUSIONS: The restoration of body weight after a laparoscopic surgical procedure was similar with CO2, air, or gasless laparoscopy. Gasless laparoscopy was associated with less renal subcapsular tumor growth than was insufflation with CO2. Therefore, the application of gasless techniques in laparoscopic oncologic surgical treatment demands further study.     

Ventilatory response to severe acute hypoxia in guinea-pigs and rats with high hemoglobin-oxygen affinity induced by cyanate

Laparoscopic pelvic lymph node dissection has been applied as a minimally invasive staging technique for men with prostate cancer. This procedure has been shown to shorten markedly postoperative hospitalization, decrease analgesic requirements and shorten convalescence period compared to open pelvic node dissection. However, the laparoscopic procedure takes longer to perform and many disposable instruments are used, thus increasing the cost. We determine the overall cost of laparoscopic versus open pelvic lymph node dissection. Between January 1989 and April 1992, 61 men underwent only staging pelvic lymph node dissection for cancer of the prostate at a single university teaching hospital. Of these patients 11 and 50 underwent open and laparoscopic pelvic lymph node dissection, respectively. Information from the hospital business office was reorganized into preoperative, intraoperative and postoperative expenses. All individual charges were transformed up or down to the dollar amounts of the 1990 to 1991 fiscal year so as to correct for inflationary changes. Preoperative costs were not significantly different between the 2 operative approaches. Intraoperative expenses were 52% greater if laparoscopic pelvic lymph node dissection was performed and can be explained by the longer operative times and use of disposable instrumentation. However, the postoperative period lasted an average of 1.61 days following laparoscopic pelvic lymph node dissection. Postoperative nursing and analgesic requirements were significantly more for patients undergoing open pelvic lymph node dissection. The overall postoperative costs following open pelvic lymph node dissection were 280% more expensive than for the laparoscopic procedure. The overall total costs were approximately $1,250 more for laparoscopic pelvic lymph node dissection. Wages lost or earned during this period and rapid return to normal activity following laparoscopic pelvic lymph node dissection would, in our opinion, justify this additional cost.     

Interictal SPECT with Tc-99m HMPAO studies in migraine patients

BACKGROUND: Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy. OBJECTIVES: The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group. METHODS: Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented. RESULTS: Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7 vs. 89.9 mg; P < 0.01), an earlier tolerance of both liquid (mean, 2.1 vs. 3.7 days; P < 0.01) and solid diets (mean, 3.6 vs. 5.5 days; P < 0.001), and an earlier time to passage of both flatus (mean, 2.2 vs. 3.6 days; P < 0.001) and feces (mean, 3.7 vs. 5.6 days; P < 0.001). Operating time was longer for the laparoscopic group (mean, 176 vs. 104 minutes; P < 0.001), whereas median time to discharge from hospital was shorter (median, 8 vs. 11 days; P = 0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients. CONCLUSIONS: In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.     

Analysis of the effectiveness of an endoscopy education program in improving residents' laparoscopic skills

OBJECTIVE: To evaluate the effectiveness of a gynecologic endoscopy education program in enhancing residents' proficiency in laparoscopic surgery. METHODS: The program was designed to provide residents with the knowledge and skills necessary for laparoscopic surgery, before entering the operating room, in a cost-effective manner that honored the principles of adult education. The 7-week program included didactic sessions to provide conceptual learning but focused on practical skills enhancement through practice in both pelvic trainer and animal laboratory settings. The program design included dominant, nondominant, and two-handed skills as well as models for laparoscopic dissection, hemostasis, and suturing. The evaluation of the program is based on timing of laparoscopic skills as well as resident and faculty evaluation of laparoscopic proficiency at the beginning and end of the program. RESULTS: Prior to the program, 48% of residents and 75% of faculty were satisfied with laparoscopic training. All residents improved operating times in pelvic trainer skills after the program, with first-year residents improving by 68%, third-year residents by 58%, and fourth-year residents by 72%. The residents self-assessment of competence in 14 laparoscopic skills revealed an increase in all skills following the program. The faculty assessment showed an upward trend in skills competence. At the conclusion of the program, 100% of residents and 92% of faculty were satisfied with the laparoscopic training. CONCLUSION: A structured program emphasizing skills enhancement is an effective approach to improve residents' performance in laparoscopic surgery.     

Comparison of laparoscopic and open nephroureterectomy for benign disease

PURPOSE: We report our experience with laparoscopic nephroureterectomy for benign disease and compare the results to a contemporary group of patients undergoing open nephroureterectomy. MATERIALS AND METHODS: Between October 1994 and March 1997, 12 women and 4 men with a mean age of 50 years (range 22 to 70) underwent laparoscopic nephroureterectomy at our hospital. Indications for operation were nonfunctioning kidneys due to vesicoureteral reflux with recurrent episodes of pyelonephritis or analgesic nephropathy before a planned renal transplantation. In comparison 11 women and 4 men with a mean age of 40 years (range 18 to 64) underwent open nephroureterectomy for various benign diseases. RESULTS: Laparoscopic and open nephroureterectomy had no significant differences regarding operative times (100 versus 124 minutes) and complication rates (25 versus 20%). In the laparoscopy group conversion to open surgery was not necessary. Patients who underwent laparoscopic nephroureterectomy had significantly less consumption of morphine equivalent for postoperative pain control (12 versus 40 mg.), shorter time to achieve mobilization and oral intake (11 versus 39 hours), shorter hospital stay (6 versus 12.7 days) and faster return to normal activities (21 versus 39 days). CONCLUSIONS: Laparoscopic nephroureterectomy in patients with benign disease has similar operative results but obvious postoperative advantages compared to the open approach.     

Laparoscopy as a cause of a false-positive Meckel's scan

A new cause of a false-positive result of a Meckel's scan is reported. An 11-year-old girl had a 3-week history of constant right lower quadrant pain that was initially managed by laparoscopic appendectomy. A repeated laparoscopy for persistent pain was nondiagnostic. A missed Meckel's diverticulum was considered as the cause of this pain, which prompted a Meckel scan. This scan revealed a periumbilical focus of activity that was interpreted as a Meckel's diverticulum attached to the anterior abdominal wall by a band. The laparotomy showed no Meckel's diverticulum. The false-positive result of the Meckel scan may be the result of inflammation from the periumbilical laparoscopic port site.     

The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies

Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.     

Blockade of morphine-induced place preference by diazepam in mice

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.     

Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy

Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux and a large (>==8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (<==11 months) the patients are doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement of the repair with PTFE mesh.     

Initial experiences and outcome of gasless laparoscopic pelvic lymph node excision combined with Schauta vaginal radical hysterectomy in stage IB cervix carcinoma

In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.