Laparoscopic Lin operation for the treatment of polycystic liver disease

Non parasitic hepatic cysts are a clinical entity that is often associated with polycystic kidney disease. We report the case of a 75 year-old woman who presented with symptomatic but non complicated polycystic liver disease. The treatment consisted of laparoscopic fenestration of a large simple cyst located in the left hepatic lobe. The postoperative course was uneventful and the patient remains free of symptoms at 18-months follow-up. Selected patients with symptomatic but uncomplicated polycystic liver disease and favourable anatomy benefit from laparoscopic fenestration of the cysts with low morbidity and hospital stay.     

Laparoscopic treatment of liver cysts

Symptomatic simple liver cysts should be treated. In this report we describe the results of a straightforward, well-tolerated laparoscopic operation for this condition. Between 1990 and 1996 we performed 19 laparoscopic liver cyst excisions. The exposed portion of the cyst wall was excised and a piece of omentum was secured into the remaining cyst cavity to prevent recurrence. The average age of the patients was 65 years (range 30 to 81 years). Eight patients (42%) had single simple cysts, nine patients (47%) had multiple simple cysts, and two patients (11%) had polycystic liver disease. Fifty-three percent of the patients had previous abdominal operations, 47% had undergone previous needle aspirations, and one had previously undergone unsuccessful laparoscopic cyst decompression elsewhere. The indications for surgery included abdominal pain, mass, early satiety, malaise, bloating, and shortness of breath. Two patients underwent concurrent cholecystectomies, and one patient underwent concurrent laparoscopic Nissen fundoplication. Follow-up, which averaged 32 months (range 3 to 68 months), is complete in all patients. There was one treatment failure among the patients with simple cysts. Both patients with polycystic liver disease have had recurrent symptoms. The laparoscopic approach to simple liver cysts is relatively straightforward, and if certain technical principles are adhered to, the success rate is very high.     

Laparoscopic cystectomy of the ovary; results of a new technique

The results of a prospective study of laparoscopic management of ovarian cysts are discussed. This technique of minimally invasive surgery was introduced at the department of Gynaecology of the Leiden University Medical Centre in 1991. Only premenopausal women with unilocular ovarian cysts smaller than 10 cm in diameter and with sonographically benign characteristics were included in this study. In a period of one year, 25 cystectomies and one ovariectomy were performed. 88% of the cysts were initially treated with hormone therapy. Mean age of the patients was 30 years (range: 21-54), average size of the cysts was 6 cm (range: 4-10) and mean operating time was 80 minutes (range: 35-120), there were no complications during operation or in the postoperative period. No laparotomies had to be performed. Three times (11.5%) pathological specimen examination revealed a corpus luteum cyst. The other 23 were non-functional cysts. No carcinoma was detected. The results of this minimally invasive surgery for removal of ovarian cysts are encouraging. Morbidity compared with the conventional cystectomy by laparotomy is low as appears from a shorter hospital stay and quicker recovery. Cystectomy of the ovary, compared with laparoscopic aspiration and fenestration, has a better therapeutic effect and the histological evaluation is more reliable. Persistent, unilocular ovarian cysts, which fulfill the criteria used in our study, are best treated by laparoscopic removal instead of laparotomy.     

The effect of the extent of A1 pulley release on the force required to flex the digits. A cadaver study on the thumb, middle and ring fingers

BACKGROUND: Laparoscopic management of cystic disease of the liver, including severe polycystic disease, is evolving. METHODS: Wide unroofing, or "fenestration," as is required for a successful result in open cases, leads to complete resolution of the cysts. This can even occur in chronic cysts, with wide-enough unroofing, given time. RESULTS: In polycystic disease, adequate fenestration of superficial, cysts allows deeper cysts to prolapse and be similarly fenestrated, thus reducing pressure effects on the liver and restoring normal function. CONCLUSION: However, because of the distortion of anatomy by this disease, it is important that an experienced liver surgeon perform such a complex procedure, as operative complications could be severe.     

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.     

Preoperative albendazole treatment for liver hydatid disease decreases the viability of the cyst

OBJECTIVE: Although in experimental models the efficacy of albendazole has been demonstrated, more clinical data are required. In this study, the effect of preoperative albendazole treatment was investigated in patients with liver hydatid cysts. DESIGN: This is a prospective non-randomized study. METHODS: In this study, the viability was assessed by the gross appearance of the cyst and intracystic pressure (ICP). The study consisted of 70 patients with 89 liver hydatid cysts in two groups. The patients in the first group (n = 29) received 10 mg/kg albendazole orally for 3 weeks before surgery. Thirty-five cysts were evaluated in this group. The second group (n = 41) with 54 liver hydatid cysts received no preoperative treatment. RESULTS: In the first group receiving preoperative albendazole, 20 cysts were viable and 15 non-viable. The median ICP was 21 (range 8-56) cm H2O in viable and 0 (range 0-8) cm H2O in non-viable cysts. In the second group, 43 cysts were viable and 11 non-viable. The median ICP was 35 (range 8-75) cm H2O in viable and 0 (range 0-2) cm H2O in non-viable cysts. The ICP values of viable cysts in the first group receiving preoperative albendazole were significantly lower (P < 0.05). The number of non-viable cysts was also significantly higher in the group treated with preoperative albendazole (P < 0.05). CONCLUSION: Albendazole in this study has proved to be effective in decreasing the viability of liver hydatid cysts when given for 3 weeks preoperatively.     

Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation

OBJECTIVE: To determine the long-term results of laparoscopic fenestration and coagulation of ovarian endometriomas and to compare them with the results of ovarian cystectomy performed by either laparotomy or laparoscopy. DESIGN: Case-control study. SETTING: Two university-affiliated hospitals. PATIENT(S): One hundred fifty-six premenopausal women with ovarian endometriomas of at least 3 cm in diameter (stage 3 and 4 endometriosis, revised American Fertility Society classification). INTERVENTION(S): Laparoscopic ovarian fenestration and coagulation (group 1, 80 patients); laparoscopic ovarian cystectomy (group 2, 23 patients); and ovarian cystectomy by laparotomy and microsurgical technique (group 3, 53 patients). MAIN OUTCOME MEASURE(S): Operative findings, recurrence rate, and cumulative clinical pregnancy rate (PR) over a 36-month follow-up period. RESULT(S): The mean (+/-SD) time to first pregnancy was significantly shorter in group 1 (1.4+/-0.2 years) than in group 2 (2.2+/-0.5 years) or group 3 (2.4+/-0.5 years). The difference between the cumulative clinical PR between the three groups was not statistically significant after 36 months of follow-up. The difference in the recurrence rate among groups 1, 2, and 3 was not statistically significant. CONCLUSION(S): Laparoscopic ovarian fenestration and coagulation of endometriomas leads to faster conception than ovarian cystectomy by laparotomy. Laparoscopic ovarian fenestration and coagulation of endometriomas is associated with cumulative clinical PRs and recurrence rates over 36 months that are similar to those associated with ovarian cystectomy.     

Expression, purification, reconstitution and inhibition of Ustilago maydis sterol 14 alpha-demethylase (CYP51; P450(14DM))

PURPOSE: To assess the efficacy of percutaneous embolization with an alcoholic solution of zein in the treatment of aneurysmal bone cysts. MATERIALS AND METHODS: Eighteen patients with aneurysmal bone cysts were treated percutaneously with alcoholic zein. The cysts were in the lower limb (n = 7), upper limb (n = 5), pelvis (n = 3), cervical spine (n = 2), and mandible (n = 1). All patients were symptomatic, three had previously undergone surgery. Percutaneous embolization was performed with fluoroscopic or computed tomographic guidance with the patient under general anesthesia. Clinical and imaging follow-up lasted 18 months to 4 years. RESULTS: Percutaneous embolization was performed in 16 cases. In two cases, cystograms showed marked venous drainage and thus embolization was not attempted. Six patients underwent repeat embolization. Complications consisted of a local transitory inflammatory reaction (n = 5), aseptic osteitis (n = 1), and a small pulmonary infarct without sequelae (n = 1). Relief of symptoms was achieved in all patients except one, who underwent surgery. At imaging, improvement was total in 13 cases (87%) and partial in two cases (13%). No recurrence was noted during follow-up. CONCLUSION: Percutaneous embolization of aneurysmal bone cysts with alcoholic zein should be considered a reliable alternative to surgery, especially in cases with a difficult surgical approach or cases of postsurgical recurrence.     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

BACKGROUND: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. METHODS: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p = ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. CONCLUSIONS: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.     

Histology and cytology of laparoscopically operated "simple ovarian cysts"

In a retrospective study the histopathological findings of 127 laparoscopically operated unilocular anechoic smooth-walled ovarian cysts have been correlated with clinical characteristics (age, duration of observation, complaints, hormonal treatment), size by ultrasound, kind and colour of cysts content as well as cytological findings. The age of patients differed from 16-61 years (mean +/- s: 36 +/- 16). The histopathologic findings yielded 15 (11.8%) functional cysts, 30 (23.6%) persistent corpus luteum cysts, 9 (7.1%) endometriomas, 7 (5.5%) cystic teratomas, 9 (7.1%) undifferenciated cysts and 57 (44.9%) cystadenomas. There were no differences between histopathologic diagnosis groups according to age and cysts size by ultrasound. Functional cysts with complaints (n = 6) may explain that the observation time in 60% of all functional cysts was smaller than 6 weeks, whereas persistent corpus luteum cysts, endometriomas, cystic teratoma and cystadenomas had been observed for longer than 6 weeks in more than two thirds. Intraoperative evaluation of cysts content as "chocolate"-like was suspicious of endometriomas, but was also present in cysts of other histopathological findings. By means of cytology, endometrioma (siderophages) was suspected in 44.4% and a cystadenoma in 42.1% of all histopathologically verified cases. In all, the cytologic findings were useful for correct histopathological diagnosis in only 33.9% of all 127 cases. It is concluded that differential diagnosis of simple ovarian cysts is not possible by clinical characteristics, neither by ultrasound nor by cytological evaluation. Ovarian cysts should be observed for at least two hormonal cycles. A hormonal treatment by combination preparations containing high doses of oestrogen is also recommended. In cases of persisting ovarian cysts laparoscopic removal is necessary.     

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.     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

BACKGROUND: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. METHODS: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). RESULTS: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases-i. e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. CONCLUSIONS: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy.     

Current therapy of coronary heart disease. Conservative measures

BACKGROUND: Intraperitoneal spillage of dermoid cyst content, if not followed immediately by abundant peritoneal lavage, can cause a chemical peritonitis with subsequent adhesion formation. STUDY DESIGN: We performed an open clinical study in a university hospital. Forty-four consecutive ovarian dermoid cysts were removed intact from 40 premenopausal women operated on between October 1993 and December 1997. The laparoscopic technique included: 1) creation of a cleavage plane between the cyst and the ovary; 2) dissection of the cyst by a combination of water, scissors, and gravity without direct traction on the cyst; and 3) extraction of the cyst after its placement inside a laparoscopic bag. RESULTS: The mean cyst diameter was 6.5 cm (range 3 to 12 cm). Mean operating time was 125 minutes (range 50 to 180 minutes). All patients were discharged within 48 hours. The cysts were dissected completely intact and were extracted without spillage in the abdominal cavity in all cases. Operative followup was available in 15 of the 40 patients; mild adhesions were found on the treated ovary in 3 (20%). CONCLUSIONS: It is always possible to prevent rupture and spillage of dermoid cysts during laparoscopic operations, but this approach is time consuming and needs expert surgical technique.     

Laparoscopic surgery of adrenal glands: indications and limits

Over the last four years it has been demonstrated that laparoscopy can be used successfully for adrenalectomy, providing certain advantages over conventional open surgery. The aim of this study was to determine the indications for laparoscopic approach in adrenal surgery. From June 1994 to June 1996 laparoscopic transabdominal flank approaches were proposed in patients with a unilateral 8 cm or less, non-malignant tumors of the adrenal gland. For tumors under 4 cm in diameter only secreting tumors were removed. Among 77 patients requiring ablation of the adrenal gland, 50 (65%) underwent a laparoscopic procedure: 29 Conn adenomas, 10 Cushing adenomas, 6 Pheochromocytomas, 4 incidentalomas. One patient had Cushing's disease and underwent bilateral resection. Mean tumor size was 26 mm (7-75 mm). Malignancy was demonstrated in 2 tumors: one cortisone secreting tumor and one leiomyosarcoma. Conversion was required in 4 cases (8%). Mean operative time for unilateral adrenalectomies was 147 minutes (50-300'). There were no deaths. Morbidity included: one hemorrhage via the trocar orifice requiring reoperation, one infarction of the spleen which regressed spontaneously, one parietal hematoma, and one case of phebitis of the lower limb. The endocrinopathy was successfully cured in all patients with secreting tumors. The 27 other patients underwent open adrenalectomy. Laparoscopic approach was not proposed due to suspected malignancy in 13 cases, previous surgery in 8 cases and multiple, bilateral and/or extra adrenal tumors in 6 cases. Laparoscopic approach to the adrenal gland is the procedure of choice in patients with Conn adenomas, Cushing adenomas and in most cases of pheochromocytomas. It is not indicated for malignant and large tumor (> 8 cm). Currently two-thirds of our patients requiring and adrenalectomy are operated laparoscopically.     

Wound metastases following laparoscopic and open surgery for abdominal cancer in a rat model

The recent application of laparoscopic resection techniques to malignant disease has raised safety concerns due to metastasis to surgical access wounds. The significance and incidence of this problem are controversial. In the present study a rat model, in which an implanted tumour was lacerated, was used to investigate whether application of laparoscopic techniques for malignant abdominal disease leads to an increased risk of tumour dissemination and implantation within the peritoneal cavity, and abdominal wall wounds. Malignant cells were implanted into the abdominal wall of 42 rats, resulting 7 days later in the growth of a tumour measuring 20-25 mm in diameter. There were three control groups: no surgery (n = 6); blunt manipulation of the tumour laparoscopically (n = 6); and blunt manipulation of the tumour at laparotomy (n = 6). Twenty-four rats underwent surgical laceration of the tumour capsule at either laparoscopy (n = 12) or laparotomy (n = 12). All rats were killed 1 week later, and examined for macroscopic evidence of tumour metastasis. The abdominal surgical wounds were excised for independent microscopic examination by a histopathologist. Growth of the primary tumour was greater in rats that had an operation than in unoperated controls, and was greater after laparotomy. However, wound metastases were five times more likely after laparoscopic tumour laceration than after the same procedure through an open incision (ten of 12 rats versus two of 12, P = 0.0033). Wound metastases following laparoscopic tumour manipulation are an important and real problem, with significant implications for the application of laparoscopic techniques to excise malignant disease in humans.     

Intermittent sequential compression of the lower limbs prevents venous stasis in laparoscopic and conventional colorectal surgery

PURPOSE: This study was designed to evaluate the influence of intraoperative intermittent sequential compression (ISC) on venous blood return from the lower limbs during laparoscopic and conventional colorectal colectomy. METHODS: Fifty patients undergoing laparoscopic (n = 25) or conventional (n = 25) colorectal surgery were included in a prospective study. Peak venous flow (PFV) and the cross-sectional area (CSA) of the femoral vein were assessed by Doppler ultrasound examination intraoperatively. RESULTS: Age, gender, and body mass index were comparable between both groups. Baseline PFV was 21 +/- 6.6 cm/s in the conventional and 18.4 +/- 6.4 cm/s in the laparoscopic group (P = 0.2). ISC increased PFV to 156 +/- 29 percent of the baseline value in the conventional group and to 161 +/- 29 percent in the laparoscopic group. PFV decreased after abdominal insufflation to 127 +/- 19 percent of the baseline value in the laparoscopic group and after laparotomy to 134 +/- 27 percent in the conventional group (P = 0.3). PFV decreased slightly in both groups during surgery but remained well above the baseline value. Baseline CSA was 1.02 +/- 0.17 cm2 in the conventional group and 1 +/- 0.23 cm2 in the laparoscopic group. ISC decreased CSA to 0.91 +/- 0.18 cm2 (conventional) and 0.85 +/- 0.18 cm2 (laparoscopic) after initiation of ISC. CSA was 0.92 +/- 0.18 cm2 after abdominal insufflation in the laparoscopic group, and it was 0.93 +/- 0.18 cm2 after laparotomy in the conventional group (P = 0.4). During surgery, there were no differences in absolute CSA or CSA changes compared with the baseline value in both groups. Postoperative circumference of the calf and thigh were not different between both groups. Postoperative thromboembolic complications did not occur. CONCLUSION: ISC effectively increases venous blood flow from the lower limbs during conventional and laparoscopic colorectal resections and may decrease the risk of postoperative deep vein thrombosis. Therefore, ISC is strongly recommended in every prolonged laparoscopic procedure.     

Congenital cystic diseases of liver and extrahepatic bile ducts

The paper presents 30-year experience in treating 158 patients with congenital cystic diseases of the liver and bile ducts. Depending on the pattern of hepatobiliary lesions, the diagnostic value of techniques, such as ultrasound, computerized tomography, scintigraphy of the liver duodenoscopy with THCG was defined. Analyzing the late outcomes provided recommendations for the most optimal surgical management: cystic fenestration and tunneling in hepatic polycystosis, pericystectomy in solitary cysts of the liver, different varieties of bile draining operations in choledochal cysts and Caroli's disease.     

Nonparasitic splenic cysts. Ultrasonographic features and follow-up

Sixty-three patients with splenic cysts, multiple in 7 cases, were reviewed. Only 3 patients had a history of previous abdominal trauma. The cysts ranged in size from less than 1 cm to 15 cm. They were anechoic in 40 patients, hypoechoic in 16, isoechoic in 4, mixed in one, and in 2 cases the echogenicity could not be assessed due to thick marginal calcifications. The echogenic cysts were larger than the anechoic ones and frequently calcified, and the findings at surgery, fine-needle aspiration biopsy and follow-up suggested the echogenicity to be related to a fresh or previous episode of intracystic hemorrhage. Initially, surgical treatment was undertaken on 10 patients, electively in 9 cases and due to cyst rupture in one. At follow-up (n = 37), the size of the cyst had increased markedly over several years in only 2 patients, necessitating delayed surgery in one. Routine follow-up of asymptomatic splenic cysts was of no clinical value.     

Laparoscopic surgery of large uterine fibromas. Operative technique and results

OBJECTIVE. To describe the technique of laparoscopic myomectomy for large myomas (5 cm and more) and to evaluate the results. RESULTS. Only myomas which are complicated (and/or resistant to properly conducted medical treatment) require surgical treatment. Between October 1, 1990 and October 31, 1994, we carried out 72 laparoscopic myomectomies for intramural myomas measuring 5 cm or more, in 71 patients. The operations lasted 130 +/- 60 min (range: 40-330 min). We converted to laparotomy for two cases (2.7%). We observed no serious per or postoperative complications. We never needed a repeat operation, whether by laparotomy or by laparoscopy. CONCLUSION. Despite these encouraging results, it must be remembered that the operation is lengthy and difficult and is reversed for laparoscopic surgeons perfectly familiar with endoscopic knot tying. Although it is a difficult technique, laparoscopic myomectomy is possible even for large myomas and those that are completely intramural. These results need to be assessed over the long term especially with respect to the risk of adhesions and the quality of the laparoscopic suture.     

Levels of endothelin-I in bronchoalveolar fluid of patients with selected respiratory tract diseases

Clinical manifestations, clinical course and therapeutic schemes were studied in 37 patients with a surgical indication for biliary cysts of the liver observed in a surgery unit over 25 years. Cyst size varied from 2 to 30 cm and was greater than 10 cm in 12 cases. Yellowish-clear contents were observed in 23 cases and purulent or hemorrhagic contents in 3 each. Twenty-three patients were asymptomatic, 14 had pain and/or complications (hemorrhage 3, infection 3, compression 3, rupture 1). Therapy was abstention in 7 cases, puncture in 5, resection of the protruding dome in 17, complete exeresis in 5, and hepatectomy in 3. There were no deaths and morbidity reached 7%. Biliary cysts of the liver can be discovered fortuitously at surgery or imagery or in patients with abdominal pain, an abdominal mass or complications including compression, intraperitoneal rupture, intracystic hemorrhage, hemobilia, acute infection, torsion, cancerization. Diagnosis requires sonography and computed tomography. Therapeutic indications are: abstention for small asymptomatic cysts. For voluminous cysts, with complications or confirmed during a supramesocolic operation, the risk of recurrence or aggravation of the complications excludes puncture or injection of a sclerosing agent. Wide resection of the protruding part of the cyst with histology resection can be performed although prospective assessment is needed. Cystectomy is not indicated if there is a diagnostic doubt. Hepatectomy is an exceptional indication retained for patients with uncontrolable hemorrhage, intra-cystic tumors or voluminous cysts destroying the lobe.