Showing papers in "Journal of Laparoendoscopic & Advanced Surgical Techniques in 2000"
TL;DR: Significant advantages of a minimally invasive surgical approach were evident in this group of patients, especially recurrence rates and incidence of postoperative adhesions, and promising early results need to be confirmed by a prospective controlled trial.
Abstract: Purpose: A retrospective study was carried out of patients who underwent laparoscopic ventral abdominal wall hernia repair (excluding groin hernias) between January 1994 and January 1999. Patients and Methods: Laparoscopic ventral hernia repair was performed on 202 patients for defects ranging from 1.5 cm to 12 cm in diameter. Of these, 35 patients had multiple hernial defects. After reduction of the hernial contents and adhesiolysis, a polypropylene mesh was used intraperitoneally in all patients, such that there was a margin of at least 3 cm from the edge of the defect as well as the previous scar. Results: The mean operating time decreased from 90 minutes in the initial 3 years to 50 minutes in the last 2 years. Postoperatively, the mean hospital stay was 1.8 days. Patients complained of somatic abdominal pain at the site of mesh insertion for a mean of 7 days. There were two postoperative hernia recurrences at a mean follow-up of 2.9 years. The incidence of seroma formation postoperatively wa...
201 citations
TL;DR: Direct observation demonstrated improved overall performance of junior residents after formal skills training on a videotrainer and efficient and valid methods of evaluating operative performance await development.
Abstract: Background and Purpose: Global assessment by direct observation has been validated for evaluating operative performance of surgery residents after formal skills training but is time-consuming. The purpose of this study was to compare global assessment performed from edited videotape with scores from direct observation. Materials and Methods: Junior surgery residents (N = 22) were randomized to 2 weeks of formal videotrainer skills training or a control group. Laparoscopic cholecystectomy was performed at the beginning and end of the rotation, and global assessment scores were compared for the training and control groups. Laparoscopic videotapes were edited: initial (2 minutes), cystic duct/artery (6 minutes), and fossa dissection (2 minutes). Two independent raters performed both direct observation and videotape assessments, and scores were compared for each rater and for interrater reliability using a Spearman correlation. Results: Correlation coefficients for videotape versus direct observation for five...
107 citations
TL;DR: A series of 89 total extraperitoneal laparoscopic repairs in 80 consecutive patients using no means of mechanical or adhesive mesh fixation, irrespective of the size of the hernial defect are reported.
Abstract: Background: Inguinal hernia repair contributes significantly to the general surgeon's workload. Since the evolution of laparoscopic inguinal hernia repair, the total extraperitoneal (TEP) repair is the technique most commonly employed by laparoscopic surgeons. This technique involves the placement of a polypropylene mesh in the preperitoneal space. The issue of fixation of this mesh remains unresolved. Surgeons have previously fixed this mesh in place using laparoscopic stapling devices, suturing techniques, or, more recently, polycyanoacrylate adhesives. However, stapling the mesh not only increases the time and expense of the procedure but can cause specific complications such as nerve entrapment syndromes and osteitis pubis. Patients and Methods: We report a series of 89 total extraperitoneal laparoscopic repairs in 80 consecutive patients using no means of mechanical or adhesive mesh fixation, irrespective of the size of the hernial defect. Results: Follow-up revealed no increase in morbidity...
97 citations
TL;DR: Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult choleCystectomies.
Abstract: Background and Purpose: The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy. Patients and Methods: In 56 of 1680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present ...
79 citations
TL;DR: The short-term results of laparoscopy in patients admitted on an emergency basis for acute small-bowel obstruction secondary to adhesions are reported, suggesting that laparoscopic adhesiolysis after the crisis has passed may produce better results, but only long-term follow-up can confirm the role of elective laparoscope.
Abstract: Background and Purpose: Postoperative adhesions are the leading cause of small-bowel obstruction in developed countries. Several arguments suggest that laparoscopy may lead to fewer adhesions than does laparotomy. We report here the short-term results of laparoscopy in patients admitted on an emergency basis for acute small-bowel obstruction secondary to adhesions. Patients and Methods: This prospective trial included 134 consecutive patients: 39 underwent emergency surgery, and 95 had laparoscopic adhesiolysis shortly after resolution of the obstruction with nasogastric suction. Of the previous operations for which the dates were known, 16% had taken place within 1 year of the obstruction and 33.5% within 5 years. In all, 27% of the patients had open laparoscopy, and 16% had conversions: 7% after elective laparoscopy and 36% after emergency laparoscopy. Results: There were no operative deaths. One patient underwent a reoperation the following day for fistula after incomplete adhesiolysis attribu...
70 citations
TL;DR: Establishment of the pneumoperitoneum is more efficient using the TrocDoc compared with the Veress needle/first trocar and the Hasson trocar, and a newly developed modified blunt trocar that might replace the two alternatives because of its efficacy and open approach.
Abstract: Purpose: To compare three techniques of establishment of pneumoperitoneum for efficacy: the Veress needle/first trocar, the Hasson trocar, and a newly developed modified blunt trocar, the TrocDoc. Patients and Methods: Between June and December 1999, 62 patients eligible for laparoscopic surgery were randomized. The effectiveness of installation of the pneumoperitoneum using the three techniques was assessed by time-motion analysis. Primary efficacy measures were total time and number of actions required to establish the pneumoperitoneum. Secondary efficacy measures were procedure-related complications, wound complications, and occurrence of CO2 leakage. Results: Two patients were withdrawn from inclusion. The three groups were comparable for age and body mass index. Total time was shortest using the TrocDoc rather than the Veress needle/first trocar and the Hasson trocar (respectively, 138 ± 58 v 237 ± 56 v 350 ± 103 seconds), and the number of actions was lowest for the Veress needle/first troc...
67 citations
TL;DR: The hand-assisted laparoscopic technique was the most efficient and open surgery was the fastest technique, because the time for every surgical motion is a factor of three shorter than for the two laparoscopy techniques.
Abstract: Purpose: To determine the most efficient technique for performing a colectomy, we used the methodology of time-motion analysis. Methods: The efficiency of five hand-assisted and six regular laparoscopic colectomies and one open colectomy, performed by four surgeons in three different hospitals, was measured. The open colectomy was analyzed as a reference procedure. Results and Conclusions: The hand-assisted laparoscopic technique was the most efficient. Hand-assisted laparoscopy was therefore less time consuming than laparoscopic surgery. Open surgery was the fastest technique, because the time for every surgical motion is a factor of three shorter than for the two laparoscopic techniques.
58 citations
TL;DR: The raw area of the removed organ is at least partially responsible for shoulder pain after laparoscopic cholecystectomy and local bupivacaine is effective in reducing such pain.
Abstract: Background: Shoulder pain is common after laparoscopic cholecystectomy (60.5%) and can delay return to normal activities. The cause is unclear but may involve referral of pain from the tra...
47 citations
TL;DR: An algorithm to evaluate stable patients with anterior abdominal stab wounds and minimize overall costs of care, incidence of nontherapeutic celiotomy, and rate of missed injuries is suggested consisting of DPL followed by observation in patients with negative DPL and by laparoscopy in patientsWith positive DPL.
Abstract: Purpose: To determine the roles of laparoscopic abdominal exploration (LE) and diagnostic peritoneal lavage (DPL) in the evaluation of abdominal stab wounds, we prospectively compared LE with mandatory celiotomy (MC) in 76 patients having anterior abdominal stab wounds penetrating the fascia over a 22-month period. Patients and Methods: Twenty-two patients underwent emergency celiotomy. The remaining patients were subjected to DPL and assigned to treatment by either celiotomy or initial LE with subsequent conversion to open exploration at the discretion of the attending surgeon. Results: Laparotomy was avoided in 55% of the 31 patients undergoing initial laparoscopy, and this group demonstrated a significant decrease in the incidence of nontherapeutic celiotomy, from 19% to 57% (P < 0.05), as well as decreased length of hospital stay (4 ± 0.6 v 5.9 ± 0.4 days; P < 0.05), and total hospital cost ($6119 ± 756 v $8312 ± 627; P < 0.05). There were no missed intraabdominal injuries or morbidity from l...
43 citations
TL;DR: A patient with infected pancreatic necrosis who was treated successfully with minimally invasive surgery is described, who continued to be asymptomatic for the 6 months of follow-up.
Abstract: We describe a patient with infected pancreatic necrosis who was treated successfully with minimally invasive surgery. Five weeks after an episode of acute uncomplicated pancreatitis, he was found to have infected pancreatic necrosis and splenic vein thrombosis. The patient underwent a laparoscopic pancreatic necrosectomy, splenectomy, and cholecystectomy. Seven days after surgery, the patient was discharged and continued to be asymptomatic for the 6 months of follow-up.
41 citations
TL;DR: Two case reports are presented of incarcerated small-bowel internal hernias through mesenteric defects following Roux-en-Y gastric bypass surgery (one case each of open and laparoscopic).
Abstract: Two case reports are presented of incarcerated small-bowel internal hernias through mesenteric defects following Roux-en-Y gastric bypass surgery (one case each of open and laparoscopic). Both patients first presented to physicians unfamiliar with bariatric surgery complaining of vague, cramping midabdominal pain, and the correct diagnosis was not revealed until laparoscopic surgery was performed. Treatment then resulted in quick recoveries. This type of hernia can evade radiologic testing. Prompt clinical recognition and treatment is necessary to prevent small-bowel infarction.
TL;DR: The radially expanding trocar produces less early postoperative pain than the conventional metal trocar, and this claim was evaluated in a randomized controlled single-blind clinical trial.
Abstract: Background and purpose: One advantage of minimal-access surgery is that it produces less pain. A radially expanding trocar has been claimed to reduce pain further. We aimed to evaluate this claim. Patients and Methods: This was a randomized controlled single-blind clinical trial. Fifty-four patients who underwent laparoscopic cholecystectomy at the Department of Surgery, United Christian Hospital, Hong Kong, between July 1997 and September 1998 were randomized into either the study group or the control group. The radially expanding 10-mm trocar was used for the epigastric port in the study group. The conventional 10-mm metal trocar was used similarly in the control group. The operation was otherwise performed with a standardized technique. Another conventional 10-mm metal trocar was used for the subumbilical port for all patients. Pain was measured using a visual analog scale. Pain scores for the epigastric port and subumbilical port were documented for 3 days after the surgery. Results: There wa...
TL;DR: Endometrial ablation with a hot-fluid balloon seems to be as effective as endometrial resection, with a lower complication rate, and balloon ablation might become the procedure of choice for endometrian ablation.
Abstract: Background: Hot-fluid balloon therapy is a recently introduced, relatively simple endometrial ablation procedure for menorrhagia. Because it is thought to be safer than other ablation procedures, it would be superior to other types of ablation if it is equally effective. The purpose of the present study was therefore to compare the safety and effectiveness of balloon ablation and transcervical resection of the endometrium (TCRE) for the treatment of menorrhagia. Patients and Methods: We performed a prospective cohort study comparing TCRE and hot-fluid balloon ablation in consecutive patients suffering from menorraghia and not responding to medical treatment. Between 1992 and 1994, all patients had TCRE, whereas from 1995 onward, all patients had balloon therapy. Outcome measures were surgical reintervention, menstrual pattern, and patient satisfaction. Assuming a 9% reintervention rate after TCRE, a series of 150 patients was required to show balloon ablation to be equally effective. Results: Of ...
TL;DR: A patient with laparoscopically excised mesenteric cyst is presented along with a literature review and laparoscopic surgical approaches have replaced open procedures in many surgical abdominal diseases.
Abstract: Benign cystic tumors are rare intra-abdominal lesions that may be retroperitoneal, mesenteric, or omental. Most of them cause nonspecific symptoms, but rarely, they cause serious complications such as volvulus, rupture, or bowel obstruction. The diagnosis of these tumors can be made by abdominal ultrasonography or CT. Their only treatment is surgical excision, which can be done by either laparotomy or laparoscopic surgery. In last decade, laparoscopic surgical approaches have replaced open procedures in many surgical abdominal diseases. In this paper, a patient with laparoscopically excised mesenteric cyst is presented along with a literature review.
TL;DR: The laparoscopic approach should be the modality of choice for most, if not all, cases of small-bowel obstruction in which there is an indication for exploration.
Abstract: Background: Small-bowel obstruction poses both a diagnostic and a therapeutic challenge. The laparoscopic approach may assist in determining the cause of the obstruction and in many cases ...
TL;DR: A laparoscopic approach to myomectomy may be safely chosen for patients with fibroids and offers the benefits of less postoperative intravenous narcotic use, a shorter hospital stay, and no greater intraoperative blood loss than abdominal myomextomy.
Abstract: Purpose: To compare laparoscopic with abdominal approaches to myomectomy. Patients and Method: Frequency matching was used to ensure similar fibroid weights among the laparoscopic and abdominal groups in this case-control study. The study group consisted of prospectively recruited patients undergoing laparoscopic (N = 5) or laparoscopically assisted (N = 20) myomectomy (lap). The control group represented both prospectively (N = 14) and retrospectively (N = 37) identified abdominal myomectomy patients (abd). Analysis of the variables was performed using a t-test, Wilcoxon rank-sum test, chi-square test, or analysis of covariance at the 0.01 significance level. Results: All results are reported after matching for fibroid weight, with the median (quartiles) aggregate weight measuring 151 g (31.0, 262.0) and 170.0 g (81.0, 285.0) for the lap and abd patients, respectively (P = 0.15). Median (quartiles) length of hospital stay (30.5 hours [25.0, 52.5] v 65.0 hours [45.0, 76.0]; P < 0.001) and duration of post...
TL;DR: A 20-year-old male patient was admitted to the authors' emergency ward because of acute respiratory insufficiency following gastroscopy 2 years after a car accident and the chest radiograph showed migration of the stomach into the left hemithorax.
Abstract: A 20-year-old male patient was admitted to our emergency ward because of acute respiratory insufficiency following gastroscopy 2 years after a car accident. The chest radiograph showed migration of the stomach into the left hemithorax. A large diaphragmatic hernia was diagnosed and repaired laparoscopically using slowly resorbable sutures and patches. Diaphragmatic rupture secondary to blunt thoracic or abdominal trauma is a rare injury, whose diagnosis may be delayed. The majority of these defects are diagnosed during laparotomy performed for other major abdominal lesions. If diaphragmatic rupture is suspected, and no lesion of a parenchymatous organ has been diagnosed, there is a role for diagnostic laparoscopy. In the absence of other abdominal injuries, diaphragmatic rupture can be repaired by minimal-access surgery.
TL;DR: Laroscopic splenectomy is a safe although complex procedure with the short recovery and ready acceptance of patients and physicians, and this technique is being used with increasing frequency.
Abstract: Background and Purpose: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned. Methods: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed. Results: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay a...
TL;DR: Gas emblism during He insufflation is more likely to be lethal than is CO2 embolism, so the possibility of venous injection should be minimized by avoiding Veress needle use.
Abstract: Background and Purpose: Whilst carbon dioxide is the gas generally used for insufflation during laparoscopy, several studies have reported adverse effects specifically associated with its use. Thes...
TL;DR: Laroscopic fundoplication can be performed safely in a hospital-affiliated outpatient setting, resulting in a significant reduction in procedure costs.
Abstract: Purpose: In order to reduce the costs of laparoscopic fundoplication, a pilot program for outpatient surgery was instituted in 1995. The risks and benefits of reducing postoperative hospitalization to ≤23 hours were assessed. Patients and Methods: Patients in ASA grade I or II (N = 22) with refractory gastroesophageal reflux disease underwent laparoscopic fundoplication over a 21-month period in a hospital-affiliated outpatient facility. The results were compared with those of a similar group of 16 patients whose surgery was performed on an inpatient basis. Results: Seventeen patients (77%) were discharged within 23 hours of surgery. The maximum length of stay was 3 days. There were no deaths. Nineteen patients (86%) reported excellent results. The average facility cost declined from $7169 for the inpatient group to $4588 for patients on operated under the outpatient protocol. The decrease resulted from a reduction in the cost of room, operating suite, supplies, and anesthesia. Conclusion: Laparo...
TL;DR: Investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundolication in its immunologic effects, and changes were similar in the two groups with the exception of IL-6.
Abstract: Background and Purpose: Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery. Patients and Methods: Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure. Results: A very fast and significant (P < 0.01) increase of the proinflammatory cyto...
TL;DR: A high proportion of women presenting with acute abdominal pain can be managed using a laparoscopic technique exclusively, and diagnostic laparoscopy provided a definitive diagnosis in 76 of the 77 cases.
Abstract: Purpose: We reviewed the records of 77 women treated for nontraumatic acute abdomen by the principal author between June 1991 and June 1996. All patients presented to either the surgeon's office or the emergency room at Northwest Hospital, which is an urban community hospital in North Seattle. Our objectives in the study were to determine the effectiveness of diagnostic laparoscopy for nontraumatic acute abdomen and the percentage of cases managed using laparoscopic technique exclusively. Patients and Methods: The mean patient age was 36.5 (range 12–65) years. The majority of these women (92%) were premenopausal. Seventy-two (93.5%) were Caucasian, and the remaining 5 (6.5%) were Asian. Thirty-eight of the women (49%) had undergone at least one prior pelvic or abdominal operation, and 28 (36%) had undergone more than one. The principal author performed preoperative clinical evaluations, then diagnostic laparoscopy for all 77 patients. Results: Laparoscopy provided a definitive diagnosis in 76 of ...
TL;DR: Laroscopic umbilical hernia herniorrhaphy is safe and technically feasible but its potential advantages, such as a lower rate of recurrence, will need to be validated with longer follow-up.
Abstract: Background: Laparoscopic technique is an alternative approach to ventral hernia repair This study evaluated the feasibility of performing umbilical hernia repair using a single 5-mm troca
TL;DR: Laparoscopic adrenalectomy was performed early in the second trimester of pregnancy in a woman with an aldosteronoma causing hypertension (254/154 mm Hg).
Abstract: Laparoscopic adrenalectomy was performed early in the second trimester of pregnancy in a woman with an aldosteronoma causing hypertension (254/154 mm Hg). The patient was later delivered o...
TL;DR: Laroscopy is an effective method for the diagnosis and treatment of surgical pathologies in patients in whom the diagnosis cannot be made with physical examination and noninvasive methods.
Abstract: Purpose: To evaluate the role of laparoscopy in the diagnosis and treatment of unexplained acute abdominal pain. Patients and Methods: Fifty-six patients with acute abdominal pain (41 women, 15 men; median age 27) who attended our hospital between July 1996 and July 1999 and in whom a definite diagnosis could not be made by conventional methods underwent diagnostic laparoscopy. Results: The laparoscopic procedure was performed under general anesthesia in 43 patients and local anesthesia in 13 patients. The median duration of laparoscopy was 16 minutes. The sensitivity and specificity of diagnostic laparoscopy were found to be 98% and 96%, respectively. The most frequent diagnosis was acute appendicitis (38%). Laparoscopic treatment of the surgical pathology was possible in 36 patients; in seven patients, conversion to laparotomy was necessary. The median postoperative hospital stay was 1 day in the diagnostic laparoscopy group. The median treatment cost was lower in the diagnostic laparoscopy group than i...
TL;DR: The learning curve since the introduction of laparoscopic cholecystectomy (LC) was analyzed in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either Laparoscopic or open chole Cytomegalectomy (OC).
Abstract: Purpose: In a prospective series of 2650 consecutive patients undergoing cholecystectomy, we analyzed the learning curve since the introduction of laparoscopic cholecystectomy (LC) in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either laparoscopic or open cholecystectomy (OC). Patients and Methods: Between July 1990 and June 1997, LC was performed in 1929 patients (73%), 203 of whom (7.5%) had to be converted to OC, while 518 patients (19.5%) had primary OC. Patients having LC were predominantly female, younger, with less comorbidity and less complicated gallstone disease than patients having OC. Results: Barring a learning curve during the first 6 months of LC, operating time remained constant at an average of 71 minutes while operating on ever more complex pathologies. The conversion rate decreased from 9.4% to 6.7% during the 7-year period. A relatively constant team of surgeons with growing experience as well as constantly improvin...
TL;DR: The results of TES were highly satisfactory in most patients although 37 (80%) developed compensatory sweating of the trunk and lower limbs, the distribution being the axillae in 15 (33%), back in 36 (78%), lower chest and abdomen in 22 (48%), lower limbs in 34 (74%) and sole in 1.
Abstract: Background and Purpose: Craniofacial hyperhidrosis may result in social phobia and has a strong negative impact on the quality of life. The traditional therapeutic options are psychotherapy and pharmacologic treatment, but these often fail. We wished to investigate whether transthoracic endoscopic sympathectomy (TES) of the lower part of the stellate ganglion is efficient and safe in the treatment of craniofacial hyperhidrosis. Patients and Methods: Between July 1995 and September 1999, a total of 21 men and 25 women with a mean age of 41.2 years (range 22–58 years) underwent TES for craniofacial hyperhidrosis. All patients were placed in a semisitting position under single-lumen intubated anesthesia. We ablated the lower part of the stellate ganglion at the second rib using a storz 8-mm 0° thoracoscope via one 0.8-cm incision just below each axilla. Questionnaires were sent to all patients postoperatively. Results: Among these 46 patients, 92 sympathectomies were performed. Usually, TES was acco...
TL;DR: A case of a giant omental cyst treated successfully by a minimally invasive approach to treat mesenteric cysts.
Abstract: Mesenteric cysts are uncommon, and their pathological type includes pseudocyst, mesothelial cyst, lymphangioma, and omental cyst. We describe a case of a giant omental cyst treated successfully by a minimally invasive approach.
TL;DR: A patient undergoing laparoscopic Nissen fundoplication had an intraoperative finding of a left Bochdalek hernia, which was repaired with an onlay of fenestrated PTFE.
Abstract: A patient undergoing laparoscopic Nissen fundoplication had an intraoperative finding of a left Bochdalek hernia, which was repaired with an onlay of fenestrated PTFE. This appears to be the first report of such a case.