Laparoscopic vs open resection of gastric stromal tumors

BACKGROUND

Gastric stromal tumors are rare neoplasms that may be benign or malignant. Given that malignant gastric stromal tumors rarely involve lymph nodes and require excision with negative margins, they appear amendable to laparoscopic excision. There are few reports of laparoscopic resection, and no comparisons have been done between laparoscopic and open surgery. This study compares the relative efficacy of the two approaches.

METHODS

Between May 1994 and December 2000, 33 patients underwent 35 operations for gastric stromal tumors. Laparoscopic resections were performed in 21 patients; open resections were done in 12 patients. The medical records of the patients were reviewed retrospectively with regard to operating time, blood loss, length of stay, and clinical course.

RESULTS

Patient demographics, tumor characteristics (mean tumor size, benign vs malignant), and presenting symptoms were similar for both groups. In the laparoscopic group, 15 wedge resections; three partial gastrectomies, and three transgastric needlescopic enucleations were performed. In the open group, six wedge resections, four antrectomies, and two partial proximal gastrectomies were performed. There were no significant differences in mean operative time (169 vs 160 min), mean estimated blood loss (106 vs 129 cc), or perioperative complication rate (9.5% vs 8.3%) between the laparoscopic and open groups, respectively. The mean length of stay was significantly less (p<0.05) in the laparoscopic group (3.8 vs 6.2 days). Average follow-up was 1.5 years. One patient in each group has died due to metastatic disease. There have been no trocar site recurrences.

CONCLUSIONS

Laparoscopic resection of gastric stromal tumors is safe and appropriate. Tumor size, operating time, and estimated blood loss were equivalent to the open approach, and there was a statistically shorter hospital stay in the laparoscopic group.

Transhepatic thrombolysis in acute portal vein thrombosis after laparoscopic splenectomy

Portal vein thrombosis is a relatively rare clinical entity that can result in substantial morbidity and mortality. Because of the risk of intestinal infarction, acute symptomatic portal vein thrombosis requires prompt intervention. Traditional treatment has included anticoagulation and/or systemic thrombolytic therapy. We report the successful management of acute portal vein thrombosis with percutaneous transphepatic thrombolytic therapy. In addition to the potential for improving regional clot lysis through direct infusion of the thrombolytic agent, this method may result in fewer systemic side effects than occur with other available treatment modalities.

Optimal teaching environment for laparoscopic ventral herniorrhaphy

The introduction of laparoscopic techniques after residency training has created a new paradigm dependent on laparoscopic workshops. This study tested the benefit of an animate course and evaluated the role of proctoring in learning to perform laparoscopic ventral hernia repair (LVHR). Surgeons who had taken a 1-day LVHR course (n = 59) were polled to determine previous experience with laparoscopic procedures and experience with LVHR after the course. Forty-eight (81%) surgeons completing the course responded. Thirty-two (67%) surgeons had performed 179 LVHRS (mean 5.6) since the course. There were no statistically significant differences between the groups performing and not performing LVHR regarding academic/private practice (P=0.8) or opportunities to perform a ventral herniorrhaphy (P = 0.6). Fifteen (31%) surgeons were precepted in their hospital operating room by the lead author. Thirteen (87%) of precepted surgeons had performed a LVHR compared with 19 (58%) of the 33 surgeons taking the course without a precepted intervention (P = 0.05). Surgeons with experience performing laparoscopic inguinal hernia repair, Nissen fundoplication, and common bile duct exploration were more likely to perform LVHR (P=0.0001). Surgeons performing only laparoscopic cholecystectomy tended to be less likely to perform LVHR, nearing statistical significance (P=0.08). Surgeons with prior advanced laparoscopic surgery experience are thus more likely to perform LVHR after participating in a 1-day course. Surgeons precepted in their hospital operating room were also more likely to perform LVHR. Participation in an animate laboratory and a precepted experience can impact the future performance of advanced laparoscopic surgery.

The Economic Benefit of Practice Guidelines for Stress Ulcer Prophylaxis

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent ( P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.

Comparison of thermal spread after ureteral ligation with the Laparo-Sonic ultrasonic shears and the Ligasure system

BACKGROUND AND PURPOSE

The extent of lateral spread of tissue injury is important in the success of a primary anastomosis. We compared the injury produced by the Laparo-sonic Coagulation Shears and the Ligasure system.

MATERIALS AND METHODS

Ureters were harvested from domestic farm pigs and ligated with the Laparo-sonic (N = 13) or Ligasure (N = 9) system. The tissues were then fixed, stained, and examined by two pathologists without knowledge of the type of treatment.

RESULTS

The mean length of thermal damage from the Ligasure was 2.11 mm (range 1.0-4.0 mm) whereas it was 1.92 (range 0.5-4.25 mm) from the Laparo-sonic system. The difference is not statistically significant.

CONCLUSION

Debridement of as much as 5 mm of each cut end produced by the Laparo-sonic or Ligasure system may be beneficial in reducing stricture and leak.

The economic benefit of practice guidelines for stress ulcer prophylaxis

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.

Laparoscopic splenectomy for massive splenomegaly

BACKGROUND

Laparoscopic splenectomy (LS) is the preferred operative approach for diseases involving normal-sized spleens. Our experience with laparoscopic splenectomy in the setting of massive splenomegaly is presented.

METHODS

A prospective review of patients undergoing LS for massive splenomegaly was conducted. Massive splenomegaly (MS) in adults was defined as a craniocaudal length >or=17 cm or a morcellated weight >or=600 g. In children, spleens measuring fourfold larger than normal for age were considered massive.

RESULTS

Forty-nine patients with MS were treated with LS. The most common primary diagnoses were lymphoma and leukemia. Mean splenic length was 20 cm (15 to 27 cm), with weights ranging from 600 to 4,750 g. Twelve patients with supermassive splenomegaly (length >22 cm) required a hand-assisted laparoscopic approach. There were no conversions to open surgery. Mean operating time was 171 minutes (90 to 369). Mean blood loss was 114 cc (<30 to 600 cc). Average length of stay was 2.3 days (1 to 16). Minor postoperative complications occurred in 3 patients.

CONCLUSIONS

Laparoscopic splenectomy in the setting of splenomegaly is safe and appears to minimize perioperative morbidity. In patients with supermassive splenomegaly, a hand-assisted laparoscopic approach may be required.

Laparoscopic adrenalectomy for pheochromocytoma

BACKGROUND

Laparoscopic adrenalectomy for Conn's syndrome, Cushing's disease, cortisol-producing adenomas, and nonfunctioning adenomas has been well established. This study was intended to evaluate the clinical outcomes of patients undergoing laparoscopic adrenalectomy for pheochromocytoma, and to assess the efficacy and safety of a minimally invasive approach.

METHODS

Data were collected prospectively on all patients undergoing laparoscopic adrenalectomy for pheochromocytoma over a 5-year period.

RESULTS

In this study, 39 consecutive patients underwent laparoscopic resection of a pheochromocytoma: 38 adrenal (23 left, 15 right) and 1 extraadrenal paraganglioma. There were no conversions to open surgery. The mean tumor size was 5.2 cm (range, 2-12.1 cm). Average operative time was 159 min (range, 100-265 min), and average estimated blood loss was 72 ml (range, 30-350 ml). Intraoperative hypertension (systolic blood pressure > 170 mmHg) occurred in 67% of the patients, and hypotension (systolic blood pressure < 90 mmHg) in 39% of the patients. The mean length of stay was 2.1 days (range, 1-4 days). There were three minor postoperative complications. During a mean follow-up period of 14 months, there were no mortalities or recurrences of endocrinopathy.

CONCLUSIONS

Laparoscopic resection of pheochromocytomas can be accomplished safely despite frequent episodes of hemodynamic variability equal to those of historic open control subjects. A short hospital stay with expedient recovery,minimal wound complications, and lack of endocrinopathy recurrence makes a minimally invasive approach the procedure of choice for the management of pheochromoctyoma.

Management of oxygenation in pediatric acute hypoxemic respiratory failure

The prognosis for patients with acute respiratory distress syndrome (ARDS) in adults and children has improved since its formal acceptance as a clinical entity in 1967. Because acute hypoxemic respiratory failure is the hallmark of acute lung injury and ARDS, the management of oxygenation is crucial. Physicians managing pediatric patients with acute lung injury or ARDS are faced with a complex array of options influencing oxygenation. Certain treatment strategies can influence clinical outcomes, such as a lung-protective ventilation strategy that specifies a low tidal volume (6 mL/kg) and a plateau pressure limit (30 cm H(2)O) (Acute Respiratory Distress Network, N Engl J Med 2000;342:1301-1308). Other lung-protective strategies such as different levels of positive end-expiratory pressure, altered inspiratory:expiratory ratios, recruitment maneuvers, prone positioning, and extraneous gases or drugs may impact clinical outcomes but require further clinical study. This paper reviews state-of-the-art strategies on the management of oxygenation in acute hypoxemic respiratory failure and attempts to guide pediatric pulmonologists in managing children with respiratory failure.

Minilaparoscopic appendectomy

The purpose of this study was to evaluate the feasibility of using 2-mm laparoscopic instruments in the treatment of appendicitis and to identify risk factors that may limit their use. Minilaparoscopic appendectomy was performed through a 2-mm port in the umbilicus for a videoendoscope, a 2-mm working port in the right upper quadrant, and a 5/12-mm suprapubic port for an endoscopic stapler. Minilaparoscopic appendectomy was attempted in 26 consecutive patients with appendicitis. Thirty-two consecutive patients undergoing conventional laparoscopic appendectomy with 5- and 10-mm instruments and videoendoscopes before the availability of 2-mm instrumentation were analyzed for comparison. Statistical comparisons were made by the Student t test and Fisher exact test. Differences were considered statistically significant at a P value less than 0.05. There were no conversions to an open appendectomy in the minilaparoscopic appendectomy or conventional laparoscopic appendectomy group. The mean operative time was 69.5 minutes for the minilaparoscopic appendectomy group and 85.5 minutes for the conventional laparoscopic appendectomy group (P = 0.02). The mean postoperative length of stay was 1.7 days for the minilaparoscopic appendectomy group and 2.5 days for the conventional laparoscopic appendectomy group (P = 0.08). There was no significant difference in the complication rates (P = 0.31). Minilaparoscopic appendectomy was completed in 13 (50.0%) patients. Independent risk factors (P = 0.05) for conversion to 5- or 10-mm ports were a retrocecal appendix and increasing patient age. There were no differences in the mean postoperative length of stay (P = 0.12) or complication rate (P = 0.39) between the two groups, but mean operative time was longer (P = 0.05) in the converted group. Perioperative outcomes for minilaparoscopic appendectomy are comparable to those of conventional laparoscopic appendectomy. The use of 2-mm instrumentation in the management of appendicitis is limited in patients with retrocecal appendicitis. Increasing patient age and a history of abdominal surgery may influence the need to convert 2-mm ports to 5- or 10-mm ports.

Laparoscopic Anterior Esophageal Myotomy and Toupet Fundoplication for Achalasia

Achalasia is an esophageal motility disorder characterized by the failure of lower esophageal sphincter relaxation and the absence of esophageal peristalsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplication for achalasia. A 9-cm myotomy was performed in most cases extending 7 cm above and 2 cm below the gastroesophageal junction. Severity of dysphagia, heartburn, chest pain, and regurgitation was graded preoperatively and postoperatively using a five-point symptomatic scale (0–4). Patients also graded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23–71 years) were diagnosed with achalasia. Mean duration of symptoms was 40.2 months (range 4–240 months). Thirty-seven patients (76%) had had a previous nonsurgical intervention or combinations of nonsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies. Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies without an antireflux procedure, and two were converted to open surgery. One patient presented 10 hours after a pneumatically induced perforation and underwent a successful laparoscopic esophageal myotomy and partial fundoplication. Mean operative time was 180.5 minutes (range 145–264 minutes). Mean length of stay was 1.98 days (range 1–18 days). There were five (10%) perioperative complications but no esophageal leaks. There was a significant difference ( P < 0.05) between the preoperative and postoperative dysphagia, chest pain, and regurgitation symptom scores. All patients stated that they were improved postoperatively. Eighty-six per cent rated their outcome as excellent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior esophageal myotomy and Toupet fundoplication effectively alleviates dysphagia, regurgitation, and chest pain accompanying achalasia and is associated with high patient satisfaction, a rapid hospital discharge, and few complications.

Minimally invasive management of paraesophageal herniation in the high-risk surgical patient

BACKGROUND

Traditional management of symptomatic paraesophageal herniation involves hernia reduction, hiatal closure, and an antireflux procedure or gastropexy. Patients with significant comorbidities may not tolerate operative repair. A new technique, laparoscopic-assisted endoscopic reduction and fixation of the stomach, may provide a minimally invasive treatment alternative.

METHODS

Eleven elderly patients with symptomatic paraesophageal herniation were managed with flexible endoscopy and double percutaneous endoscopic gastrostomy (PEG) tube insertion with or without laparoscopic assistance.

RESULTS

All patients presented with a symptomatic paraesophageal hernia. Mean age was 78.3 years (range 72 to 84). Each was deemed at high risk for definitive repair due to preexisting coronary artery disease as well as at least two other serious comorbidities. Hernia reduction and intra-abdominal fixation of the stomach was achieved in each case using flexible endoscopy and double PEG insertion. Laparoscopic assistance for reduction and gastropexy was utilized in 9 cases. Mean operative time was 61 minutes (range 28 to 104). Average length of stay was 2.8 days (range 0 to 12). One minor and three major postoperative complications occurred. Over a mean follow-up of 4.1 months (range 2 to 7), all patients have resumed oral intake and achieved weight gain.

CONCLUSIONS

Patients with symptomatic paraesophageal herniation require intervention to alleviate symptoms and avoid the complications of gastric incarceration. For the high-risk patient, endoscopic reduction and PEG with laparoscopic assistance appears to provide effective treatment.

Laparoscopic anterior esophageal myotomy and toupet fundoplication for achalasia

Achalasia is an esophageal motility disorder characterized by the failure of lower esophageal sphincter relaxation and the absence of esophageal peristalsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplication for achalasia. A 9-cm myotomy was performed in most cases extending 7 cm above and 2 cm below the gastroesophageal junction. Severity of dysphagia, heartburn, chest pain, and regurgitation was graded preoperatively and postoperatively using a five-point symptomatic scale (0-4). Patients also graded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23-71 years) were diagnosed with achalasia. Mean duration of symptoms was 40.2 months (range 4-240 months). Thirty-seven patients (76%) had had a previous nonsurgical intervention or combinations of nonsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies. Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies without an antireflux procedure, and two were converted to open surgery. One patient presented 10 hours after a pneumatically induced perforation and underwent a successful laparoscopic esophageal myotomy and partial fundoplication. Mean operative time was 180.5 minutes (range 145-264 minutes). Mean length of stay was 1.98 days (range 1-18 days). There were five (10%) perioperative complications but no esophageal leaks. There was a significant difference (P < 0.05) between the preoperative and postoperative dysphagia, chest pain, and regurgitation symptom scores. All patients stated that they were improved postoperatively. Eighty-six per cent rated their outcome as excellent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior esophageal myotomy and Toupet fundoplication effectively alleviates dysphagia, regurgitation, and chest pain accompanying achalasia and is associated with high patient satisfaction, a rapid hospital discharge, and few complications.

Mini-laparoscopic versus laparoscopic approach to appendectomy

BACKGROUND

The purpose of this clinical study is to evaluate the feasibility of using 2-mm laparoscopic instruments to perform an appendectomy in patients with clinically suspected acute appendicitis and compare the outcome of this mini-laparoscopic or "needlescopic" approach to the conventional laparoscopic appendectomy.

METHODS

Two groups of patients undergoing appendectomy over 24 months were studied. In the first group, needlescopic appendectomy was performed in 15 patients by surgeons specializing in advanced laparoscopy. These patients were compared with the second or control group that included 21 consecutive patients who underwent laparoscopic appendectomy. We compared the patients' demographic data, operative findings, complications, postoperative pain medicine requirements, length of hospital stay, and recovery variables. Differences were considered statistically significant at a p-value < 0.05.

RESULTS

Patient demographics, history of previous abdominal surgery, and operative findings were similar in both groups. There was no conversion to open appendectomy in either group. No postoperative morbidity or mortality occurred in either group. The needlescopic group had a significantly shorter mean operative time (p = 0.02), reduced postoperative narcotics requirements (p = 0.05), shorter hospital stay (p = 0.04), and quicker return to work (p = 0.03) when compared with the laparoscopic group.

CONCLUSIONS

We conclude that the needlescopic technique is a safe and effective approach to appendectomy. When performed by experienced laparoscopic surgeons, the needlescopic technique results in significantly shorter postoperative convalescence and a prompt recovery.

Effectiveness of the Ultrasonic Coagulating Shears, LigaSure Vessel Sealer, and Surgical Clip Application in Biliary Surgery: A Comparative Analysis

Advancements in laparoscopic surgery are often dictated by the limitations of technical instrumentation. Energy sources other than electrosurgery have become popular with the promise of quick and effective vascular control. With their success surgeons have begun using these on structures other than blood vessels with little or no data establishing their efficacy or safety. This study evaluates alternative energy sources in sealing ductal structures for possible use in liver or gallbladder surgery. After elective cholecystectomy cystic ducts (n = 45) were resealed ex vivo with surgical clips (n = 14), ultrasonic coagulating shears (n = 16), or electrothermal bipolar vessel sealer (n = 15), and bursting pressures were measured. Nineteen additional human cystic ducts were randomized to seal by ultrasonic coagulating shears (n = 9) or electrothermal bipolar vessel sealer (n = 10) and fixed in 10 per cent buffered formalin for histologic evaluation of thermal spread (mm). After this nine adult pigs were randomized to laparoscopic ligation and transection of the common bile duct using surgical clips (n = 3), ultrasonic coagulating shears (n = 3), or electrothermal bipolar vessel sealer (n = 3). The animals underwent necropsy for assessment of seal integrity on the sixth postoperative day. In the ex vivo study the mean cystic duct bursting pressure was 621 mm Hg with surgical clips and 482 mm Hg with the electrothermal bipolar vessel sealer ( P = 0.39). The mean cystic duct bursting pressure after ultrasonic coagulating shears was 278 mm Hg, which was statistically less than surgical clips ( P = 0.007) and electrothermal bipolar vessel sealer ( P = 0.02). The mean thermal spread was 3.5 mm for ultrasonic coagulating shears and 13.4 mm for electrothermal bipolar vessel sealer ( P = 0.0002). All animals undergoing ligation and transection of the common bile duct with ultrasonic coagulating shears and electrothermal bipolar vessel sealer developed bile peritonitis by postoperative day 6 as a result of seal leak. All animals undergoing surgical clip ligation and transection of the common bile duct maintained seal integrity. The mean common bile duct pressure above the surgical clip was 12 mm Hg (range 10–14). In conclusion the acute ex vivo study demonstrated a significant difference in the cystic duct bursting pressure between surgical clips and ultrasonic coagulating shears and between electrothermal bipolar vessel sealer and ultrasonic coagulating shears. The ultrasonic coagulating shears and electrothermal bipolar vessel sealer failed to maintain seal integrity in the in vivo animal study. Given the failure of the ultrasonic coagulating shears and electrothermal bipolar vessel sealer in the animal model these energy sources should not be used for transection of the cystic duct or major hepatic ducts during hepatobiliary surgery.

Laparoscopic Splenectomy in Patients with Normal-Sized Spleens versus Splenomegaly: Does Size Matter?

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens ( P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.

Effectiveness of the ultrasonic coagulating shears, LigaSure vessel sealer, and surgical clip application in biliary surgery: a comparative analysis

Advancements in laparoscopic surgery are often dictated by the limitations of technical instrumentation. Energy sources other than electrosurgery have become popular with the promise of quick and effective vascular control. With their success surgeons have begun using these on structures other than blood vessels with little or no data establishing their efficacy or safety. This study evaluates alternative energy sources in sealing ductal structures for possible use in liver or gallbladder surgery. After elective cholecystectomy cystic ducts (n = 45) were resealed ex vivo with surgical clips (n = 14), ultrasonic coagulating shears (n = 16), or electrothermal bipolar vessel sealer (n = 15), and bursting pressures were measured. Nineteen additional human cystic ducts were randomized to seal by ultrasonic coagulating shears (n = 9) or electrothermal bipolar vessel sealer (n = 10) and fixed in 10 per cent buffered formalin for histologic evaluation of thermal spread (mm). After this nine adult pigs were randomized to laparoscopic ligation and transection of the common bile duct using surgical clips (n = 3), ultrasonic coagulating shears (n = 3), or electrothermal bipolar vessel sealer (n = 3). The animals underwent necropsy for assessment of seal integrity on the sixth postoperative day. In the ex vivo study the mean cystic duct bursting pressure was 621 mm Hg with surgical clips and 482 mm Hg with the electrothermal bipolar vessel sealer (P = 0.39). The mean cystic duct bursting pressure after ultrasonic coagulating shears was 278 mm Hg, which was statistically less than surgical clips (P = 0.007) and electrothermal bipolar vessel sealer (P = 0.02). The mean thermal spread was 3.5 mm for ultrasonic coagulating shears and 13.4 mm for electrothermal bipolar vessel sealer (P = 0.0002). All animals undergoing ligation and transection of the common bile duct with ultrasonic coagulating shears and electrothermal bipolar vessel sealer developed bile peritonitis by postoperative day 6 as a result of seal leak. All animals undergoing surgical clip ligation and transection of the common bile duct maintained seal integrity. The mean common bile duct pressure above the surgical clip was 12 mm Hg (range 10-14). In conclusion the acute ex vivo study demonstrated a significant difference in the cystic duct bursting pressure between surgical clips and ultrasonic coagulating shears and between electrothermal bipolar vessel sealer and ultrasonic coagulating shears. The ultrasonic coagulating shears and electrothermal bipolar vessel sealer failed to maintain seal integrity in the in vivo animal study. Given the failure of the ultrasonic coagulating shears and electrothermal bipolar vessel sealer in the animal model these energy sources should not be used for transection of the cystic duct or major hepatic ducts during hepatobiliary surgery.

Laparoscopic splenectomy in patients with normal-sized spleens versus splenomegaly: does size matter?

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens (P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.

Initial results with an electrothermal bipolar vessel sealer

BACKGROUND

An electrothermal bipolar vessel sealer (EBVS; Ligasure, Valleylab, Boulder, CO, USA) was developed as an alternative to suture ligatures, hemoclips, staplers, and ultrasonic coagulators for ligating vessels and tissue bundles. The EBVS seals vessels up to 7 mm in diameter by denaturing collagen and elastin within the vessel wall and surrounding connective tissue. This study is the first to determine the clinical efficacy and safety of this instrument and delineate its potential timesavings in both experimental (animal) and clinical scenarios.

METHODS

A prospective review of the author's clinical experience with the EBVS in laparoscopic and open operations from October 1998 to March 2000 was performed. In addition, five Yorkshire domestic pigs underwent 150-cm small intestine resections (n = 10) using the EBVS (n = 5) and suture ligatures (n = 5). Measurements included time to complete intestinal resection, the number of applications per minute for each method, and the presence of postapplication bleeding. Statistical analysis was performed using Student's t-test.

RESULTS

The EBVS was used in 98 cases (46 laparoscopic and 52 open) with a mean of 43 applications (range, 10-150 applications) per case. The operations included 53 colon and/or small bowel resections (54.1%), 24 fundoplications (24.5%), 12 gastric resections (12.2%), 3 splenectomies, 2 pancreatectomies, 1 adrenalectomy, 1 bilateral salpingo-oopherectomy, 1 pancreatic cyst-jejunostomy, and 1 vagotomy with gastrojejunostomy. In all these cases, the EBVS was intended to be the only means of vessel ligation. An alternative ligation technique was required for bleeding in only 13 (0.3%) of more than 4,200 applications of the EBVS. No postoperative hemorrhagic complications occurred. There was an estimated mean reduction in operative time of 39 min per open procedure, and a mean prolongation in operative time of 8 min per laparoscopic procedure when the EBVS was used in lieu of suture ligatures, hemoclips, staplers, or ultrasonic coagulators. In the animal model, the mean time for completion of the intestinal resection was 251.9 s for the EBVS and 702.0 s for ligatures (p < 0.001). The mean number of applications per minute was 7.6 for the EBVS and 1.8 for ligatures (p < 0.001). No postapplication bleeding was seen.

CONCLUSIONS

Initial clinical results from the use of EBVS in laparoscopic and open procedures demonstrate it to be safe and effective, reducing operative time in open procedures. Suture ligatures, ties, hemoclips, and other ligating techniques were used rarely (0.3%) after an application of the EBVS. In an experimental animal model, the EBVS was significantly faster and more efficient (more applications per minute) than ligatures for intestinal resection.

Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen

BACKGROUND

In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure.

PATIENTS AND METHODS

We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach.

RESULTS

In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations.

CONCLUSION

Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions.

Laparoscopic splenectomy for malignant diseases

A variety of malignant diseases involving the spleen, both primary and metastatic, may require splenectomy for diagnosis or therapeutic reasons. The role of minimally invasive surgery in the management of malignant diseases involving the spleen is not well defined because of a lack of reported experience with laparoscopic splenectomy in this group. A reluctance to perform laparoscopic splenectomy in these patients may be explained by the technical and oncological challenges that often accompany malignant splenic diseases such as splenomegaly, perisplenitis, hilar lymphadenopathy, and fear of splenic disruption and tumor spillage. In our experience, the adoption of a lateral technique and the use of hand-assisted devices has allowed for the successful completion of laparoscopic splenectomy for malignant hematologic diseases including spleens up to 28 cm in length and greater than 3 kg morcellated weight. Laparoscopic splenectomy reliably alleviates the symptoms related to splenomegaly and reverses the hematologic abnormalities of hypersplenism. Although laparoscopic splenectomy for malignant diseases is feasible, the role of minimally invasive surgery in the staging of Hodgkin's lymphoma remains undetermined.

Optimal teaching environment for laparoscopic splenectomy

BACKGROUND

Traditional surgical teaching depends on graduated acquisition of skill learned in residency. The introduction of minimal access techniques after residency training has created a new paradigm dependent on animate course experiences and limited preceptor training. The outcome of performance of a new skill "learned" in these settings has not been assessed. The purpose of this study was to test the benefit of an animate course compared with a precepted operating room experience in learning to perform a laparoscopic splenectomy.

METHODS

All attending surgeons who had taken a 1-day course to learn laparoscopic splenectomy (n = 37) and those who had undergone an intraoperative preceptorship (in their hospital) by the lead author (n = 15) were polled to ascertain their previous experience with laparoscopy and with laparoscopic splenectomy since the intervention. The course included lectures, operative videos, and an animal lab. Statistical differences were measured using a t test.

RESULTS

Thirty-two of the 37 (86.5%) taking the course and all 15 of the precepted surgeons responded. There was no difference between the groups regarding prior laparoscopic experience (P = 0.73), laparoscopic training during residency (P = 0.74), academic or private practice (P = 0.48), or follow-up since the intervention (P = 0.36). The participants graded the courses (1 to 5, 5 = excellent) at an average of 4.72. Fourteen of 15 precepted surgeons have performed laparoscopic splenectomy as compared with 2 of 32 taking courses (nonprecepted surgeons; P <0.0001). The number of laparoscopic splenectomies performed totaled 112 for precepted surgeons and 4 for nonprecepted surgeons (P = 0.0003). The nonprecepted surgeons performed significantly more open splenectomies than laparoscopic (95 versus 13 respectively, P = 0.02). Reasons quoted not to proceed with laparoscopic splenectomy included waiting for the perfect patient, concern of hilar management, and splenic size.

CONCLUSION

Surgeons precepted in their own operating room performed a laparoscopic splenectomy more readily than those gaining experience from a course only (93% versus 6%, respectively) despite no difference in their preintervention experience and having the opportunity to do so. The expectation of the eventual performance of advanced laparoscopic techniques depends on a precepted experience.

Preperitoneal Richter hernia after a laparoscopic gastric bypass

Trocar-site incisional hernias are potentially dangerous because of their susceptibility to become Richter hernias. The authors describe a morbidly obese patient in whom developed an unusual type of Richter hernia after a laparoscopic isolated Roux-en-Y gastric bypass at a 10-mm trocar site. Although the fascial closure of the trocar hernia site was intact, a hernia developed through the peritoneum into the preperitoneal space. For morbidly obese patients, the thick preperitoneum is a potential space that allows for the development of a Richter hernia, despite adequate fascial closure. It is recommended that all 10-mm and 12-mm trocar sites be closed, incorporating the peritoneum into the fascial closure to obliterate the preperitoneal space, to prevent this postoperative complication.

Surgical experience with nonfunctioning neuroendocrine tumors of the pancreas

Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more indolent natural history compared with pancreatic adenocarcinoma. This retrospective report reviews the surgical experience with nonfunctioning neuroendocrine tumors in an academic referral center. Statistical analysis was performed using Student's t test and Kaplan-Meier method compared with log-rank tests. Thirty-eight patients (24 males and 14 females) underwent surgery for a neuroendocrine tumor of the pancreas from 1984 through 1999. Twenty-eight patients with a mean age of 59.9 years had nonfunctioning islet cell tumors and 10 patients with a mean age of 59.1 years had functioning islet cell tumors (four gastrinomas, three glucagonomas, two insulinomas, and one vipoma). The nonfunctioning islet cell tumors were located in the head, neck, or uncinate process in 14 patients (50%), the body in seven (25%), and the tail in seven (25%). Operative procedures for the nonfunctioning islet cell tumors included nine pancreaticoduodenectomies, 12 distal pancreatectomies, three palliative bypasses, and four exploratory laparotomies without a resection or bypass. Mean survival for the four patients explored and not resected or bypassed was 7 months. Median survival for node-negative patients was 124 months, for node-positive patients 75 months, and for patients with metastasis to the liver 9 months. Estimated 2-year actuarial survival for the node-negative patients was 77.8 per cent, for node-positive patients 71.4 per cent, and for patients with metastasis to the liver 36.4 per cent. Six patients (60%) with node-negative disease, three (43%) with node-positive disease, and one (9%) with metastasis to the liver are alive at a mean follow-up of 41.8 months (range 1-167). Significant differences in median survival and 2-year survival were demonstrated between the node-positive/node-negative patients and those with metastasis to the liver (P = 0.003). Patients with localized nonmetastatic disease should be considered for pancreatic resection as estimated median survival is 75 months or greater. Hepatic metastasis is a major predictor of survival.

Surgical Experience with Nonfunctioning Neuroendocrine Tumors of the Pancreas

Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more indolent natural history compared with pancreatic adenocarcinoma. This retrospective report reviews the surgical experience with nonfunctioning neuroendocrine tumors in an academic referral center. Statistical analysis was performed using Student's t test and Kaplan-Meier method compared with log-rank tests. Thirty-eight patients (24 males and 14 females) underwent surgery for a neuroendocrine tumor of the pancreas from 1984 through 1999. Twenty-eight patients with a mean age of 59.9 years had nonfunctioning islet cell tumors and 10 patients with a mean age of 59.1 years had functioning islet cell tumors (four gastrinomas, three glucagonomas, two insulinomas, and one vipoma). The nonfunctioning islet cell tumors were located in the head, neck, or uncinate process in 14 patients (50%), the body in seven (25%), and the tail in seven (25%). Operative procedures for the nonfunctioning islet cell tumors included nine pancreaticoduodenectomies, 12 distal pancreatectomies, three palliative bypasses, and four exploratory laparotomies without a resection or bypass. Mean survival for the four patients explored and not resected or bypassed was 7 months. Median survival for node-negative patients was 124 months, for node-positive patients 75 months, and for patients with metastasis to the liver 9 months. Estimated 2-year actuarial survival for the node-negative patients was 77.8 per cent, for node-positive patients 71.4 per cent, and for patients with metastasis to the liver 36.4 per cent. Six patients (60%) with node-negative disease, three (43%) with node-positive disease, and one (9%) with metastasis to the liver are alive at a mean follow-up of 41.8 months (range 1–167). Significant differences in median survival and 2-year survival were demonstrated between the node-positive/node-negative patients and those with metastasis to the liver ( P = 0.003). Patients with localized nonmetastatic disease should be considered for pancreatic resection as estimated median survival is 75 months or greater. Hepatic metastasis is a major predictor of survival.

Laparoscopic lumbar interbody spinal fusion

Laparoscopic ALIF is an evolving technique requiring the participation of a laparoscopic surgeon experienced in advanced laparoscopic techniques and knowledgeable in anterior lumbar spinal exposures. Initial enthusiasm for this technique was fostered by the development of interbody fusion devices and a method of exposing the anterior lumbar spine, which takes advantage of the ability of minimally invasive surgeries to improve exposure and visualization while minimizing collateral tissue damage and injury to healthy tissue. Preliminary studies have demonstrated laparoscopic ALIF feasibility. These same studies have been able to prove only minor advantages with the laparoscopic versus open technique using the current implants and bone grafting techniques for single-level disc disease. General acceptance of laparoscopic ALIF awaits further investigation. Reasons for a lack of general acceptance include the expense of the interbody fusion devices and laparoscopic equipment, the unfamiliarity of this advanced laparoscopic technique to spine and general surgeons, and the steep learning curve of the procedure. Intraoperative complications that arise are often severe, such as vascular injuries. Many skeptics appropriately believe that initial enthusiasm and zealousness must be tempered with scientific effort that provides data from long-term follow-up. For laparoscopic ALIF to gain general acceptance, randomized comparisons of laparoscopic ALIF to open ALIF and posterior lumbar spinal fusion and controlled studies with long-term follow-up documenting symptomatic outcome variables and spinal fusion rates must be completed. As new modalities are developed, minimally invasive techniques may facilitate their utility. The indications, procedures, and surgical principles of ALIF are unchanged, and physicians must not invent indications to justify the technique; however, eventually we may be able to redefine the indications to take full advantage of the endoscopic techniques and biological advances.

Mini-laparoscopic splenectomy

BACKGROUND AND PURPOSE

Since the introduction of mini-laparoscopic instruments (2- to 3-mm diameter), their utility and safety have been questioned. Their application in cholecystectomy has recently been documented. This study determined the adequacy and safety of these minimally invasive instruments in laparoscopic splenectomy.

METHODS

Retrospective review of all 16 mini-laparoscopic splenectomies performed by the authors was carried out. Diagnoses included immune thrombocytopenia (5), spherocytosis (6), and beta-thalassemia, sickle-cell disease, splenic mass, cyst, and splenomegaly in 1 case each. The average age of the patients was 20.1 years (range 4-70 years); seven patients were adults. Ten of the patients were female. The patients' body mass index ranged from 17 to 25 kg/m2. Splenomegaly (at least two times normal size: 100-200 g for children, 400-600 g for adults) was present in each case. A three-trocar technique was used in 15 patients, and a fourth trocar was required in only one case.

RESULTS

The average operative time and blood loss were 114 minutes (range 60-195 minutes) and 44 mL (range 10-150 mL), respectively. There were no intraoperative complications, and no patient required transfusion. Conversion to standard laparoscopy or laparotomy did not occur. The mean hospital stay was 1.4 days (range 1-2 days). With an average 20-month follow-up, no wound, septic, or other complications have been identified. All patients or their families (in the case of children) graded the cosmetic outcome as excellent.

CONCLUSION

The use of mini-laparoscopic instruments for splenectomy is safe and effective in children and adults with a normal body mass index, even in the case of splenomegaly. Operative times are reasonable, and hospital stays are brief. The postoperative cosmetic appearance is excellent.

Hand-Assisted Laparoscopic Splenectomy

The success of laparoscopic cholecystectomy has resulted in the broad application of minimally invasive techniques in many surgery specialties. The theoretical advantages of laparoscopy over conventional open operations, including less postoperative pain, faster overall recovery, and better cosmetic results have been achieved leading to its acceptance by surgeons and the public alike. Numerous abdominal procedures have been adapted to minimally invasive approaches including bowel resection, inguinal and ventral hernia repair, anti-reflux techniques, and solid organ removal such as splenectomy.

Geometry and reproducibility in 360 degrees fundoplication

BACKGROUND

In this study, we set out to precisely define two symmetrical points-a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or "floppy") 360 degrees fundoplication (FP).

METHODS

For the terms of this study, circumference = c; diameter = d; c/d = pi; pi = 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n = 5) and intraoperatively (n = 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c.

RESULTS

The smallest measured value for c was 7.5 cm (d = 2.39 cm); the largest value for c was 10.0 cm (d = 3.18 cm). The mean value was 8.35 cm (d = 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d = 2.66 cm. This technique creates a correctly oriented, symmetrical, "floppy," true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible.

CONCLUSIONS

Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a "floppy" 360 degrees fundoplication.

Laparoscopic splenectomy for malignant diseases

A variety of malignant diseases involving the spleen, both primary and metastatic, may require splenectomy for diagnosis or therapeutic reasons. The role of minimally invasive surgery in the management of malignant diseases involving the spleen is not well defined because of a lack of reported experience with laparoscopic splenectomy in this group. A reluctance to perform laparoscopic splenectomy in these patients may be explained by the technical and oncological challenges that often accompany malignant splenic diseases such as splenomegaly, perisplenitis, hilar lymphadenopathy, and fear of splenic disruption and tumor spillage. In our experience, the adoption of a lateral technique and the use of hand-assisted devices has allowed for the successful completion of laparoscopic splenectomy for malignant hematologic diseases including spleens up to 28 cm in length and greater than 3 kg morcellated weight. Laparoscopic splenectomy reliably alleviates the symptoms related to splenomegaly and reverses the hematologic abnormalities of hypersplenism. Although laparoscopic splenectomy for malignant diseases is feasible, the role of minimally invasive surgery in the staging of Hodgkin's lymphoma remains undetermined.

Laparoscopic repair of a chronic diaphragmatic hernia

Diaphragmatic injuries that remain undetected after an acute traumatic event may lead to the formation of a diaphragmatic hernia. Symptoms of a chronic diaphragmatic hernia are related to the incarceration of abdominal contents in the defect or to impingement of the lung, heart, or thoracic esophagus by abdominal viscera. A 49-year-old woman with a symptomatic chronic diaphragmatic hernia from an unrecognized iatrogenic injury to the left hemidiaphragm sought treatment. The diaphragmatic injury occurred 2 years earlier when a low, left-sided chest tube was placed for a persistent pleural effusion 2 weeks after a lower lobectomy for an aspergilloma. The patient's diaphragmatic hernia was diagnosed after an upper gastrointestinal series and an esophagogastroduodenoscopy. Approximately 75% of her stomach was incarcerated in the diaphragmatic defect. The diaphragmatic hernia was repaired laparoscopically using a 9 cm x 10-cm polytetrafluoroethylene patch sewn with nonabsorbable, interrupted, horizontal mattress sutures. Improvement of video technology, laparoscopic instruments, and surgical skills has allowed surgeons to expand the boundaries of advanced therapeutic laparoscopy. These factors facilitated the authors' standard tension-free prosthetic repair of a chronic diaphragmatic hernia using minimally invasive techniques.

Initial results with a stapled gastrojejunostomy for the laparoscopic isolated roux-en-Y gastric bypass

BACKGROUND

The gastric pouch to jejunum anastomosis is a critical step in the performance of an isolated Roux-en-Y gastric bypass. When performing this procedure laparoscopically, intracorporeal suturing of the gastric pouch to Roux-en-Y jejunum anastomosis is technically demanding, time consuming, and perhaps the most prohibitive part of the operation. We devised a unique, effective, and simple method to perform this anastomosis using an EEA stapler. This report describes this technique and its follow-up in our series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass utilizing this technique.

METHODS

A prospective analysis was performed identifying the technical success, leak rate, and postoperative incidence of anastomotic stenosis and its management in a consecutive series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass with a gastrojejunal anastomosis constructed with a 21-mm or 25-mm EEA stapler.

RESULTS

Forty-eight patients underwent laparoscopic isolated Roux-en-Y gastric bypass. Mean age was 40.9 years (range 22 to 64) and mean body mass index was 52.3 kg/m(2) (range 31 to 76 kg/m(2)). There were no mortalities. Three patients (6.3%) were converted to an open procedure, but only 1 because of an inability to perform the gastrojejunal anastomosis (short jejunal mesentery). There was 1 leak (2.1%) from the gastrojejunal anastomosis. It was successfully managed nonoperatively. Thirteen patients (27.1%) patients developed an anastomotic stenosis requiring endoscopic balloon dilatation. Seven of the 13 patients required only a single dilatation and have had no recurrence of dysphagia. Six of the 13 patients needed 2 to 4 dilatations, and all are swallowing normally. None have required surgical revision. After 12 months of follow-up, the mean weight loss was 115 pounds and mean decrease in body mass index was 18.5 kg/m(2).

CONCLUSIONS

The stapled EEA gastrojejunal anastomosis for the laparoscopic isolated Roux-en-Y gastric bypass is safe and effective. Anastomotic stenosis occurs in approximately one quarter of patients, but it can be managed well with endoscopic balloon dilatation.

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation

BACKGROUND

Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation.

METHODS

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement.

RESULTS

All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required.

CONCLUSIONS

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments.

Left thoracoscopic sympathectomy and stellate ganglionectomy for treatment of the long QT syndrome

The long QT syndrome (LQTS) is a rare inherited cardiac disorder that may induce fatal cardiac arrhythmias. Patients diagnosed with this disorder generally have several treatment options, including beta-blockade, cardiac pacing, an implantable automatic defibrillator, or a high thoracic left sympathectomy. We report the case of a 6-year-old girl with the LQTS treated by left thoracoscopic sympathectomy and stellate ganglionectomy. The procedure was performed after an initial thorascopic attempt at another institution failed due to inadequate resection of the sympathetic chain. Operative time was 85 min and blood loss was minimal. There were no intraoperative or postoperative complications. The girl's QT interval decreased and she was discharged on the 4th postoperative day. After 9 months of follow-up, she remains asymptomatic. We conclude that the LQTS patients who fail medical treatment can be treated successfully with left thoracoscopic cervicothoracic sympathectomy. We recommend that the extent of sympathectomy for treating the LQTS be T1-T4 and either the entire stellate ganglion or at least the inferior one-third.

Hand-assisted laparoscopic splenectomy

The success of laparoscopic cholecystectomy has resulted in the broad application of minimally invasive techniques in many surgery specialties. The theoretical advantages of laparoscopy over conventional open operations, including less postoperative pain, faster overall recovery, and better cosmetic results have been achieved leading to its acceptance by surgeons and the public alike. Numerous abdominal procedures have been adapted to minimally invasive approaches including bowel resection, inguinal and ventral hernia repair, anti-reflux techniques, and solid organ removal such as splenectomy.

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Initial experience with the advanced breast biopsy instrumentation system

BACKGROUND

Advanced breast biopsy instrumentation is a recently designed alternative to large-core stereotactic and open needle localized breast biopsies. This minimally invasive technique uses digital stereotactic imaging to perform excisional biopsies of suspicious, nonpalpable mammographic lesions. The role of the ABBI system in the management of breast cancer has not yet been defined.

METHODS

A retrospective review to evaluate the safety, accuracy, and cost effectiveness of the ABBI system as performed by a single surgeon on 107 patients from February 1, 1997 to January 31, 1998. We also discuss the use of the ABBI system as a therapeutic breast cancer technique. All patients had nonpalpable mammographic lesions. The mammographic abnormalities were either architectural distortion, microcalcifications, or stellate and nodular densities.

RESULTS

Using the ABBI stereotactic unit, 110 breast biopsies were performed in 107 patients during a 12-month period. The mammographic abnormality was accurately localized and successfully biopsied in 99% (109 of 110) of the procedures as confirmed by specimen radiographs, stereotactic images, permanent pathologic sections, and 6-month follow-up mammograms. There were no intraoperative complications. Two patients developed postoperative wound hematomas and there was 1 postoperative wound infection. Six in situ cancers and 21 invasive cancers were diagnosed with the ABBI system. Two additional invasive cancers were diagnosed in patients with ductal carcinoma in situ at reexcision. Four patients with invasive ductal carcinoma and 1 patient with ductal carcinoma in situ had negative margins on their stereotactic biopsies and did not undergo reexcision by lumpectomy or mastectomy. Each of the 4 patients with invasive ductal carcinoma underwent axillary node dissections with postoperative radiation therapy and chemotherapy or tamoxifen. During the study period, the average hospital patient charge for a stereotactic breast biopsy was $2,377.75, and for an open excisional needle localized biopsy it was $3,028.00 (P <0.05). The stereotactic breast biopsy offered a total cost savings of $71,527.50 in our series of patients.

CONCLUSION

Advanced breast biopsy instrumentation is a safe, accurate, and cost-effective method for performing breast biopsies. In addition, the ABBI system may be able to excise small in situ or invasive breast cancers.

Laparoscopic cholecystectomy in an academic hospital: evaluation of changes in perioperative outcomes

OBJECTIVE

Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital.

METHODS

A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer's exact test.

RESULTS

Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group.

CONCLUSION

Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct supervision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same.