Coelioscopic cholecystectomy. Preliminary report of 36 cases

Laparoscopic versus open repair of perforated gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis

BACKGROUND

Surgical repair of perforated gastroduodenal ulcers remains a common indication for emergent surgery. The aim of this study was to test the hypothesis that the laparoscopic approach (LA) would be associated with reduced length of stay compared to the open approach.

METHODS

Patients with acute, perforated gastroduodenal ulcer were identified in the National Surgical Quality Improvement Program database, of whom 50 had the LA. One-to-one case/control matching on the basis of age, American Society of Anesthesiologists class, gender, and cardiac disease was evaluated for outcome analysis.

RESULTS

After matching, the 2 groups had similar characteristics. The rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the LA by an average of 5.4 days.

CONCLUSIONS

The LA appears to be safe in mild to moderately ill patients with perforated peptic ulcer disease and is associated with reduced use of hospital resources.

Risk Factors for Conversion from Laparoscopic to Open Surgery: Analysis of 2138 Converted Operations in the American College of Surgeons National Surgical Quality Improvement Program

Minimal access procedures have influenced surgical practice and patient expectations. Risk of laparoscopic conversion to open surgery is frequently cited but vaguely quantified. The present study examines three common procedures to identify risk factors for laparoscopic conversion to open (LCO) events. Cross-sectional analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2005 to 2009) identified cases with laparoscopic procedure codes for appendectomy, cholecystectomy, and bariatric procedures. The primary outcome was conversion of a laparoscopic procedure to its open equivalent. Summary statistics for laparoscopic and LCO groups were compared and logistic regression analysis was used to estimate patient and operative risk factors for conversion. Of 176,014 selected laparoscopic operations, 2,138 (1.2%) were converted. Most patients were female (68%) and white (71.2%); mean age was 45.1 years. LCO cholecystectomy was significantly more likely (n = 1526 [1.9%]) and LCO bariatric procedures were less likely (n = 121 [0.3%]); appendectomy was intermediate (n = 491 [1.0%], P < 0.001). Patient factors associated with LCO included male sex ( P < 0.001), age 30 years or older ( P < 0.025), American Society of Anesthesiologists Class 2 to 4 ( P < 0.001), obesity ( P < 0.01), history of bleeding disorder ( P = 0.036), or preoperative systemic inflammatory response syndrome or sepsis ( P < 0.001). LCO was associated with greater incidence of postoperative complications, including death, organ space surgical site infection, sepsis, wound dehiscence, and return to the operating room ( P < 0.001). Overall LCO incidence is low in hospitals participating in ACS-NSQIP. Conversion risk factors include patient age, sex, obesity, and preoperative comorbidity as well as the procedure performed. This information should be valuable to clinicians in discussing conversion risk with patients.

Gallstone-related abdominal abscess 8 years after laparoscopic cholecystectomy

An unusual collection of fluid in the perihepatic space needs to be investigated for abscess in patients with a remote history of cholecystectomy.

Background:

A common intraoperative complication during laparoscopic cholecystectomy is gallbladder perforation with spillage of gallstones. The undesirable consequence of spilled gallstones is the formation of abscesses months or years after an operation.

Case Description:

Our clinical report describes an intraabdominal abscess formation in an 82-year-old man that developed 8 years after a laparoscopic cholecystectomy. A computed tomography scan of the abdomen showed an elongated fluid collection in the right abdominal compartment musculature at the level of the internal oblique muscle. Abdominal ultrasonography confirmed a large fluid collection, with 2 echogenic masses in the dependent portion. Incision and drainage of the abscess were performed, and 2 gallstones were found.

Conclusion:

Any unusual collection of fluid in the perihepatic space and abdominal wall in the area of the surgical incision in a patient with a remote history of cholecystectomy should be evaluated for abscess related to retained gallstone. Early abscess formation is usually diagnosed and treated by the surgeon. However, the late manifestation might be a clinical problem seen in the primary care physician's office. Therefore, the primary care physician should incorporate diagnosis of gallstone-related abscess in patients with abdominal abscess formation of unknown etiology.

Minimally invasive surgery: national trends in adoption and future directions for hospital strategy

BACKGROUND

Surgeons have rapidly adopted minimally invasive surgical (MIS) techniques for a wide range of applications since the first laparoscopic appendectomy was performed in 1983. At the helm of this MIS shift has been laparoscopy, with robotic surgery also gaining ground in a number of areas.

METHODS

Researchers estimated national volumes, growth forecasts, and MIS adoption rates for the following procedures: cholecystectomy, appendectomy, gastric bypass, ventral hernia repair, colectomy, prostatectomy, tubal ligation, hysterectomy, and myomectomy. MIS adoption rates are based on secondary research, interviews with clinicians and administrators involved in MIS, and a review of clinical literature, where available. Overall volume estimates and growth forecasts are sourced from The Advisory Board Company's national demand model which provides current and future utilization rate projections for inpatient and outpatient services. The model takes into account demographics (growth and aging of the population) as well as non demographic factors such as inpatient to outpatient shift, increase in disease prevalence, technological advancements, coverage expansion, and changing payment models.

RESULTS

Surgeons perform cholecystectomy, a relatively simple procedure, laparoscopically in 96 % of the cases. Use of the robot as a tool in laparoscopy is gaining traction in general surgery and seeing particular growth within colorectal surgery. Surgeons use robotic surgery in 15 % of colectomy cases, far behind that of prostatectomy but similar to that of hysterectomy, which have robotic adoption rates of 90 and 20 %, respectively.

CONCLUSIONS

Surgeons are using minimally invasive surgical techniques, primarily laparoscopy and robotic surgery, to perform procedures that were previously done as open surgery. As risk-based pressures mount, hospital executives will increasingly scrutinize the cost of new technology and the impact it has on patient outcomes. These changing market dynamics may thwart the expansion of new surgical techniques and heighten emphasis on competency standards.

Single-incision versus conventional laparoscopic cholecystectomy in patients with uncomplicated gallbladder disease: a meta-analysis

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment for cholecystectomy. Recently, single-incision laparoscopic cholecystectomy (SILC) has been suggested as an alternative technique.

METHODS

Six databases were searched and reference lists of retrieved articles were checked to identify eligible studies. Data from randomized clinical trials related to the safety and effectiveness of SILC versus conventional laparoscopic cholecystectomy (CLC) were extracted by 2 independent reviewers. Odds ratio and mean differences were calculated with 95% confidence intervals based on intention-to-treat analyses whenever possible.

RESULTS

Fifteen studies with 1113 patients met the eligibility criteria. Methodologic quality was unclear in most trails. Operating time was significantly longer in the single-incision laparoscopic surgery group compared with the CLC group (P<0.00001). Cosmesis was improved in single-incision laparoscopic patients at 1 month (P<0.00001). The pooled mean difference in pain scores at 24 hours was -0.75 in favor of the SILC technique (P=0.04). There was no significant difference in the conversion rates, adverse events, analgesia requirements, or the length of hospital stay between the 2 groups.

CONCLUSIONS

The current evidence shows that patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder who prefer a better cosmetic outcome, SILC offers a safe alternative to CLC. Further high-powered randomized trials are need to determine whether SILC truly offer any advantages, especially be focused on failure of technique, adverse events, cosmesis, and quality of life.

Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy

Background

Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC.

Methods

Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents.

Results

Some 74·9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0·030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P &lt; 0·001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions.

Conclusion

SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. Registration number: NCT00370344 (http://www.clinicaltrials.gov).

Shaping tissue with shape memory materials

After being severely and quasi-plastically deformed, shape memory materials are able to return to their original shape at the presence of the right stimulus. After a brief presentation about the fundamentals, including various shape memory effects, working mechanisms, and typical shape memory materials for biomedical applications, we summarize some major applications in shaping tissue with shape memory materials. The focus is on some most recent development. Outlook is also discussed at the end of this paper.

Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis

BACKGROUND

Laparoscopic hepatectomy (LH) has been proposed as a safe and feasible treatment option for liver diseases. However, the short- and long-term outcomes of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) have not been adequately assessed. Thus, as another means of surgical therapy for hepatocellular carcinoma (HCC), we assessed the feasibility of performing LH as the standard procedure for disease in the left lateral lobe and peripheral right segments for HCC in selected patients.

METHODS

Literature search included PubMed, Embase, Science Citation Index, SpringerLink, and secondary sources, from inception to March 2012, with no restrictions on languages or regions. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed by the Q statistic. Subgroup and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of study quality.

RESULTS

A total of 1238 patients (LH 485, OH 753) from 15 studies were included. The pooled odds ratios for postoperative morbidity and incidence of negative surgical margin in LH were found to be 0.37 (95 % confidence interval [CI] 0.27-0.52; P < 0.01) and 1.63 (95 % CI 0.82-3.22; P = 0.16), respectively, compared with OH. Blood loss was significantly decreased in the LH (weighted mean difference -224.63; 95 % CI -384.87 to -64.39; P = 0.006). No significant difference was observed between the both groups for long-term outcomes of overall survival and recurrence-free survival.

CONCLUSIONS

In patients with solitary left lateral lobe/right peripheral subcapsular tumors treated with minor resection, this meta-analysis demonstrated that compared to OH, LH may have short-term advantages in terms of blood loss and postoperative morbidity for HCC. Both procedures have similar long-term outcomes. It may be time to consider changing the standard procedures for treatment of HCC in the left lateral lobe and peripheral subcapsular right segments in selected patients.

Single-incision laparoscopic cholecystectomy versus multi-incision laparoscopic cholecystectomy: a meta-analysis of randomized clinical trials

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is theoretically supposed to be associated with better cosmetic results and less surgical-site pain than multi-incision laparoscopic cholesystectomy (MILC). So far, several relevant randomized controlled trials (RCTs) have been reported, but the results are conflicting.

MATERIALS AND METHODS

Meta-analysis was conducted with all the qualified RCTs comparing SILC with MILC. The databases include PubMed, EmBase, and the Cochrane Library, and the censor data were collected up to November 2011. The analyzed outcome variables included postoperative pain score, analgesia requirements, morbidity, conversion rate, operative time, postoperative hospital stay, and postoperative cosmetic score. Analyses were based on the intention-to-treat principle, if possible. All the calculations and statistical tests were performed using ReviewerManager version 5.1.2 software.

RESULTS

Nine trials with a total of 755 patients (SILC in 400 patients, MILC in 355 patients) were identified and analyzed. SILC resulted in significantly longer operative time (P=.005) and higher postoperative cosmetic score on Day 30 after operation (P<.00001). There was no statistically significant difference between the groups in terms of postoperative pain score, analgesia requirements, morbidity, conversion rate, and postoperative hospital stay.

CONCLUSIONS

Based on the current meta-analysis, SILC appears to be as safe and effective as MILC to remove the gallbladder and results in a longer operative time and higher cosmetic satisfaction on Day 30 after surgery.

NOTES, MANOS, SILS and other new laparoendoscopic techniques

A new way of opening a body cavity can be a revolution in surgery. In 1980s, laparoscopy changed how surgeons had been working for years. Natural orifice translumenal endoscopic surgery (NOTES), minilaparoscopy-assisted natural orifice surgery (MANOS), single incision laparoscopic surgery (SILS) and other new techniques are the new paradigm in our way of operating in the 21^st century. The development of these techniques began in the late 90s but they have not had enough impact to develop and evolve. Parallels between the first years of laparoscopy and NOTES can be made. Working for an invisible surgery, not only for cosmesis but for a less invasive surgery, is the target of NOTES, MANOS and SILS performed by surgeons and endoscopists over the last 10 years. The future flexible endoscopic platforms and the fusion between laparoscopic instruments and devices and robotic surgery will be a great advance for “scarless surgery”.

Evaluation of hemodynamic changes using different intra-abdominal pressures for laparoscopic cholecystectomy

Biliary diseases known since ages constitute major portion of digestive tract disorders world over. Among these cholelithiasis being the fore runner causing general ill health, thereby requiring surgical intervention for total cure. The study was undertaken in an attempt to compare the hemodynamic changes in patient undergoing laparoscopic cholecystectomy using different intra-abdominal pressures created due to carbon dioxide insufflation. The patients were randomly allocated to one of the three groups in which different levels of intra-abdominal pressures (8-10 mmHg,11-13 mmHg and 14 mmHg and above) were maintained. The base line parameters monitored were heart rate, non invasive blood pressur(systolic and mean)and end tidal carbon dioxide. All the parameters were monitored at various intervals i.e. Immediately during insufflation, 5 min, 10 min, 20 min, 30 min after CO2 insufflation and after every 10 min if surgery exceeds 30 min, at exsufflation,10 min after CO2 exsufflation. Patients were ventilated with Pedius Drager Ventilator keeping tidal volume 8-10 ml/kg and respiratory rate 12-14 breaths/min. During surgery patients were placed in reverse Trendlenburg position (head up) at 15 °. The results obtained were evaluated statistically and analyzed. Baseline characteristics were found to be comparable. Hemodynamic variables were reported as mean and standard deviation. Statistical significance among groups was evaluated using Analysis of Variance and unpaired student t test (two tailed). Inter-group comparisons were made using Bonferroni test. A p-value of <0.05 was considered as statistically significant. In all the three groups the mean heart rate (baseline 84.08 ± 12.50, 87.96 ± 15.73 and 86.92 ± 17.00 respectively) increased during CO2 insufflation and the rise in heart rate continued till exsufflation after which it decreased and at 10 min after exsufflation the heart rates were comparable with the baseline. The inter-group comparison of mean heart rate between I & III was statistically significant at 10, 20, 30 min after CO2 insufflation which continued at exsufflation and 10 min after CO2 exsufflation [p < 0.05]. The inter-group comparison between I & III showed statistically significant difference in systolic blood pressure at 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p = 0.0001] and mean arterial pressure at 5, 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p = 0.0001]. Comparison between Group I and Group III & between Group II and Group III showed highly significant statistical difference in EtCO2 immediately after insufflation and the same trend was seen till the completion of surgery and even 10 min after exsufflation [p = 0.001]. The conclusion drawn from the study was that laparoscopic cholecystectomy induces significant hemodynamic changes intraoperatively, the majority of pathophysiological changes are related to cardiovascular system and are caused by CO2 insufflation .A high intra-abdominal pressure due to CO2 insufflation is associated with more fluctuations in hemodynamic parameters and increased peritoneal absorption of CO2 as compared to low intraabdominal pressure so low pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse hemodynamic effects of CO2 insufflation.

Body temperature evaluation during induced pneumoperitoneum with CO₂: an experimental study in pigs

BACKGROUND

In prolonged laparoscopic procedures, hypothermia is frequently observed. The possible influence of the vasodilating action of CO(2), due to its increased levels in the blood during the laparoscopic procedures, has yet to be studied. The objective of this study was, therefore, to evaluate body temperature patterns in pigs subjected to pneumoperitoneum with CO(2).

METHODS

Thirty male pigs were allocated into three groups of ten animals each: group I, anesthetic procedure and abdominal puncture only; group II, the same as for group I and insufflation with CO(2); and group III, the same as for group I and insufflation with medical grade compressed air. After anesthetic induction and surgical preparation, rectal and esophageal temperatures were measured every 10 min. Blood was collected during the experiment for the gasometric measurement of pCO(2). Animals were insufflated with no gas loss and were kept anesthetized for 180 min. For statistical analysis, Friedman and Kruskal-Wallis tests were used at a level of significance of 95% (P < 0.05).

RESULTS

Animals in groups I and II (P = 0.000) had a statistically significant drop in both esophageal and rectal temperatures during the experiment, but not animals in group III. However, when the groups were compared among themselves, no statistically significant differences were found at any of the times measured. A statistically significant drop in pCO(2) levels was observed for groups I and III, but not for animals in groups II.

CONCLUSIONS

The use of CO(2) did not significantly affect body temperature variation in pigs subjected to pneumoperitoneum. However, CO(2) produced a temperature drop pattern different than that of compressed air, indicating that CO(2) may lead to thermoregulatory changes and influence the peripheral temperature drop.

Is cholecystectomy necessary after endoscopic treatment of bile duct stones in patients older than 80 years of age?

BACKGROUND AND AIMS

Although patients with cholecystocholedocholithiasis are generally referred to cholecystectomy after endoscopic sphincterotomy (ES) and common bile duct clearance, we often have a conflict whether cholecystectomy is necessary in very elderly patients with comorbid diseases. The aim of this study is to assess whether cholecystectomy in very elderly patients is justified after ES.

PATIENTS AND METHODS

Patients with cholecystocholedocholithiasis who underwent ES and stone extraction and were followed-up for more than 10 years were retrospectively reviewed. We divided these patients into two groups: the elderly group (equal to or more than 80 years old) and young group (less than 80 years old) and compared late biliary complications and mortality.

RESULTS

The 10-year cumulative incidence of overall biliary complications was significantly lower in cholecystectomized patients than in patients with gallbladder in situ in the young group (7.5 vs. 21.7%, p = 0.0037), but not different in the elderly group (8.3 vs. 7.4%, p = 0.92). When each complication was evaluated separately, the rate of recurrent common bile duct stones (CBDS) was not different, but that of acute cholecystitis was significantly lower in the elderly group than in the young group (4.1 vs. 22.6%, p = 0.011).

CONCLUSIONS

In very elderly patients the incidence of acute cholecystitis is low even when the gallbladder is preserved after endoscopic treatment of CBDS, with a similar risk of CBDS recurrence. Thus, it may not be necessary to recommend cholecystectomy after ES for CBDS in very elderly patients.

Laparoscopic adrenalectomy: lessons learned from 306 cases

INTRODUCTION

Laparoscopic adrenalectomy has become the standard of care for the surgical treatment of benign adrenal pathology. We present the following case series documenting our experience in refinement of this approach.

PAIENTS AND METHODS

Analysis of patient records identified those in whom laparoscopic adrenalectomy was performed from January 1997 through February 2010. Study variables included indications, operative time, blood loss, length of hospital stay, histopathological evaluation, and complications.

RESULTS

Laparoscopic adrenalectomy was performed in 306 patients using the transperitoneal lateral approach. No major operative complications were noted, and postoperative complications included a pulmonary embolism and 2 cases of pneumonia. Conversion to the open approach was necessitated in two cases. The median operative time was 95±29 minutes (range, 45-145 minutes). Estimated blood loss was 60 mL (range, 30-150 mL). The mean size of the removed gland was 5.9±1.6 cm (range, 3-13 cm). The mean size of the tumor was 5±2 cm (range, 0.5-12 cm). The median hospitalization was 4±3.7 days (range, 2-22 days). Adrenal pathology included adenoma (n=164), pheochromocytoma (n=79), hyperplasia (n=35), metastatic carcinoma (n=22), cyst (n=9), myelolipoma (n=9), hemangioma (n=3), ganglioneuroma (n=3), and melanoma (n=2).

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery.

Cholecystectomy: from Langenbuch to natural orifice transluminal endoscopic surgery

Gallstones have led to pain and complications in humankind for millennia. Beginning in the 1880s, cholecystectomy, performed through a sizable abdominal incision, was the treatment of choice for symptomatic cholelithiasis. During the late 1980s pioneering surgeons first used laparoscopic techniques to remove the gallbladder. Although initially associated with a significantly increased rate of bile duct injury, the clinical advantages of laparoscopy compared to open operation became readily apparent, ushering in the "laparoscopic revolution." More recently, attempts at rendering cholecystectomy even less invasive--smaller or fewer incisions or eliminating abdominal incisions altogether--have been described, with limited clinical series reported. At the current time, laparoscopic cholecystectomy is the gold standard for gallbladder removal, and any newer techniques must be demonstrated to result in superior outcomes for widespread adoption.

Novel reconstruction of the extrahepatic biliary tree with a biosynthetic absorbable graft

OBJECTIVES

The reference standard technique for the reconstruction of the extrahepatic biliary tree is Roux-en-Y hepaticojejunostomy. This procedure is not without complications and may not be feasible in some patients. This project sought to evaluate a novel approach for repairing common bile duct injuries with a biosynthetic graft. This allows for the reconstruction of the anatomy without necessitating an intestinal bypass.

METHODS

Study subjects were 11 mongrel hounds. Utilizing an open approach, the common bile duct was transected in each animal. A 1-cm graft of a synthetic bioabsorbable prosthesis was interposed over a 5-Fr pancreatic stent and sewn in place as an interposition tube graft with absorbable sutures. Intraoperative cholangiograms and monthly liver function tests were completed. Animals were killed at 6, 7, 8, 10 and 12 months.

RESULTS

The first five animals were killed early in the process of protocol development. One animal developed obstructive symptoms and was killed on postoperative day 14. The next five animals were longterm survivors without evidence of clinically significant graft stenosis. Mean alkaline phosphatase and total bilirubin were normal, at 140 U/l and 0.2 mg/dl, respectively. Histology showed the complete replacement of the graft with native tissue at 6 months.

CONCLUSIONS

  Biliary reconstruction using a synthetic bioabsorbable prosthetic as an interposition tube graft is feasible based on initial results.

Who did the first laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) has served as the igniting spark in the laparoscopic surgery explosion; however, it is unclear who created the spark. The question remains: Who did the first LC?

Bile duct injuries during open and laparoscopic cholecystectomy in the laparoscopic era: alarming trends

BACKGROUND

After the introduction of laparoscopic cholecystectomy (LC), scientific discussion and concern about iatrogenic bile duct injuries (BDIs) have been limited mostly to BDIs sustained in LC, while BDIs sustained in open cholecystectomy (OC) and in all cholecystectomies have not been the center of attention.

METHODS

This study included all patients who sustained BDI in OC or LC in southwest Finland between 1997 and 2007. All data were collected retrospectively in June 2009.

RESULTS

Altogether 75 BDIs were encountered in a total of 8349 cholecystectomies, for an overall incidence of 0.90%. Twenty BDIs (15 Amsterdam type A and 5 type B, C, or D) occurred in the 1616 OCs (incidence rate = 1.24%), and 55 (26 type A and 29 type B, C, or D) in the 6733 LCs (incidence rate = 0.82%). All the BDIs in the OCs were missed while 11/29 of the major BDIs in the LCs were detected at the time of surgery. Fifty-four of 59 type A, B, and C BDIs could be treated endoscopically.

CONCLUSIONS

In the laparoscopic era, OC is associated with a high number of BDIs, if minor BDIs are included. Excluding some major LC BDIs, BDIs are, as a rule, missed at the time of surgery. More than 90% of Amsterdam types A, B, and C BDIs can be treated endoscopically, whereas type D BDI remains an absolute indication for surgery.

Is laparoscopy contraindicated in giant adrenal masses?

The first laparoscopic adrenalectomy was performed and described by Gagner in 1992. Since then, this technique has become more and more widespread and there is common agreement in the literature that it is the gold standard for adrenalectomy. Laparoscopic adrenalectomy is indicated in benign adrenal masses, and it is routinely performed in masses smaller than 5 to 7 cm. The laparoscopic procedure in masses larger than this cut-off is discussed, although many investigators agree about its feasibility, safety and effectiveness. We present this case: man, 39 years old, large palpable mass in the right hypochondrium. Computed tomography scan (CT) suggested the diagnosis of giant adrenal myelolipoma (15x12x7 cm). Complete adrenal endoclinologic evaluation showed that the lesion was not a secreting tumor. Laparoscopic adrenalectomy was performed with good results.

Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy

BACKGROUND

Although intraoperative cholangiography has been recommended for avoiding bile duct injury during laparoscopic cholecystectomy, radiographic cholangiography is time consuming and may itself cause injury to the bile duct. Recently, a novel fluorescent cholangiography technique using the intravenous injection of indocyanine green (ICG) has been developed.

METHODS

In 52 patients undergoing laparoscopic cholecystectomy, 2.5 mg ICG was injected intravenously 30 min before the patient entered the operating room or following intubation. A fluorescent imaging system, which consisted of a xenon light source and a laparoscope with a charge-coupled device camera that could filter out light wavelengths below 810 nm, was used. Fluorescent cholangiography was performed during dissection of Calot's triangle, and its ability to delineate biliary anatomy was compared with that of preoperative cholangiography.

RESULTS

Fluorescent cholangiography delineated the cystic duct in all 52 patients, and the cystic duct-common hepatic duct junction was visible before dissection of Calot's triangle in 50 patients. Fluorescent imaging also identified all accessory bile ducts that had been diagnosed before surgery in eight patients.

CONCLUSION

Fluorescent cholangiography enables real-time identification of biliary anatomy during dissection of Calot's triangle. This simple technique may become standard practice for avoiding bile duct injury during laparoscopic cholecystectomy, replacing radiographic cholangiography.

Delayed assessment and eager adoption of laparoscopic cholecystectomy: Implications for developing surgical technologies

Despite the prevailing emphasis in the medical literature on establishing evidence, many changes in the practice of surgery have not been achieved using proper evidence-based assessment. This paper examines the adoption of laparoscopic cholecystectomy (LC) into regular use for the treatment of cholecystitis and the process of its acceptance, focusing on the limited role of technology assessment in its appraisal. A review of the published medical literature concerning LC was performed. Approximately 3000 studies of LC have been conducted since 1985, and there have been nearly 8500 publications to date. As LC was adopted enthusiastically into practice, the results of outcome studies generally showed that it compared favorably with the traditional, open cholecystectomy with regard to mortality, complications, and length of hospital stay. However, despite the rapid general agreement on surgical technique, efficacy, and appropriateness, there remained lingering doubts about safety, outcomes, and cost of the procedure that suggested that essential research questions were ignored even as the procedure became standard. Using LC as a case study, there are important lessons to be learned about the need for important guidelines for surgical innovation and the adoption of minimally invasive surgical techniques into current clinical and surgical practice. We highlight one recent example, natural orifice transluminal endoscopic surgery and how necessary it is to properly evaluate this new technology before it is accepted as a safe and effective surgical option.

Laparoscopic adrenalectomy: balancing the operative indications with the technical advances

Laparoscopic adrenalectomy contributed significantly to reduction of morbidity and improvement of postoperative patient recovery time. The adoption of this technique had substantial impact on the management of adrenal incidentalomas. Although laparoscopic adrenalectomy should be in general avoided for known primary adrenal cancers, it is appropriate for metastasectomy of isolated adrenal metastatic disease.

Transition from pure laparoscopic to robotic-assisted radical prostatectomy: a single surgeon institutional evolution

PURPOSE

To review a single surgeon experience of transitioning to a robotic-assisted laparoscopic prostatectomy program (RALP) with prior pure laparoscopic radical prostatectomy (LRP) experience.

MATERIALS AND METHODS

A retrospective review of surgical results from a single surgeon performing LRP transitioning to RALP was performed. Two hundred five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared with 45 patients undergoing LRP by the same surgeon. Operative, pathologic, and functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized for assessing urinary and sexual parameters.

RESULTS

Preoperative parameters (age, PSA, Gleason score) were similar in both RALP and LRP groups. Operative time (190 vs. 299 minutes), estimated blood loss (253 vs. 299 ml), and length of stay (1.6 vs. 2.6 days) were reduced in RALP vs. LRP. Although not statistically significant, there was a trend toward fewer transfusions with RALP (2.0% vs. 4.4%) as well as a lower positive margin rate in organ-confined (pT2) disease (9.8%, RALP vs. 20%, LRP). Continence at 12 months was 94% following RALP as opposed to 82% after LRP. In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 81% potency at 12 months as opposed to only 62% following LRP.

CONCLUSIONS

The transition from LRP to RALP, in concert with an institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results.

Laparoscopic cholecystectomy in the obese: results with the traditional and fundus-first technique

INTRODUCTION

The aim of this study was to assess retrospectively the results of laparoscopic cholecystectomy (LC) performed in obese patients at our institution with the traditional technique and with the fundus-first (FF) technique.

PATIENTS AND METHODS

We performed a retrospective analysis of 194 obese patients that underwent LC between 1994 and December 2007 at our institution. Surgical techniques were compared with respect to operative times, conversion to open cholecystectomy, postoperative complications, mortality, and length of postoperative stay.

RESULTS

In the reviewed period, LC was performed in 113 (58.2%) patients with obesity type I (OTI), 55 (28.3%) patients with obesity type II (OTII), and 26 (13.5%) patients with obesity type III (OTIII). None of the differences among obese groups treated with the two techniques were statistically significant, with the exception of the lower operative times in the OTIII patients treated with the FFLC. The median operating time in the OTIII group was, respectively, 90 minutes for traditional LC and 65 (range, 45-130) for FFLC (P < 0.05).

DISCUSSION AND CONCLUSIONS

This study achieved to conclude that LC in the obese is a safe, feasible, and efficient operation, but remains a demanding procedure even in experienced hands. FFLC can support the traditional LC in the treatment of obese patients, yielding a complication rate comparable with the traditional technique. In our study, it significantly reduced the operative time in OTIII patients, simplifying all the intra-abdominal maneuvers and the gallbladder dissection.

Laparoscopic distal pancreatectomy with splenic conservation: an operation without increased morbidity

Objectives. The advent of minimally invasive techniques was marked by a paradigm shift towards the use of laparoscopy for benign distal pancreatic masses. Herein we describe one center's experience with laparoscopic distal pancreatectomy. Methods. A retrospective chart review was performed for all distal pancreatectomies completed laparoscopically from 1999 to 2009. Outcomes from those cases completed with a concurrent splenectomy were compared to the spleen-preserving procedures. Results. Twenty-four patients underwent laparoscopic distal pancreatectomy. Seven had spleen-conserving operations. There was no difference in the mean estimated blood loss (316 versus 285 mL, P = .5) or operative time (179 versus 170 minutes, P = .9). The mean tumor size was not significantly different (3.1 versus 2.2 cm, P = .9). There was no difference in the average hospital stay (7.1 versus 7.0 days, P = .7). Complications in the spleen-preserving group included one iatrogenic colon injury, two pancreatic fistulas, and two cases of iatrogenic diabetes. In the splenectomy group, two developed respiratory failure, three acquired iatrogenic diabetes, and two suffered pancreatic fistulas (71% versus 41%, P = .4). Conclusions. The laparoscopic distal pancreatectomy is a safe operation with a low morbidity. Splenic conservation does not significantly increase the morbidity of the procedure.

Three-port versus four-port laparoscopic cholecystectomy: meta-analysis of randomized clinical trials

BACKGROUND

Since the first laparoscopic cholecystectomy was reported, the four-trocar laparoscope has become the golden standard procedure. Some surgeons, however, thought that the three-port technique may be safe, effective, and economic. Our meta-analysis compared the three-port technique to the four-port technique.

METHODS

We searched the Cochrane Library, MEDLINE, EMBASE, and Chinese Biomedical Literature Database. Quality assessment and data extraction were done by two reviewers independently. The statistical analysis was performed by RevMan4.2.10 software.

RESULTS

A total of five publications comprising 591 patients met the inclusion criteria. The result showed that three-port technique could not reduce the analgesia requirements: the sample mean difference (SMD) and 95% confidence interval (CI) were -0.28 (-0.66, 0.10). There were no significant differences between the two groups in terms of operating time [weighted mean difference (WMD) = 2.08, 95% CI (-3.63, 7.79)], success rate [odds ratio (OR) = 0.99,95% CI (0.31, 3.12)], or postoperative hospital stay [OR = -0.52,95% CI (-1.22, 0.17)].

CONCLUSIONS

The current evidence showed that the two groups had similar operating times, success rates, analgesia requirements, and postoperative hospital stays. The methodological qualities of studies are not high, so more high-quality studies are needed for further analysis.

Elective laparoscopic cholecystectomy for surgical trainees: predictive factors of operative time

AIM

To determine pre-operative criteria to predict duration and technical difficulty of laparoscopic cholecystectomies that will aid in identifying patients suitable for training lists.

METHOD

A prospective analysis of 835 consecutive patients who underwent laparoscopic cholecystectomies. Data collected included patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (ES), duration of surgery (from skin incision to skin closure), peri-operative and postoperative complications and histological gallbladder wall thickness.

RESULTS

Post-operative complications were seen in 3% (n=20). Overall open conversion rate was 2%. The mean duration of surgery was 78.76 +/- 1.75 minutes. Age, ERCP and ES were not independent predictors of a long operation time. However, a positive correlation was seen with histological gallbladder wall thickness and duration of surgery (p=0.001). The mean operating time for gallbladder wall thickness < 3 mm was 72.1 +/- 1.62 minutes whereas that for > 3 mm thickness was 83.3 +/- 2.05 minutes (p=<0.001).

CONCLUSION

Gallbladder wall thickness can be used as an independent predictor of a long operation time.

A new model for health care delivery

BACKGROUND

The health care delivery system in the United States is facing cost and quality pressures that will require fundamental changes to remain viable. The optimal structures of the relationships between the hospital, medical school, and physicians have not been determined but are likely to have a large impact on the future of healthcare delivery. Because it is generally agreed that academic medical centers will play a role in the sustainability of this future system, a fundamental understanding of the relative contributions of the stakeholders is important as well as creativity in developing novel strategies to achieve a shared vision.

DISCUSSION

Core competencies of each of the stakeholders (the hospital, the medical school and the physicians) must complement the others and should act synergistically. At the same time, the stakeholders should determine the common core values and should be able to make a meaningful contribution to the delivery of health care.

SUMMARY

Health care needs to achieve higher quality and lower cost. Therefore, in order for physicians, medical schools, and hospitals to serve the needs of society in a gratifying way, there will need to be change. There needs to be more scientific and social advances. It is obvious that there is a real and urgent need for relationship building among the professionals whose duty it is to provide these services.

N.O.T.E.S.: the progression of a novel and emerging technique

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the latest and perhaps most significant innovation in surgery since Phillipe Mouret of France performed the first laparoscopic cholecystectomy in 1987. This new "minimum-invasive" concept that promises scar-free surgery is steadily gathering momentum. It is another milestone in our quest to eliminate surgical trauma, speed patient recovery time and decrease surgical wound-related complications. On 22 July 2005, the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) published a white paper highlighting the barriers to NOTES development, which included the need for appropriate selection of access points, effective closure of the enterotomy site, innovative tools, stable platforms and improved endoscopic orientation. These are just some of the many issues that need to be resolved before the NOTES concept and technique could become a common feature of modern surgery. The publication of the white paper ushered in the beginning of multiple research projects using animal models to test the application of NOTES and its newly developed instruments. The success in animal models was followed by several highly selected successful human trials. National and international surgical innovation departments should now be created where medical industry personnel including inventors, designers and engineers can work together with the medical and surgical providers to address all the limitations affecting NOTES progress.

Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial

BACKGROUND

Post-laparoscopic pain syndrome is well recognized and characterized by abdominal and particularly shoulder tip pain; it occurs frequently following laparoscopic cholecystectomy. The etiology of post-laparoscopic pain can be classified into three aspects: visceral, incision, and shoulder. The origin of shoulder pain is only partly understood, but it is commonly assumed that the cause is overstretching of the diaphragmatic muscle fibers owing to a high rate of insufflations. This study aimed to compare the frequency and intensity of shoulder tip pain between low-pressure (7 mmHg) and standard-pressure (14 mmHg) in a prospective randomized clinical trial.

METHODS

One hundred and forty consecutive patients undergoing elective laparoscopic cholecystectomy were randomized prospectively to either high- or low-pressure pneumoperitoneum and blinded by research nurses who assessed the patients during the postoperative period. The statistical analysis included sex, mean age, weight, American Society of Anesthesiologists (ASA) grade, operative time, complication rate, duration of surgery, conversion rate, postoperative pain by using visual analogue scale, number of analgesic injections, incidence and severity of shoulder tip pain, and postoperative hospital stay. p < 0.05 was considered indicative of significance.

RESULTS

The characteristics of the patients were similar in the two groups except for the predominance of males in the standard-pressure group (controls). The procedure was successful in 68 of 70 patients in the low-pressure group compared with in 70 patients in the standard group. Operative time, number of analgesic injections, visual analogue score, and length of postoperative days were similar in both groups. Incidence of shoulder tip pain was higher in the standard-pressure group, but not statistically significantly so (27.9% versus 44.3%) (p = 0.100).

CONCLUSIONS

Low-pressure pneumoperitoneum tended to be better than standard-pressure pneumoperitoneum in terms of lower incidence of shoulder tip pain, but this difference did not reach statistical significance following elective laparoscopic cholecystectomy.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM

To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury.

METHODS

From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively.

RESULTS

Bile duct injury was caused by cholecystectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini-incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively.

CONCLUSION

Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Evaluation of a single preoperative dose of pregabalin for attenuation of postoperative pain after laparoscopic cholecystectomy

BACKGROUND

Postoperative pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy. We have evaluated the efficacy of a single preoperative dose of pregabalin for attenuating postoperative pain and fentanyl consumption after laparoscopic cholecystectomy.

METHODS

Sixty adults (16-60 yr), ASA physical status I and II, of either sex undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized placebo controlled, double-blind study. Subjects were divided into two groups of 30 each to receive either a matching placebo or pregabalin 150 mg, administered orally 1 h before surgery. Postoperative pain (static and dynamic) was assessed by a 100 mm visual analogue scale, where 0, no pain; 100, worst imaginable pain. Subjects received patient-controlled i.v. fentanyl analgesia during the postoperative period. Results were analysed by Student's t-test, chi(2) test, Mann-Whitney U-test, and Fisher's exact test.

RESULTS

Postoperative pain (static and dynamic) and postoperative patient-controlled fentanyl consumption were reduced in the pregabalin group compared with the placebo group (P<0.05). Side-effects were similar in both groups.

CONCLUSIONS

A single preoperative oral dose of pregabalin 150 mg is an effective method for reducing postoperative pain and fentanyl consumption in patients undergoing laparoscopic cholecystectomy.