Coelioscopic cholecystectomy. Preliminary report of 36 cases

Limits and advantages of fundus-first laparoscopic cholecystectomy: lessons learned

BACKGROUND

Fundus-first cholecystectomy is well recognized as a safe technique during open cholecystectomy (OC) because it minimizes the risk of injuries to the biliary structures at the Calot's triangle. Fundus-first laparoscopic cholecystectomy (FFLC), like the OC, has been proposed as a safe method to approach the cystic duct in cases of difficult anatomy in order to limit biliary injuries and to reduce the conversion rate. The aim of our study was to highlight the limits and advantages of the FFLC, in order to evaluate whether the potential complications are counterbalanced by the expected reduction of the conversion rate.

METHODS

We retrospectively analyzed 1965 consecutive cases of laparoscopic cholecystectomies performed for gallbladder disease from 1994 to 2005. Reasons for adoption of the FFLC, conversion to OC, and complications were compiled.

RESULTS

The FLC was performed in 29 cases (1.5%) and was successful in 23 patients (80%). The median operating time for the FFLC was 65 minutes (range, 40-170). In 6 patients (20%), FFLC was eventually converted to open operation. Intraoperative cholangiography (IOC) was performed successfully in 17 cases (74%). Common bile duct (CBD) stones were found in 6 cases (20%). Minor complications occurred in 6 patients (20%). No CBD injuries occurred. Two cases of residual CBD stones were treated postoperatively. Mortality rate was nil.

CONCLUSIONS

The FLC remains a safe option when dealing with patients with difficult anatomy at the Calot's triangle, but its adoption needs a good surgical judgment. Considering the high incidence of CBD stones in this series, the high failure rates in performing an IOC represent the most important limiting factor.

Ten years of laparoscopic cholecystectomy: a comparison between a developed and a less developed country

OBJECTIVE

To compare the specific features and outcomes of laparoscopic cholecystectomy in two university hospitals, one in a developing country, Bosnia-Herzegovina, and the other in a well developed country, Italy.

METHODS

Between January 1996 and December 2005, a total of 2018 patients underwent laparoscopic cholecystectomy in Mostar Clinical Hospital, Bosnia-Herzegovina (1066) and in Chieti University Hospital, Chieti, Italy (952). Differences in patients' presentations, diagnostic protocols, medication, surgical treatment, complications and outcomes were analyzed.

RESULTS

The number of patients with life-threatening conditions was lower in Italy (15 or 1.5% vs. 53 or 4.9%; P<0.001), as was the use of analgesia and antibiotics (131 or 13.96% vs. 873 or 81.97%; P<0.001). Open-access biliary surgery was rare in Italy, where the vast majority of patients were operated laparoscopically; only 44 (4.41%) patients had open-access surgery, including 35 (3.61%) conversion patients. In comparison, 1669 (61%) patients in Bosnia-Herzegovina underwent open-access operations. There was a significant difference, in favor of the Italian hospital, in the number of surgical complications (8 or 0.84% vs. 40 or 3.75%; P<0.002) and also in the number of postoperative infections following surgical incision (0 or 0.0% vs. 6 or 0.56%; P<0.033).

CONCLUSIONS

It is encouraging for surgeons in Bosnia-Herzegovina to find that satisfactory results can be achieved in a developing country. However, the number of complications encountered in the Mostar hospital emphasizes the need for further improvement of surgical technique through better structured training combined with strict supervision of junior staff. The finding of postoperative infections in the Bosnia-Herzegovina hospital, despite that their occurrence was relatively rare, highlights the necessity for further improvement of hospital infection control.

Laparoscopic cholecystectomy: complications and conversions with the 3-trocar technique: a 10-year review

BACKGROUND

Traditional laparoscopic cholecystectomy (LC) includes the use of 4 trocars. The aim of this study is to show that LC can be performed safely with the 3-trocar technique, thus simplifying a very well-known technique.

METHODS

We performed a retrospective analysis of 1878 patients (male-to-female ratio was 1:3; median age of 44 y) that underwent 3-trocar LC between May 1994 and December 2004.

RESULTS

Three-trocar LC was successful in 1774 patients (94%) with a postoperative morbidity of 1.5% (0.5% of major complications), which includes 2 minor common bile duct lesions (type D according to Strasberg classification) and 1 right common iliac artery laceration. Mortality was nil. Among 249 cases of acute cholecystitis, the 3-trocar LC was successful in 172 patients (70%). The adoption of a fourth trocar was necessary in only 82 patients (4.3%). Conversion to laparotomy occurred in a total of 67 patient (3.5%), 22 of which directly from the 3-trocar technique. The median operating time of the 3-trocar LC was 40 minutes (range, 16 to 130) for chronic cholecystitis, and 80 minutes (range, 30 to 145) for acute cholecystitis. The difference in duration of the surgical procedure between the 2 groups was significant (P<0.05). Severe adhesions were more commonly the reason for conversion (P<0.05).

CONCLUSIONS

The study achieves to conclude that the 3-trocar technique can be safely performed, is not technically demanding, and yields in experienced hands a complication rate comparable with the conventional LC. Furthermore, it is less expensive and has a better cosmetic result.

Dissemination of bacteria labeled with technetium-99m after laparotomy and abdominal insufflation with different CO2 pressures on rats

PURPOSE: To asses the dissemination of bacteria labeled with technetium-99m (99mTc) from peritoneal cavity after different surgical procedures. METHODS: Bacteria of the Escherichia coli species labeled with 99mTc were used in a concentration of 10(8) units of colony-makers for ml (UFC/ml) and 1ml was inoculated through intra-peritoneal via. Forty-eight rats were divided into four groups: control, laparotomy, pneumoperitoneum with 10mmHg and pneumoperitoneum with 20mmHg of CO2. Procedures were performed 20 min after injection of the inoculum and lasted 30 min. Animals were sacrificed after six hours (Group 1) and 24 hours (Group 2). Samples of blood, liver and spleen were collected for radioactivity counting. RESULTS: After six hours, indirect detection of the bacteria in different organs was uniform in all groups. After 24 hours, a larger detection of technetium was observed in the livers of animals of the group insufflated with 20mmHg of CO2, when compared with those of control group (p<0.01). The other groups did not present statistically significant variations. CONCLUSIONS: The use of a higher intra-abdominal pressure was associated with a higher bacterial dissemination to the liver. The application of lower intra-abdominal pressures may be associated with a lower dissemination of the infectious status during laparoscopic approach of peritonitis status.

Patient recall after diagnostic laparoscopy for abdominal pain

BACKGROUND

The purpose of the study was to ascertain how well patients recall their discharge diagnosis and details of their surgical procedure after a diagnostic laparoscopy at our institution.

METHODS

Three hundred and forty-five patients were identified as being eligible in the study. Patient characteristics and treatment details were recorded. They were then contacted by telephone and 258 patients participated (response rate 75%). They were asked the same seven questions by an investigator who was blinded to their treatment details and their responses recorded.

RESULTS

The sample consisted of 248 (96%) women and 10 (4%) men. Only seven persons (3%) were incorrect about the state of their appendix. However, 108 persons (42%) were incorrect about their discharge diagnosis. Seventy-one patients (28%) were unhappy with the information they received while in hospital. Age, whether pathology was found, dissatisfaction or type of operation was not found to significantly influence patient recall of diagnosis.

CONCLUSION

We found that patients having a diagnostic laparoscopy at our institution often leave the hospital dissatisfied and with a poor understanding of their discharge diagnosis. This has important implications for future assessments of acute abdominal pain in these patients and can lead to misinformation and unnecessary surgical procedures.

Spilled gallstones: the source of an enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.

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 cholecys-tectomy 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.

Management of gallstone pancreatitis

Gallstones are the most common cause of acute pancreatitis in the western world. Most patients with ABP suffer a mild attack and are expected to make a full recovery. They can be managed supportively and undergo laparoscopic cholecystectomy with IOC during their initial hospitalization to prevent recurrence. If necessary, laparoscopic common bile duct exploration can be performed. Otherwise, postoperative ERCP can be performed to remove common bile duct stones. Patients with severe ABP require ICU admission, close clinical monitoring, and aggressive fluid resuscitation. There is a bimodal mortality in severe ABP with most late deaths caused by septic complications. Antibiotics should be used judiciously and are usually warranted only in the presence of infection or sepsis. ERCP, +/- ES, should be performed when signs of cholangitis are present. Early ERCP should be considered in patients with severe ABP who do not improve clinically. CT scanning should be performed to assess for necrosis or peripancreatic fluid collections. Patients with no fluid collections can undergo cholecystectomy once their clinical condition improves. Patients with peripancreatic fluid collections should be followed with serial CT scans. Laparoscopic cholecystectomy should be performed once resolution of the fluid collection is documented. If fluid collections do not resolve after 6 weeks, patients should undergo concurrent cholecystectomy and fluid drainage procedures. Sterile necrosis can be closely monitored and does not require necrosectomy unless the patient's clinical status deteriorates. Patients with infected necrosis should undergo necrosectomy when they are clinically stable. After recovery from an attack of severe ABP, patients require close follow-up because late complications are common. Currently, no single test can establish the diagnosis or predict the severity of ABP. A prompt diagnosis requires a high degree of suspicion and clinical acumen. Recognizing patients with severe pancreatitis is an important priority because it affects the type and timing of intervention. The management of these patients requires close clinical observation and a multidisciplinary approach between the surgeon, radiologist, gastroenterologist, and intensivist.

Three-port versus standard four-port laparoscopic cholecystectomy: a randomized controlled clinical trial in a community-based teaching hospital in eastern Nepal

OBJECTIVES

With increasing surgeon experience, laparoscopic cholecystectomy has undergone many refinements including reduction in port number and size. Three-port laparoscopic cholecystectomy has been reported to be safe and feasible in various clinical trials. However, whether it offers any additional advantages remains controversial. This study reports a randomized trial that compared the clinical outcomes of 3-port laparoscopic cholecystectomy versus conventional 4-port laparoscopic cholecystectomy.

METHODS

Seventy-five consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to undergo either the 3-port or the 4-port technique. Four surgical tapes were applied to standard 4-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the 4 sites was assessed on the first day after surgery by using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length of the operation, postoperative stay, and patient satisfaction score on surgery and scars.

RESULTS

Demographic data were comparable for both groups. Patients in the 3-port group had shorter mean operative time (47.3+/-29.8 min vs 60.8+/-32.3 min) for the 4-port group (P=0.04) and less pain at port sites (mean score using 10-cm unscaled VAS: 2.19+/-1.06 vs 2.91+/-1.20 (P=0.02). Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score (mean score using 10-cm unscaled VAS: 8.2+/-1.7 vs 7.8+/-1.7, P=0.24) on surgery and scars were similar between the 2 groups.

CONCLUSION

Three-port laparoscopic cholecystectomy resulted in less individual port-site pain and similar clinical outcomes with fewer surgical scars and without any increased risk of bile duct injury compared with 4-port laparoscopic cholecystectomy. Thus, it can be recommended as a safe alternative procedure in elective laparoscopic cholecystectomy.

Innovation in surgery: a historical perspective

OBJECTIVE

To describe the field of surgical innovation from a historical perspective, applying new findings from research in technology innovation.

BACKGROUND

While surgical innovation has a rich tradition, as a field of study it is embryonic. Only a handful of academic centers of surgical innovation exist, all of which have arisen within the last 5 years. To this point, the field has not been well defined, nor have future options to promote surgical innovation been thoroughly explored. It is clear that surgical innovation is fundamental to surgical progress and has significant health policy implications. A process of systematically evaluating and promoting innovation in surgery may be critical in the evolving practice of medicine.

METHODS

A review of the academic literature in technology innovation was undertaken. Articles and books were identified through technical, medical, and business sources. Luminaries in surgical innovation were interviewed to develop further relevance to surgical history. The concepts in technology innovation were then applied to innovation in surgery, using the historical example of surgical endoscopy as a representative area, which encompasses millennia of learning and spans multiple specialties of care.

RESULTS

The history of surgery is comprised largely of individual, widely respected surgeon innovators. While respecting individual accomplishments, surgeons as a group have at times hindered critical innovation to the detriment of our profession and patients. As a clinical discipline, surgery relies on a tradition of research and attracting the brightest young minds. Innovation in surgery to date has been impressive, but inconsistently supported.

CONCLUSION

A body of knowledge on technology innovation has been developed over the last decade but has largely not been applied to surgery. New surgical innovation centers are working to define the field and identify critical aspects of surgical innovation promotion. It is our responsibility as a profession to work to understand innovation in surgery, discover, translate, and commercialize advances to address major clinical problems, and to support the future of our profession consistently and rationally.

Innovation in surgery: a historical perspective

OBJECTIVE

To describe the field of surgical innovation from a historical perspective, applying new findings from research in technology innovation.

BACKGROUND

While surgical innovation has a rich tradition, as a field of study it is embryonic. Only a handful of academic centers of surgical innovation exist, all of which have arisen within the last 5 years. To this point, the field has not been well defined, nor have future options to promote surgical innovation been thoroughly explored. It is clear that surgical innovation is fundamental to surgical progress and has significant health policy implications. A process of systematically evaluating and promoting innovation in surgery may be critical in the evolving practice of medicine.

METHODS

A review of the academic literature in technology innovation was undertaken. Articles and books were identified through technical, medical, and business sources. Luminaries in surgical innovation were interviewed to develop further relevance to surgical history. The concepts in technology innovation were then applied to innovation in surgery, using the historical example of surgical endoscopy as a representative area, which encompasses millennia of learning and spans multiple specialties of care.

RESULTS

The history of surgery is comprised largely of individual, widely respected surgeon innovators. While respecting individual accomplishments, surgeons as a group have at times hindered critical innovation to the detriment of our profession and patients. As a clinical discipline, surgery relies on a tradition of research and attracting the brightest young minds. Innovation in surgery to date has been impressive, but inconsistently supported.

CONCLUSION

A body of knowledge on technology innovation has been developed over the last decade but has largely not been applied to surgery. New surgical innovation centers are working to define the field and identify critical aspects of surgical innovation promotion. It is our responsibility as a profession to work to understand innovation in surgery, discover, translate, and commercialize advances to address major clinical problems, and to support the future of our profession consistently and rationally.

The Development of Minimally Invasive Spine Surgery

The modern era of minimally invasive spine surgery has its roots in percutaneous techniques developed in the mid-twentieth century. The widespread application of minimally invasive techniques seen today is predicated on technologic developments of only the past 10 years, however. This article reviews the development of minimally invasive spinal surgery as it has evolved for the cervical, thoracic, and lumbar spine. Each new development has sought to equal or improve on the effectiveness demonstrated by comparable open surgical techniques while reducing iatrogenic tissue trauma and resultant postoperative pain and disability, to produce overall better outcomes for patients.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas

PURPOSE

The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons.

METHODS

We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection.

RESULTS

There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool.

CONCLUSIONS

Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas

PURPOSE

The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons.

METHODS

We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection.

RESULTS

There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool.

CONCLUSIONS

Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.

Apprentissage de la chirurgie laparoscopique: quelles méthodes pour le chirurgien en formation?

The introduction of laparoscopic approaches to surgery has been responsible for increased morbidity and has necessitated the development of a system of apprenticeship training in and out of the operating room for surgeons making their debut in the laparoscopic arena. This study, based on published data in the surgical literature, aims to evaluate the tools currently available for both teaching and evaluating competence in laparascopic surgery. Video simulators currently being used for teaching laparoscopic skills do not permit an objective evaluation of skill acquisition. Virtual reality simulators have the advantage of permitting an apprenticeship in laparoscopic surgical technique and a simultaneous assessment of the acquisition of surgical dexterity. This new technology should enable a better preparation of young surgeons for the operating room of the future.

Unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

BACKGROUND/PURPOSE

Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC.

METHODS

Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed.

RESULTS

These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14-37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12-99 months) after LC.

CONCLUSIONS

Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.

A survey of the current surgical treatment of gallstones in Queensland

BACKGROUND

To survey the current practice of general surgeons in Queensland in their management of patients with gallstones.

METHODS

A postal survey of 123 surgeons practising in Queensland.

RESULTS

There were 114 responses to the questionnaire (92.7%) and seven were excluded from the analysis. Laparoscopic cholecystectomy (LC) was preferred by 97.2% and operative cholangiography was almost always attempted by 82.3%. One-third of surgeons used drains routinely. In cases of acute cholecystitis, 56 surgeons (52.3%) favoured laparoscopic cholecystectomy on the same admission. Operative cholangiography (OC) was almost always attempted by 64.8% of surgeons during acute laparoscopic cholecystectomy. Only 3.8% of surgeons frequently offered day case surgery and 51% never offered it.

CONCLUSIONS

Laparoscopic cholecystectomy is the treatment of choice of nearly all Queensland surgeons in the elective and acute situations. Routine operative cholangiography is favoured by the majority of surgeons. Day case surgery is presently offered by a minority of surgeons.

Biliary-Colonic Fistula: A Case Report and Literature Review

We report the occurrence of common bile duct obstruction and biliary-colonic fistula after open cholecystectomy. Although it is a very unusual complication after cholecystectomy, biliary-colonic fistula should be part of the differential diagnosis for patients presenting with sepsis after open or laparoscopic cholecystectomy. After confirmation and characterization of the injury by endoscopic retrograde cholangiopancreatography and cholangiogram, assessment for undrained collections by computed tomography scan, control of sepsis and coagulopathy, and nutritional support, surgical repair was undertaken. The patient underwent fistula take-down between the common bile duct and the colon at the hepatic flexure, primary closure of the colon enterotomy, and a Roux-en-Y end-to-side hepaticojejunostomy at the confluence of the right and left hepatic ducts. Recovery was uneventful and the patient was doing well at the 6-month follow-up. Surgical repair should be undertaken by surgeons with extensive experience in hepatobiliary reconstruction.

Operating room costs of laparoscopic cholecystectomy: does surgeon volume matter?

Very few studies have addressed the issue of surgeon volume on cost savings of laparoscopic cholecystectomy (LC) in Asian countries. The objectives of the study were to analyze LC operating-room (OR) costs between two study hospitals and to examine the effect of surgeon volume on OR costs. Patients diagnosed with gallbladder disease who underwent LC in October through December 2002 at two acute tertiary-care hospitals were included. Patient demographics and clinical information were derived from patient charts. Cost information was obtained from purchasing departments or specific cost centers. Three multivariate linear regression models were performed to examine the association between surgeon volume, cost, and utilization. There were no significant differences in patient demographics and disease severity between the two hospitals. Hospital A consumed fewer resources than did hospital B (NTdollars 21,674 vs NTdollars 26,417). Direct materials cost, direct professional costs, and indirect costs varied significantly by study hospital and by surgeon volume. High-volume surgeons incurred lower costs and shorter stay as compared with low-volume surgeons. Patients who scored in the American Society of Anesthesiologists physical status (ASA PS) 3 incurred significantly higher costs and longer hospital stays than did patients with ASA PS 1. The present study supports the proposal that hospital management and experience of surgeons are of equal importance in maintaining the standing of hospitals in competitive positions. In addition to the differences in hospital management and surgeon volume, the patient severity of illness also needs to be taken into consideration in cost containment.

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Laparoscopy in transplantation

BACKGROUND

Solid-organ transplantation has become the treatment of choice for patients with end-stage renal disease, end-stage liver failure, and some patients with type 1 diabetes mellitus. Similarly, surgical expertise and mechanical improvements have led to significant advances in laparoscopic surgery. Laparoscopic interventions are sometimes not pursued in transplant recipients due to the lack of strong supporting evidence for the use of laparoscopic techniques in these patients.

METHODS

Using an extensive literature search, we review herein the available data on the utility of laparoscopic interventions in transplant recipients, with particular attention to the risks and benefits, indications, and contraindications for this complex patient population.

RESULTS

Although randomized trials are few, multiple case reports indicate that many transplant recipients have benefited from laparoscopic interventions.

CONCLUSION

The well-known benefits of laparoscopy could be extended to transplant recipients.

LAPAROSCOPIC AND OPEN COLORECTAL SURGERY IN EVERYDAY PRACTICE: RETROSPECTIVE STUDY

BACKGROUND

Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department.

METHODS

Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire.

RESULTS

A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups.

CONCLUSION

Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

Neuroendoscopy for spinal disorders: a brief review

Neuroendoscopy has grown rapidly in the last 20 years as a therapeutic modality for treating a variety of spinal disorders. Spinal endoscopy has been widely used to treat patients with cervical, thoracic, and lumbosacral disorders safely and effectively. Although it is most commonly used with minimally invasive lumbar spine surgery, endoscopy has gained widespread acceptance for the treatment of thoracic disc herniations and for anterior release and rod implantation in the correction of thoracic spinal deformity. The authors review the use of endoscopy in spine surgery and in the treatment of spinal disorders as well as in the treatment of intrathoracic nonspinal lesions. Endoscopy has some significant advantages over open or other minimally invasive techniques in that it can allow for better visualization of the lesion, smaller incision sizes with reduced morbidity and mortality, reduced hospital stays, and ultimately lower cost. In addition, spinal endoscopy allows observers and operating room staff to be more involved in each case and fosters education. Spinal endoscopy, like any novel modality, carries with it additional risks and the surgeon must always be prepared to convert to an open procedure. The learning curve for spinal endoscopy is steep and the procedure should not be attempted alone by a novice surgeon. Nevertheless, with training and experience, the spine surgeon can achieve better outcomes, reduced morbidity, and better cosmesis with spinal endoscopy, and the operating times are comparable to open procedures. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve further roles as a mainstay in spine surgery.

Laparoscopic cholecystectomy - is there a need to convert?

INTRODUCTION

The difficult gallbladder is the most common 'difficult' laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk. We present our experience of 6147 cases since January 1993 in a single center with respect to conversion to open cholecystectomy.

METHODS

Patients who underwent laparoscopic cholecystectomy (LC) from January 1993 to December 2004 were analyzed. The cases were analyzed in relation to conversion rate to open surgery, factors affecting the conversion, and completion rate of LC. Patients having absolute contraindications to LC like cardiovascular and pulmonary disease were not included in the study.

RESULTS

Out of 6147 cases, 1518 patients (21.5%) were identified as difficult cases. Laparoscopic cholecystectomy was successfully completed in 6125 patients with a completion rate of 99.6%. Laparoscopic procedure had to be converted to the open procedure in 22 patients with a conversion rate of 0.36% of the total LCs performed and 1.66% of the difficult cases. Conversion had to be done due to several reasons.

CONCLUSION

It can be reliably concluded that LC is the preferred method even in the difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands the surgeon should keep a low threshold for conversion to open surgery and it should be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.

Ten Years of Laparoscopic Adrenalectomy: Lesson Learned from 104 Procedures

The purpose of this study was to evaluate the short- and long-term results of 104 consecutive laparoscopic adrenalectomies performed during a period of 10 years in two specialist centers. One hundred four patients underwent laparoscopic adrenalectomy in two specialist centers in Italy between 1994 and 2003. Indications to laparoscopic adrenalectomy were aldosterone-secreting adenoma (20%), pheochromocytoma (24%), cortisol-secreting adenoma (11.5%), incidentaloma (26.9%), multiple endocrine neoplasia (MEN) type 2A (2.8%), adrenal metastases from lung cancer (3.8%), adrenal cyst (6.7%), and angiomyolipoma (3.8%). Transperitoneal anterior and lateral approaches were adopted in 17 and 84 patients, respectively. Retroperitoneal approach was adopted in three patients. Mean operative time was 108 ± 39.1 minutes (range, 40–300 minutes). There was no correlation between adrenal tumor diameter and operative time. Mean intraoperative blood loss was 106 mL (range, 40–600 mL). Intraoperative complication rate and conversion rate were 4.8 per cent (5 cases). Laparoscopic adrenalectomy is a safe procedure. After a relatively short learning curve, it can be performed successfully by any surgeon with low operative morbidity and mortality. The size of the adrenal tumor should not be considered a contraindication to this procedure.

New Approaches to the Minimally Invasive Treatment of Liver Cancer

Unlike laparoscopic cholecystectomy, laparoscopic hepatectomy has been slow to gain acceptance because of its association with technical difficulties. Many surgeons feel there are few advantages in laparoscopic hepatectomy when compared to open surgery. The liver is the organ most susceptible to bleeding while dissecting the parenchyma and the resected liver usually requires a wide abdominal incision to deliver the resected specimen. Both the improvement of surgeons' skills and the development of technology have improved results, however, the indication of laparoscopic hepatectomy for malignancy is still controversial. This article focuses on the current status of minimally invasive treatment for liver malignancy.

Laparoscopic skills training and assessment

BACKGROUND

The introduction of laparoscopic techniques to general surgery was associated with many unnecessary complications, which led to the development of skills laboratories to train novice laparoscopic surgeons. This article reviews the tools currently available for training and assessment in laparoscopic surgery.

METHODS

Medline searches were performed to identify articles with combinations of the following key words: laparoscopy, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers.

RESULTS

Current training involves the use of box trainers with either innate models or animal tissues; it lacks objective assessment of skill acquisition. Virtual reality simulators have the ability to teach laparoscopic psychomotor skills, and objective assessment is now possible using dexterity-based and video analysis systems.

CONCLUSION

The tools are now available for the development of a structured, competency-based, laparoscopic surgical training programme.

Patient information following emergency laparoscopy for right iliac fossa pain

Laparoscopy is increasingly used as a diagnostic and therapeutic tool in the management of emergency surgical admissions. Laparoscopic scars give little clue to the operation performed. Hence, the future assessment of patients re-admitted with abdominal pain, often needs to rely on the patient's own account of the operation performed. This study attempted to evaluate the quality of communication between surgeons and patients regarding the results of their laparoscopy and how much information was retained by the patients on discharge. Seventy-seven patients were identified from computerised medical records. A detailed case note review was undertaken looking at operative findings, procedure performed, and documentation of surgeon-to-patient communication. A questionnaire was posted to patients asking their opinion regarding the quality of communication from surgeons. The questionnaire asked specific questions regarding the patient's understanding of the operation performed and its findings. Overall communication between surgeons and patients was good. However, a small proportion of patients were unsure of their diagnosis and what therapeutic procedure had been performed following laparoscopy. This included one patient (out of 28 who had undergone laparoscopic appendectomy) who was unsure if their appendix had been removed. Two from 12 patients diagnosed with pelvic pathology at laparoscopy who were unclear of their diagnosis and two patients with histologically normal appendices who thought their appendices had been inflamed at removal. Greater effort must be made to inform patients of their laparoscopic findings and any therapeutic procedure performed. We recommend the use of written information leaflets to be sent to the patient's home address to ensure that all patients are fully aware of their laparoscopic findings. For any future emergency admission, the patient's knowledge of any previous surgery and whether their appendix is in situ is of considerable diagnostic value to the assessing clinician. More effort must be made to enable patients to retain such necessary information.

Mechanisms of postoperative ileus

Postoperative ileus is an iatrogenic condition that follows abdominal surgery. Three main mechanisms are involved in its causation, namely neurogenic, inflammatory and pharmacological mechanisms. In the acute postoperative phase, mainly spinal and supraspinal adrenergic and non-adrenergic pathways are activated. Recent studies, however, show that the prolonged phase of postoperative ileus is caused by an enteric molecular inflammatory response and the subsequent recruitment of leucocytes into the muscularis of the intestinal segments manipulated during surgery. This inflammation impairs local neuromuscular function and activates neurogenic inhibitory pathways, inhibiting motility of the entire gastrointestinal tract. The mechanisms underlying the recruitment of the inflammatory cells, and their interaction with the intestinal afferent innervation, are discussed. Finally, opioids administered for postoperative pain control also contribute to a large extent to the reduction in propulsive gastrointestinal motility observed after abdominal surgery.

Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience

Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 1.4% incidence of bile duct injuries during laparoscopic cholecystectomy. The aim of this study was to report on an institutional experience with the management of complex bile duct injuries and outcome after surgical repair. Data were collected prospectively from 40 patients with bile duct injuries referred for surgical treatment to our center between April 1998 and December 2003. Prior to referral, 35 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In 77.5% of the patients, complex type E1 or type E2 BDI was found. Concomitant with bile duct injury, seven patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 33 patients. In two patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Five patients, one with primary nondiagnosed Klatskin tumor, required right hepatectomy. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Because of progressive liver insufficiency, one of them was listed for high-urgency liver transplantation but died prior to intervention. At the median follow-up of 589 days, 82.5% of the patients are in excellent general condition. Seven patients have signs of chronic cholangitis. Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.

Laparoscopic surgery for colorectal cancer: the state of the art

Laparoscopic techniques have expanded since their introduction 15 years ago. The laparoscopic approach for colorectal surgery has been slower to develop than other fields of surgery. However, this approach does provide significant benefits for colorectal resection, although concerns regarding the ability to satisfy oncological criteria have restricted its use in the past. This review studies the published data on the use of laparoscopic surgery for colorectal cancer including the short- and long-term outcomes. New long-term outcome data is now available which is likely to encourage the use of this technique for colon cancer resection. Laparoscopic rectal cancer resection is also discussed including the more limited outcome data that is available.

The standard of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy?

METHOD

Literature review.

RESULTS

Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones.

CONCLUSION

The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

Minimally invasive spinal surgery: a historical perspective

The concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based. Minimally invasive treatments have been undertaken in all areas of the spinal axis since the 20th century. Lumbar disc disease has been treated using chemonucleolysis, percutaneous discectomy, laser discectomy, intradiscal thermoablation, and minimally invasive microdiscectomy techniques. The initial use of thoracoscopy for thoracic discs and tumor biopsies has expanded to include deformity correction, sympathectomy, vertebrectomy with reconstruction and instrumentation, and resection of paraspinal neurogenic tumors. Laparoscopic techniques, such as those used for appendectomy or cholecystectomy by general surgeons, have evolved into procedures performed by spinal surgeons for anterior lumbar discectomy and fusion. Image-guided systems have been adapted to facilitate pedicle screw placement with increased accuracy. Over the past decade, minimally invasive treatment of cervical spinal disorders has become feasible by applying technologies similar to those developed for the thoracic and lumbar spine. Endoscope-assisted transoral surgery, cervical laminectomy, discectomy, and foraminotomy all represent the continual evolution of minimally invasive spinal surgery. Further improvement in optics and imaging resources, development of biological agents, and introduction of instrumentation systems designed for minimally invasive procedures will inevitably lead to further applications in minimally invasive spine surgery.

Randomized clinical trial of laparoscopic cholecystectomy performed with mini-instruments

BACKGROUND

The outcomes after traditional laparoscopic cholecystectomy (LC; one 10-mm port, one 12-mm port and two 5-mm ports) and minilaparoscopic cholecystectomy (MLC; three 3-mm ports and one 12-mm port) for gallstone disease were compared.

METHODS

The study was a randomized, single-blind trial comparing LC with MLC. Only elective patients were eligible for inclusion. LC was a routine procedure at the institution in which the study was performed, whereas MLC was introduced after a short training period. The randomization period was from January to December 2001.

RESULTS

Of 175 patients who had elective minimal access cholecystectomy during the randomization period, 135 entered the trial: 68 underwent LC and 67 underwent MLC. The groups were matched for age, sex and preoperative characteristics. Median (range) operating times for LC and MLC were similar (45 (20-120) and 50 (20-170) min respectively). Intraoperative and postoperative complication rates, the time for the patient to resume walking, eating and passing stools, and median hospital stay were the same in the two groups. The level of postoperative pain was lower in the MLC group at 1 h (P = 0.011), 3 h (P = 0.012), 6 h (P = 0.003), 12 h (P = 0.052) and 24 h (P = 0.034). Patients who had MLC received fewer injections of analgesic (P = 0.036) and more patients in this group expressed satisfaction with the cosmetic result (P = 0.001).

CONCLUSION

MLC took a similar time to perform and caused less postoperative pain than the standard laparoscopic procedure. Reducing the port size further enhanced the advantages of laparoscopic over open cholecystectomy.

Laparoscopy and its current role in the management of colorectal disease

OBJECTIVE

To evaluate the current place of laparoscopy in the management of colorectal disease.

METHOD

A literature search was undertaken on Medline between the period 1991 and 2002.

RESULTS

From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions.

CONCLUSION

The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

Choledocholithiasis caused by migration of a surgical clip into the biliary tract following laparoscopic cholecystectomy

As experience with laparoscopic cholecystectomy (LC) has increased, so have the number and variety of complications. We report a case of choledocholithiasis caused by migration of a surgical clip applied during LC. A 57-year-old Japanese man who had undergone LC 6 years previously was referred to our hospital with pruritus and jaundice. Magnetic resonance cholangiopancreatography and ultrasonography revealed a solid mass in the common hepatic duct and dilatation of the intrahepatic bile ducts. Abdominal arteriography demonstrated interruption of the right hepatic artery by surgical clips. Five days after a biopsy of the mass was performed through a percutaneous transhepatic biliary drainage tube, the mass moved to the terminus of the common bile duct along with one of the surgical clips. A basket catheter was used to remove the mass via endoscopy. Despite the fact that other clips in the common hepatic duct were partially exposed, the patient has been well for 2 years with no additional interventions.

Three-port vs standard four-port laparoscopic cholecystectomy

BACKGROUND

Since the first laparoscopic cholecystectomy (LC) was reported in 1990, it has met with widespread acceptance as a standard procedure using four trocars. The fourth (lateral) trocar is used to grasp the fundus of the gallbladder so as to expose Calot's triangle. It has been argued that the fourth trocar is not necessary in most cases. Therefore, the aim of this study was to compare the three-port vs the four-port technique.

METHODS

Between 1998 and 2000, 200 consecutive patients undergoing elective LC for gallstone disease were randomized to be treated via either the three- or four-port technique.

RESULTS

There was no difference between the two groups in age, sex, or weight. In terms of outcome, there was no difference between the two groups in success rate, operating time, number of oral analgesic tablets (paracetamol), visual analogue score, or postoperative hospital stay; however, the three-port group required fewer analgesic injections (nalbuphine) (0.4 vs 0.77, p = 0.024).

CONCLUSION

The three-port technique is as safe as the standard four-port one for LC. The main advantages of the three-port technique are that it causes less pain, is less expensive, and leaves fewer scars.

The added cost of urgent cholecystectomy to health systems

BACKGROUND

The purpose of this study is to assess the cost and reimbursement differential between elective and urgent laparoscopic cholecystectomy.

STUDY DESIGN

All visits for laparoscopic cholecystectomy (ICD-9 Code 51.23) to the University of Michigan Health System were reviewed for 1997 to 2001 (n = 752). Data were obtained from the University of Michigan Data Warehouse. Patients were grouped into urgent and elective cases, and further subgrouped into complicated and uncomplicated cases based on Diagnostic Related Group (DRG) coding.

RESULTS

Total costs were determined for 13 distinct facility cost centers with average costs greater than $10 per case. Reimbursement was also assessed. Total costs were approximately 90% higher in urgent cases. The largest contributors to increased costs were nursing care and pharmacy costs. The emergent group experienced a pre-operative delay to surgery of 1.8 days. Reimbursement was similar for both elective and urgent patients when stratified by complicated and uncomplicated DRGs.

CONCLUSIONS

The urgency of the operation significantly elevates the costs and resource consumption associated with laparoscopic cholecystectomy. These cost differences should also be recognized when setting reimbursement premiums under risk-bearing systems, such as Medicare Diagnosis Related Group reimbursement. Consideration for including urgent operation as a comorbidity should be assessed.