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Habermalz B, Sauerland S, Decker G, Delaitre B, Gigot JF, Leandros E, Lechner K, Rhodes M, Silecchia G, Szold A, Targarona E, Torelli P, Neugebauer E. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2008; 22:821-48. [PMID: 18293036 DOI: 10.1007/s00464-007-9735-5] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 11/23/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS. METHODS An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon. RESULTS Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS. CONCLUSION Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.
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Affiliation(s)
- B Habermalz
- Institute for Research in Operative Medicine, University Witten/Herdecke, Witten/Herdecke, IFOM, Ostmerheimer Strasse 200, 51109, Köln, Germany
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Laparoscopic Diagnosis and Treatment of Primary Torsion of the Greater Omentum. Surg Laparosc Endosc Percutan Tech 2008; 18:102-5. [DOI: 10.1097/sle.0b013e3181576902] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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203
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Ates M, Sevil S, Bakircioglu E, Colak C. Laparoscopic repair of peptic ulcer perforation without omental patch versus conventional open repair. J Laparoendosc Adv Surg Tech A 2008; 17:615-9. [PMID: 17907974 DOI: 10.1089/lap.2006.0195] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Laparoscopic surgery, a minimally invasive technique, has recently begun to be used on perforated peptic ulcers effectively and frequently. Nevertheless, most studies have shown that the disadvantages of the laparoscopic treatment of peptic ulcers are a long operation time, a high reoperation rate, and a need for an experienced surgeon. Thus, the objective of the current study was to compare the safety and efficacy of optimized laparoscopic surgery without an omental patch for a perforated peptic ulcer within a shorter operational time with conventional open surgery in a 4-year period. PATIENTS AND METHODS From May 2002 to June 2006, 35 consecutive patients with a clinical diagnosis of a perforated peptic ulcer were prepared prospectively to undergo either an open or optimized laparoscopic surgery. RESULTS Seventeen patients with a perforated peptic ulcer underwent simple laparoscopic repair without an omental patch. Three patients (17.6%) who were begun by the laparoscopic approach had to be converted to open surgery. Eighteen patients underwent conventional open surgery. The mean operative time for laparoscopic repair was 42.10 minutes (range, 35-60), which was significantly shorter than the 55.83 minutes for open repair (range, 35-72; P = 0.001). Postoperative parenteral analgesic requirements were lower after laparoscopic repair (75.0 mg) than that after an open repair procedure (101.39 mg; P = 0.02). There was no statistically significant difference between the procedures in terms of hospital stay (5 vs. 5.33 days; P = 0.37) and the timing of access to normal daily activity (6.8 vs. 7.1 days) (P = 0.54). CONCLUSIONS Laparoscopic surgery, when optimized by a simple repair without an omental patch and 10 mm of a large-channel aspirator-irrigator, may be safely and effectively applied to the patients with small duodenal perforated peptic ulcers (<10 mm) and because of its having low risk factors. The procedure may be an alternative treatment to other procedures when in experienced hands.
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Affiliation(s)
- Mustafa Ates
- Department of General Surgery, Malatya State Hospital, Malatya, Turkey.
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204
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Kassahun WT, Schulz T, Richter O, Hauss J. Unchanged high mortality rates from acute occlusive intestinal ischemia: six year review. Langenbecks Arch Surg 2008; 393:163-71. [PMID: 18172675 DOI: 10.1007/s00423-007-0263-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 12/10/2007] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Acute intestinal ischemia (AII) is an uncommon surgical emergency that has been increasing in incidence and remains a highly lethal condition with a difficult diagnosis. We undertook this study to evaluate our experience in treating this condition with a view to expand the cumulative information in the literature. MATERIALS AND METHODS Between January 2000 and December 2006, 60 patients with AII caused by thrombotic vascular event underwent surgery at our surgical center. The patients' medical records including data covering demographic features, comorbid medical conditions, medical risk factors, clinical symptoms, history and physical examination findings, and biochemical and radiologic examinations were reviewed. Operative records, the American Society of Anesthesiology physical status classification (ASA-PS), postoperative complications, duration of hospital stay, and final outcome were also considered. RESULTS Of the 60 patients with primary thrombotic vascular event, 20 patients had embolism and 19 patients arterial thrombosis. In 21 patients, mesenteric venous thrombosis was the etiology of AII. The median age was 73 years (range, 43-96). Higher ASA classification, age >70 years, late presentation, and high serum lactate levels were predictors of adverse outcome. The overall death rate was 60% (36/60), which was within the range of that observed in the published series. CONCLUSION AII remains a highly lethal condition. Mortality rates remain as high as they did decades ago due in part to advanced presentation and advanced age with multiple associated conditions and risk factors, all of which are independent predictors of adverse outcome.
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Affiliation(s)
- Woubet T Kassahun
- Department of Surgery II, Faculty of Medicine, University of Leipzig, Liebig Strasse 20a, 04103, Leipzig, Germany.
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Wind J, Koopman AG, van Berge Henegouwen MI, Slors JFM, Gouma DJ, Bemelman WA. Laparoscopic reintervention for anastomotic leakage after primary laparoscopic colorectal surgery. Br J Surg 2007; 94:1562-6. [PMID: 17702090 DOI: 10.1002/bjs.5892] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leakage is associated with high morbidity and mortality rates. The aim of this study was to assess the potential benefits of a laparoscopic reintervention for anastomotic leakage after primary laparoscopic surgery. METHODS Between January 2003 and January 2006, ten patients who had laparoscopic colorectal resection and later developed anastomotic leakage had a laparoscopic reintervention. A second group included 15 patients who had relaparotomy after primary open surgery. RESULTS Patient characteristics were comparable in the two groups. The median time from first operation to reintervention was 6 days in both groups. There were no conversions. The intensive care stay was shorter in the laparoscopic group (1 versus 3 days; P = 0.002). Resumption of a normal diet (median 3 versus 6 days; P = 0.031) and first stoma output (2 versus 3 days; P = 0.041) occurred earlier in the laparoscopic group. The postoperative 30-day morbidity rate was lower (four of ten patients versus 12 of 15; P = 0.087) and hospital stay was shorter (median 9 versus 13 days; P = 0.058) in the laparoscopic group. No patient developed incisional hernia in the laparoscopic group compared with five of 15 in the open group (P = 0.061). CONCLUSION These data suggest that laparoscopic reintervention for anastomotic leakage after primary laparoscopic surgery is associated with less morbidity, faster recovery and fewer abdominal wall complications than relaparotomy.
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Affiliation(s)
- J Wind
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
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206
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Gong EM, Zorn KC, Gofrit ON, Lucioni A, Orvieto MA, Zagaja GP, Shalhav AL. Early laparoscopic management of acute postoperative hemorrhage after initial laparoscopic surgery. J Endourol 2007; 21:872-8. [PMID: 17867944 DOI: 10.1089/end.2006.0393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The use of laparoscopic surgery has been well established for the management of abdominal emergencies. However, the value of this technique for postoperative hemorrhage in urology has not been characterized. We present our favorable experience with laparoscopic exploration after urologic surgery and suggest guidelines for laparoscopic management of post-laparoscopy bleeding. PATIENTS AND METHODS Three patients who developed hemorrhage shortly after laparoscopic urologic surgery and were managed by laparoscopic exploration were identified from a series of 910 laparoscopic urologic procedures performed at our institution from October 2002 to June 2006. RESULTS Three patients, who were hemodynamically stable (two after robot-assisted laparoscopic prostatectomy, one after laparoscopic radical nephrectomy), required prompt surgical exploration for postoperative hemorrhage not stabilized by blood transfusion (mean 2.7 units) at a mean of 19.4 hours after initial surgery. Clots were evacuated with a 10-mm suction-irrigator. Two patients were found to have abdominal-wall arterial bleeding and were managed with suture ligation. The third patient demonstrated diffuse bleeding from the prostatic bed, which was controlled with Surgicel and FloSeal. Bleeding was efficiently controlled in all patients, and none required post-exploration transfusion. The mean post-exploration hospital stay was 2.3 days. CONCLUSION Significant hemorrhage after urologic laparoscopy is a rare event. We found laparoscopic exploration to be an excellent way to diagnose and correct such hemorrhage in certain patients. Early diagnosis with clinical and hematologic studies, a lowered threshold for surgical exploration, and specific operative equipment may decrease patient morbidity and the need for open surgical exploration.
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Affiliation(s)
- Edward M Gong
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois 60637, USA
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207
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Kim KH, Kim MC, Kim SH, Park KJ, Jung GJ. Laparoscopic management of a primary small bowel volvulus: a case report. Surg Laparosc Endosc Percutan Tech 2007; 17:335-8. [PMID: 17710063 DOI: 10.1097/sle.0b013e31806c7d04] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.
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Affiliation(s)
- Ki-Han Kim
- Department of Surgery, Dong-A University College of Medicine, Busan, Korea
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208
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Cheng SP, Chang YC, Liu CL, Yang TL, Jeng KS, Lee JJ, Liu TP. Factors associated with prolonged stay after laparoscopic cholecystectomy in elderly patients. Surg Endosc 2007; 22:1283-9. [DOI: 10.1007/s00464-007-9610-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 08/09/2007] [Accepted: 09/22/2007] [Indexed: 12/13/2022]
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209
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The laparoscopic approach in abdominal emergencies: has the attitude changed? : A single-center review of a 15-year experience. Surg Endosc 2007; 22:1255-62. [PMID: 17943358 DOI: 10.1007/s00464-007-9602-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 07/31/2007] [Accepted: 08/13/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopy has been practiced more and more in the management of abdominal emergencies. The aim of the present work was to illustrate retrospectively the results of a case-control 5-year experience of laparoscopic versus open surgery for abdominal emergencies carried out at our institution, especially with regard to whether our attitude toward use of this procedure has changed as compared with the beginning of our laparoscopic emergency experience (1991-2002). MATERIALS AND METHODS From January 2002 to January 2007 a total of 670 patients underwent emergent and/or urgent laparoscopy (small bowel obstruction, 17; gastroduodenal ulcer disease, 16; biliary disease, 118; pelvic disease and non-specific abdominal pain (NSAP), 512; colonic perforations, 7) at the hands of a surgical team trained in laparoscopy RESULTS The conversion rate was 0.15%. Major complications ranged as high as 1.9% with no postoperative mortality. A definitive diagnosis was accomplished in 98.3% of the cases, and all such patients were treated successfully by laparoscopy. CONCLUSIONS We believe that laparoscopy is not an alternative to physical examination/good clinical judgment or to conventional noninvasive diagnostic methods in treating the patient with symptoms of an acute abdomen. However it must be considered an effective option in treating patients in whom these methods fail and as a challenging alternative to open surgery in the management algorithm for abdominal emergencies.
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210
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Schijven MP, Schout BMA, Dolmans VEMG, Hendrikx AJM, Broeders IAMJ, Borel Rinkes IHM. Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands. Surg Endosc 2007; 22:472-82. [PMID: 17762954 PMCID: PMC2234445 DOI: 10.1007/s00464-007-9491-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Revised: 05/28/2007] [Accepted: 06/13/2007] [Indexed: 01/29/2023]
Abstract
BACKGROUND Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands. METHODS Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire. RESULTS A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines. CONCLUSIONS A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.
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Affiliation(s)
- M P Schijven
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, PO box 85500, 3508, GA, Utrecht, the Netherlands.
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211
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Borzellino G, Sauerland S, Minicozzi AM, Verlato G, Di Pietrantonj C, de Manzoni G, Cordiano C. Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg Endosc 2007; 22:8-15. [PMID: 17704863 DOI: 10.1007/s00464-007-9511-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 03/11/2007] [Accepted: 03/24/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis. BACKGROUND It is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. METHODS Literature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques. RESULTS Seven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2-2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found. CONCLUSION A lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.
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Affiliation(s)
- Giuseppe Borzellino
- 1st Department of General Surgery, OCM Borgo Trento Hospital, University of Verona, Verona, Italy.
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212
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Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A. Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis. Dis Colon Rectum 2007; 50:1157-63. [PMID: 17294319 DOI: 10.1007/s10350-006-0851-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Purulent or fecal peritonitis is one of the most serious complications of acute diverticulitis. Up to one-fourth of patients hospitalized for acute diverticulitis require an emergent operation for a complication, including abscess, peritonitis, or stenosis. Open Hartmann's procedure has been the operation of choice for these patients. The advantages of laparoscopy could be combined with those of the primary resection in selected patients with peritonitis complicating acute diverticulitis. However, because of technical difficulties and the theoretic risk of poorly controlled sepsis, laparoscopic Hartmann's procedure has been seldom reported for such patients. METHODS Data were prospectively collected from 2003 to 2005 in a single referral center specialized in abdominal emergencies. Laparoscopic Hartmann's procedure (Stage 1) was performed in selected patients with peritonitis complicating acute diverticulitis. Secondarily, Hartmann's reversal (Stage 2) also was performed laparoscopically. RESULTS Thirty-one patients were studied. The median Mannheim Peritonitis Index score was 21 (+/-5; range, 12-32). The conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively. There was no perioperative uncontrolled sepsis. Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively. Stoma reversal was possible in 90 percent of patients. CONCLUSIONS The results of this small series demonstrated that the indications of laparoscopy in diverticulitis could be extrapolated to selected patients with peritonitis. The technical feasibility and safety of laparoscopic Hartmann's procedure in selected patients seem acceptable. However, larger-scale, controlled studies are needed to define more accurately the role of laparoscopy in complicated diverticulitis.
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Affiliation(s)
- Elie Chouillard
- Department of General and Minimally Invasive Surgery, Centre Hospitalier Intercommunal, 10, rue du Champ Gaillard, Poissy, France.
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213
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Santaniello M, Bergamaschi R. Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis 2007; 9:494-5. [PMID: 17573741 DOI: 10.1111/j.1463-1318.2006.01177.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- M Santaniello
- Department of Surgery, Lehigh Valley Hospital, Penn State University Campus, Allentown, PA 18105-1556, USA
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214
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López-Tomassetti Fernández EM, Martín Malagón A, Delgado Plasencia L, Arteaga González I. Laparoscopic repair of incarcerated low spigelian hernia with transperitoneal PTFE DualMesh. Surg Laparosc Endosc Percutan Tech 2007; 16:427-31. [PMID: 17277661 DOI: 10.1097/01.sle.0000213728.80332.c8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There are different types of hernias that can develop at certain sites in the abdominal wall. Spigelian hernia (SH) is a protrusion of abdominal contents through a defect in the spigelian aponeurosis, in proximity to the external margin of the rectus muscle. Usually, abdominal wall hernia sac contains the omentum but may also contain small intestine that might become trapped in the hernia. When ischemia of herniated contents is suspected, urgent surgical treatment is advocated. Elective laparoscopic repair of SH is still under discussion. However, a recent randomized study comparing open and laparoscopic repair as elective treatment suggested that extraperitoneal laparoscopic repair is the technique that offers best results for the patients. Recent development of new biologic materials and technologies in laparoscopy has led to improved results. We report the successful repair of incarcerated low SH that was successfully managed by urgent laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh hernioplasty.
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215
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Abstract
With increasing experience in minimally invasive surgery, laparoscopy's role in abdominal trauma can be defined exactly. Main exclusion criteria are hemodynamic instability and increased intracranial pressure. A literature review of 1996 to 2006 reveals perforating injury mainly of the left thoracoadominal area as the most important indication for laparoscopy . Its goal is to determine intraperitoneal lesions and integrity of the abdominal wall and diaphragm. Minor injuries of the parenchymatous organs and diaphragm can be successfully repaired laparoscopically. In blunt abdominal trauma, laparoscopy is used as a complementary diagnostic device in case ultrasound and multislice CT show unclear findings and the patient's clinical status requires invasive measures. The clear weakness of laparoscopy in abdominal trauma is its inability to identify reliably hollow viscus perforation and retroperitoneal injury. In this, sensitivity is only 25%. In case of proven lesions of the gastrointestinal tract, conversion to laparotomy is to be considered. Despite the reports on laparoscopic treatment, open repair of hollow organ injuries is still to be recommended.
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Affiliation(s)
- H P Becker
- Abteilung für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Rübenacher Strasse 170, 56072 Koblenz, Deutschland.
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216
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Villeta Plaza R, Landa García JI, Rodríguez Cuéllar E, Alcalde Escribano J, Ruiz López P. [National project for the clinical management of healthcare processes. The surgical treatment of cholelithiasis. Development of a clinical pathway]. Cir Esp 2007; 80:307-25. [PMID: 17192207 DOI: 10.1016/s0009-739x(06)70975-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Because surgical treatment of gallstones is highly prevalent, this topic is particularly suitable for a national study aimed at determining the most important indicators and developing a clinical pathway. OBJECTIVES To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. PATIENTS AND METHODS A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000) with 76 variables analyzed in each patient. RESULTS Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received. CONCLUSIONS Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days.
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Affiliation(s)
- R Villeta Plaza
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Hospital Príncipes de Asturias, Alcalá de Henares, Madrid, España
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Wyers MC, Powell RJ, Nolan BW, Cronenwett JL. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. J Vasc Surg 2007; 45:269-75. [PMID: 17264001 DOI: 10.1016/j.jvs.2006.10.047] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2006] [Accepted: 10/29/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Acute mesenteric ischemia (AMI) caused by arterial occlusive disease requires prompt diagnosis and revascularization to avoid the high mortality associated with this disease. In an attempt to minimize the magnitude of operation for arterial occlusive AMI, we have developed a new technique of endovascular recanalization and open retrograde stenting of the superior mesenteric artery (SMA) during laparotomy so that the bowel can also be assessed and resected if necessary. METHODS All emergent mesenteric revascularizations for arterial occlusive AMI performed at Dartmouth-Hitchcock Medical Center from 2001 to 2005 (n = 13) were retrospectively reviewed. Outcomes were analyzed with respect to the method of revascularization and other perioperative variables. Restenosis was evaluated with duplex ultrasound imaging. RESULTS Three different revascularization methods were used: surgical bypass (n = 5), antegrade percutaneous stenting (n = 2), and retrograde open mesenteric (SMA) stenting (ROMS, n = 6). Satisfactory revascularization was achieved in all cases and all methods. ROMS was successfully accomplished in three of six patients after antegrade attempts to cross the SMA from the arm were unsuccessful. At 17%, the ROMS group had the lowest hospital mortality compared with bypass at 80% (P = .08) and percutaneous stent at 100% (P = .11). All five of the surviving patients treated with ROMS were discharged to home after a mean hospital stay of 20 days (range, 6 to 38 days). During a mean follow-up of 13 +/- 7 months, three patients died of unrelated causes, of which two were being followed with asymptomatic recurrent SMA stenosis detected by duplex scan. The two surviving patients are alive and well, but one has required percutaneous SMA stenting of a progressive asymptomatic restenosis. CONCLUSION Retrograde open SMA stenting during laparotomy for AMI has a high technical success rate and provides an attractive alternative to surgical bypass in these often critically ill patients. Because it is combined with open laparotomy, it honors the essential surgical principles of evaluating and resecting nonviable bowel. Restenosis rates appear to be high, so that patients must be followed closely. Further study and development of this new hybrid technique is warranted.
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Affiliation(s)
- Mark C Wyers
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA.
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218
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Aktueller Stand der diagnostischen Laparoskopie und Thorakoskopie. Chirurg 2006. [DOI: 10.1007/s00104-006-1255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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219
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Poulin EC, Gagné JP, Boushey RP. Advanced laparoscopic skills acquisition: the case of laparoscopic colorectal surgery. Surg Clin North Am 2006; 86:987-1004. [PMID: 16905420 DOI: 10.1016/j.suc.2006.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acquisition of advanced technical skills requires commitment, time, patience, and discipline (eg, the 10-year rule). Dabbling is not a recipe for success. Despite the value of all other teaching methods, guided practice with feedback is essential to develop the high level of visuospatial perceptual ability (observation and performance with feedback) that is necessary for advanced MIS. The necessary ingredients to skill acquisition for advanced MIS procedures (laparoscopic colorectal surgery) for a practicing surgeon include introduction through short courses, access to skill stations, and access to preceptorship or mini-sabbatical. For residents in training, there is no better alternative than an MIS fellowship. In an ideal world where there are enough trainers, the residency environment should provide this training. Comprehensive strategies of knowledge transfer for practicing surgeons should be designed with the input of experts in knowledge transfer.
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Affiliation(s)
- Eric C Poulin
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
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220
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Neugebauer EAM, Sauerland S. Guidelines for emergency laparoscopy. World J Emerg Surg 2006; 1:31. [PMID: 17052332 PMCID: PMC1634741 DOI: 10.1186/1749-7922-1-31] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2006] [Accepted: 10/19/2006] [Indexed: 11/10/2022] Open
Abstract
Acute abdominal pain is a leading symptom in many surgical emergency patients. Laparoscopy allows for accurate diagnosis and immediate therapy of many intraabdominal pathologies. The guidelines of the EAES (European Association for Endoscopic Surgery) provides scientifically founded recommendations about the role of laparoscopy in the different situations. Generally, laparoscopy is well suited for the therapy of the majority of diseases that cause acute abdominal pain.
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Affiliation(s)
- Edmund AM Neugebauer
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
| | - Stefan Sauerland
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
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221
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Champault G, Descottes B, Dulucq JL, Fabre JM, Fourtanier G, Gayet B, Johanet H, Samama G. [Laparoscopic surgery. The recommendations of specialty societies in 2006 (SFCL-SFCE)]. ACTA ACUST UNITED AC 2006; 143:160-4. [PMID: 16888601 DOI: 10.1016/s0021-7697(06)73644-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- G Champault
- Société Française de Chirurgie Laparoscopique (SFCL), Service de Chirurgie Digestive, CHU Jean Verdier, Bondy.
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222
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Serejo LGG, da Silva-Júnior FP, Bastos JPC, de Bruin GS, Mota RMS, de Bruin PFC. Risk factors for pulmonary complications after emergency abdominal surgery. Respir Med 2006; 101:808-13. [PMID: 16963245 DOI: 10.1016/j.rmed.2006.07.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Revised: 07/18/2006] [Accepted: 07/27/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Pulmonary complications are common after abdominal surgery. Although a variety of risk factors have been described for these complications, studies so far have focused on elective interventions. The aim of this study was to determine the incidence and predictors of pulmonary complications following emergency abdominal surgery. METHODS This was a prospective cohort study. Pre and intra-operative data were collected through interview and chart review and their association with the occurrence of postoperative pulmonary complications (PPC) were analyzed. RESULTS Two hundred and sixty-six consecutive adult patients were included and seventy-five (28.2%) developed PPC. Age >50 years (adjusted OR=3.86; P<0.001), body mass index (BMI) <21 kg/m(2) or 30 kg/m(2) (adjusted OR=2.43; P=0.007) and upper or upper/lower abdominal incision (adjusted OR=2.57; P=0.027) were independently associated with PPC. Patients submitted to multiple procedures tended to be at a higher risk for PPC (adjusted OR=1.73; P=0.079). The development of PPC was associated with prolonged hospital stay (P<0.001) and increased death rate (P<0.001). CONCLUSIONS Pulmonary complications are frequent among patients undergoing abdominal emergency surgery and lead to increased length of hospital stay and death rate. Older age, abnormal BMI, upper or upper/lower abdominal incision and multiple procedures are predictors of PPC in this setting.
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Affiliation(s)
- Livia Goreth Galvão Serejo
- Department of Medicine, Faculdade de Medicina, Universidade Federal do Ceará, rua Prof. Costa Mendes 1608, 60430-040 Fortaleza, Ceará, Brazil
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223
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Slim K, Chipponi J. Laparoscopy for every acute appendicitis? Surg Endosc 2006; 20:1785-6. [PMID: 16960668 DOI: 10.1007/s00464-006-0106-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Accepted: 04/20/2006] [Indexed: 02/04/2023]
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224
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Warren O, Kinross J, Paraskeva P, Darzi A. Emergency laparoscopy--current best practice. World J Emerg Surg 2006; 1:24. [PMID: 16945124 PMCID: PMC1564132 DOI: 10.1186/1749-7922-1-24] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 08/31/2006] [Indexed: 12/18/2022] Open
Abstract
Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. This review critically evaluates the current evidence base for the use of laparoscopy, both diagnostic and interventional, in the emergency abdomen, and provides guidance for surgeons as to current best practise. Laparoscopic surgery is firmly established as the best intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies but requires further randomised controlled trials to definitively establish its role in other conditions.
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Affiliation(s)
- Oliver Warren
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - James Kinross
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Paraskevas Paraskeva
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Ara Darzi
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
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Champault G, Descottes B, Dulucq JL, Fabre JM, Fourtanier G, Gayet B, Johanet H, Samama G. [Laparoscopie surgery: guidelines of specialized societies in 2006, SFCL-SFCE]. ANNALES DE CHIRURGIE 2006; 131:415-20. [PMID: 16762309 DOI: 10.1016/j.anchir.2006.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- G Champault
- Service de Chirurgie Digestive, CHU Jean-Verdier, avenue du-14-juillet, 93140 Bondy, France.
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226
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Lacaine F. L’appendicectomie par laparoscopie ou la chirurgie factuelle à l’épreuve du feu. ACTA ACUST UNITED AC 2006; 143:139. [PMID: 16888597 DOI: 10.1016/s0021-7697(06)73640-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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227
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Agresta F, Ciardo LF, Mazzarolo G, Michelet I, Orsi G, Trentin G, Bedin N. Peritonitis: laparoscopic approach. World J Emerg Surg 2006; 1:9. [PMID: 16759400 PMCID: PMC1459264 DOI: 10.1186/1749-7922-1-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Accepted: 03/24/2006] [Indexed: 12/16/2022] Open
Abstract
Background Laparoscopy has became as the preferred surgical approach to a number of different diseases because it allows a correct diagnosis and treatment at the same time. In abdominal emergencies, both components of treatment – exploration to identify the causative pathology and performance of an appropriate operation – can often be accomplished via laparoscopy. There is still a debate of peritonitis as a contraindication to this kind of approach. Aim of the present work is to illustrate retrospectively the results of a case-control experience of laparoscopic vs. open surgery for abdominal peritonitis emergencies carried out at our institution. Methods From January 1992 and January 2002 a total of 935 patients (mean age 42.3 ± 17.2 years) underwent emergent and/or urgent surgery. Among them, 602 (64.3%) were operated on laparoscopically (of whom 112 -18.7% – with peritonitis), according to the presence of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than two previous major abdominal surgeries or massive bowel distension were not treated Laparoscopically. Peritonitis was not considered contraindication to Laparoscopy. Results The conversion rate was 23.2% in patients with peritonitis and was mainly due to the presence of dense intra-abdominal adhesions. Major complications ranged as high as 5.3% with a postoperative mortality of 1.7%. A definitive diagnosis was accomplished in 85.7% (96 pat.) of cases, and 90.6% (87) of these patients were treated successfully by Laparoscopy. Conclusion Even if limited by its retrospective feature, the present experience let us to consider the Laparoscopic approach to abdominal peritonitis emergencies a safe and effective as conventional surgery, with a higher diagnostic yield and allows for lesser trauma and a more rapid postoperative recovery. Such features make Laparoscopy a challenging alternative to open surgery in the management algorithm for abdominal peritonitis emergencies.
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Affiliation(s)
- Ferdinando Agresta
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
- Via Borgo Coilsola, 1 31010 Fregona (TV), Italy
| | - Luigi Francesco Ciardo
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
| | - Giorgio Mazzarolo
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
| | - Ivan Michelet
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
| | - Guido Orsi
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
| | - Giuseppe Trentin
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
| | - Natalino Bedin
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, Vittorio Veneto, (TV) Italy
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Abstract
Diverticular disease of the sigmoid colon involves more than 50% of population over 60 years, and much more in people older than 80 years. Most patients remain asymptomatic, but, about 10-20% develop complications requiring surgery. Colonic diverticulitis represents an acute bowel inflammation, in many cases, confined only to the sigmoid and descending colon. Recurrent attacks and complications of diverticulitis require surgical procedure, although most cases can be managed medically. The cause of acute diverticulitis remains obscure. It has been speculated that obstruction at the mouth of the diverticulum results in diverticulitis, similar to appendicitis, but this is no longer the accepted theory, and some feel that chronic inflammation precedes clinical diverticulitis. .
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