"First, do no harm": monitoring outcomes during the transition from open to laparoscopic live donor nephrectomy in a Canadian centre

OBJECTIVE

During the learning curve for laparoscopic live donor nephrectomy (LLDN), donor morbidity and poorer graft function may be increased. To minimize these risks, a dedicated team of laparoscopic, urologic and transplant specialists worked together to introduce the technique. This study was undertaken to validate this approach by comparing donor and recipient outcomes and studying our learning curve during the transition from open (OLDN) to LLDN.

METHODS

We compared 59 LLDNs with 34 OLDNs performed for adult recipients. Data were collected prospectively for LLDN and retrospectively for OLDN. We compared donor outcomes and recipient graft function in the 2 groups, and we used the cumulative sum (CUSUM) method to generate learning curves; p < 0.05 was considered statistically significant.

RESULTS

From the donor standpoint, the complication rate was 10% in the laparoscopic group, compared with 21% in the open group. Length of stay was shorter after LLDN (3 v. 5 d, p < 0.001). Among the recipients, there were no significant differences in the incidences of ureteral complications, delayed graft function (DGF), creatinine levels, acute rejection or patient and graft survival. When we used the incidence of DGF after OLDN as a benchmark, CUSUM analysis revealed a downward inflection point for DGF after 30 cases, consistent with an improvement in performance.

CONCLUSION

At our institution, a team approach has allowed the safe introduction of LLDN without a significant negative impact on recipient outcomes and with a reduction in donor length of stay. Using DGF as an outcome, we observed improved performance after 30 cases.

Ethical issues in laparoscopic hysterectomy

Hysterectomy is performed for a wide range of benign and malignant conditions, such as fibroids, menorrhagia and pelvic pain, and gynaecological malignancies. One in four women has a chance of undergoing hysterectomy in her lifetime. Conventionally abdominal hysterectomy is done through the open approach. However, many patients assume that the modern laparoscopic hysterectomy is superior to the standard approach. Laparoscopic surgical centres are mushrooming in major cities. This article presents ethical considerations involved in the decision-making process of choosing from the surgical options available.

Optimal management of the morbidly obese patient SAGES appropriateness conference statement

BACKGROUND

Obesity is a growing health problem that contributes to numerous life-threatening or disabling disorders, including coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, and obstructive sleep apnea. Significant weight reduction in the morbidly obese improves or reverses associated illness and benefits well-being. The purpose of the SAGES Appropriateness Conference was to summarize the state of the art for open and laparoscopic operations for the morbidly obese.

METHODS

The English literature comparing bariatric procedures was reviewed and grouped by level of evidence by three surgeons (BS, LV, and CC). From more than 1,500 articles, all conference participants were provided with reprints and table summaries of no less than 50 selected manuscripts. Ten experts were requested to present reviews and make evidence-based arguments for and against the open and laparoscopic approaches in written format. An expert panel of six surgeons, including an ethicist and patient, commented on implications of data presented. The finalized statement was e-mailed to all participants for approval and comment.

RESULTS

Consensus statements were achieved on various aspects of morbid obesity, including indications for surgery, resolution of comorbid illnesses with significant weight loss, and the importance of committed bariatric program. Our panel of experts agreed, in general, to the advantages of laparoscopic approaches compared to open operations in skilled hands.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass (RYGB) affords improved short-term recovery compared to open gastric bypass. Laparoscopic adjustable banding can be performed with lower average mortality than either RYGB or any of the malabsorptive operations, and it produces variable degrees of short-term weight loss. Prospective randomized trials are needed to compare gastric bypass, malabsorptive, and restrictive procedures.

Should diagnostic hysteroscopy be a routine procedure during diagnostic laparoscopy in women with normal hysterosalpingography?

The advantage of hysteroscopy (HSC) over hysterosalpingography (HSG) in the accuracy of the diagnosis of uterine cavity abnormalities that may cause or contribute to infertility has been shown by numerous studies. The aim of this study was to analyse the results obtained from diagnostic HSC performed routinely during diagnostic laparoscopy in the investigation of the infertile women, to evaluate the effectiveness of the procedure in the diagnosis of uterine causes of female infertility. Ninety-three infertile patients with normal uterine cavity as demonstrated in HSG underwent diagnostic laparoscopy and hysteroscopy in this infertility unit. The hysteroscopy showed a normal cavity in 80 cases (88%), giving a false-negative rate of 12% for HSG. The pathologies found included small adhesions (two cases), an arcuate fundus (two cases), an endometrial polyp (three cases), and endometrial hyperplasia was diagnosed in four cases. In the absence of a positive history or a radiographical suggestion of endometrial abnormalities, or both, HSC made little diagnostic contribution towards elucidating the cause of female infertility or to finding a pathology that could affect the chances of achieving a normal pregnancy. However, in view of the low complication rates, minimal time requirement, and a negligible effect on the post-operative course, HSC could be performed on all infertile patients undergoing diagnostic laparoscopy.