Laparoscopic management of peptic ulcer disease

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

Laparoscopic proximal gastric vagotomy--neuralgic points of technique

Laparoscopic proximal gastric vagotomy is a valuable therapeutic tool in the management of patients suffering from recurrent duodenal ulcer disease, the therapeutic principle being the effective reduction of gastric acid output without gastrotomy or gastric resection. The method is based on the well-documented conventional technique, which has been evaluated for over 15 years. The division of all vagal fibres to the gastric fundus and body is essential for complete vagotomy in order to ensure a sufficient reduction in gastric acid. The operation time is between 2 and 3 hours. Eighteen patients have been treated successfully with this minimally invasive and safe procedure in our unit. The functional and cosmetic results are excellent. The comparatively lower costs are, last but not least, an important advantage.

Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy

Simplified parietal cell vagotomies (Taylor's and Hill-Barker's procedures) were proposed more than a decade ago to make the operation easier and faster. Efficacy and safety have proven to be as good as with proximal gastric vagotomy. The Hill-Barker operation is particularly simplified by the laparoscopic approach, which enables the procedure to be performed very precisely. The limited trauma of minimally invasive vagotomy has increased the interest in peptic ulcer surgery, especially for patients with chronic duodenal ulcer disease who cannot or do not want to take long-term continuous medication, or who are resistant to it. We describe our technique of performing the laparoscopic Hill-Barker procedure. Our initial results with eleven patients show no operative mortality and minimal morbidity with early discharge and ulcer of all patients. Of the 9 cases which are evaluable, 8 are pain-free and one had an ulcer recurrence after incomplete vagotomy.

Laparoscopic proximal gastric vagotomy

Proximal gastric vagotomy, considered the conventional surgical treatment of choice for peptic ulcer disease, is now performed laparoscopically. Thirty-three patients underwent the procedure. Seven patients were treated on an emergency basis for perforated peptic ulcer. Morbidity and mortality of the procedure were zero. Patient acceptance (Visick staging) was good to excellent in 22 of 25 patients in follow-up. Laparoscopic proximal gastric vagotomy appears to be a good treatment in chronic peptic ulcer disease even when complicated by an acute perforation.

Highly selective vagotomy: use of a ligature carrier

A ligature carrier for use in typing the neurovascular bundle along the lesser curve of the stomach during highly selective vagotomy is described. This is presented as a safe and efficient way of performing this part of the operation.

Lesser curve disconnection using a stapling device: highly selective vagotomy made quicker and easier

A stapling device has been used to disconnect the lesser curve of the stomach during highly selective vagotomy in a consecutive series of ten patients. This modification renders the operation technically easier and quicker to perform. Postoperative recovery was uneventful in all patients, and in the subsequent follow-up period of 7-15 months, no problems relating to the technique were encountered.

[Stapling devices on stomach and small bowel (author's transl)]

Sutures, blind closures, and anstomoses can be performed on the stomach and the small bowel with LDS, GIA, TA, and EEA staplers. The advantage of using these devices is a fast, clean operation, with safety comparable to the conventional technique. Leakage in sutures and anastomoses occur in 1% and after duodenal closure in 2.6%. Bleeding has been observed with the GIA and LDS staplers (0.7%-1%). Mortality is equal to the conventional technique. The time saved during operations and fewer infections justify the elevated costs of the stapling devices.