Incontinence rates after cutting seton treatment for anal fistula

OBJECTIVE

To determine the incidence of anal incontinence after the use of cutting seton treatment for anal fistula.

METHOD

Literature searches were performed on PubMed, MEDLINE and Google Scholar using the words 'cutting seton(s)', 'seton(s)' and 'anal fistula'. An analysis of the data in the collected references was performed.

RESULTS

The average rate of incontinence following cutting seton use was 12%. The rate of incontinence increased as the location of the internal opening of the fistula moved more proximally. In the studies that described the types of incontinence, liquid stool was the most common followed closely by flatus incontinence. Incontinence associated with the treatment of fistulas defined as nonspecific cryptoglandular in nature was 18%.

CONCLUSION

The high incontinence rates that result from the use of cutting setons suggest that this commonly used therapy can damage the continence musculature. Other techniques that do not involve cutting the sphincter, when available, should be preferred, especially for higher fistulas.

Decreased cerebrospinal fluid absorption during abdominal insufflation

BACKGROUND

Intracranial pressure (ICP) is known to rise during induced CO(2) pneumoperitoneum. This rise correlates with an increase in inferior vena caval pressure; therefore, it is probably associated with increased pressure in the lumbar venous plexus. Branches of this plexus communicate with arachnoid villi in the lumbar cistern and the dural sleeves of spinal nerve roots-areas where cerebrospinal fluid (CSF) absorption to normally takes place. The increased venous pressure in this area may impede CSF absorption. Because CSF is produced at a constant rate, decreased absorption will increase ICP. We hypothesized that increased ICP occurring during abdominal insufflation is due, at least in part, to decreased absorption of CSF. The purpose of this study is to show that CSF absorption is inhibited during abdominal insufflation.

METHODS

After appropriate approval was obtained, 16 domestic swine were anesthetized and injected into the CSF with 100 microcuries (microCu) of I(131) radioactive iodinated human serum albumin (RISA) in 2 ml of normal saline. Eight subjects underwent CO(2) abdominal insufflation to 15 mmHg and were maintained for 4 h. A control group did not undergo insufflation. Blood levels of RISA were measured over a 4-h period to determine the rate of CSF absorption.

RESULTS

Blood levels of RISA increased at a slower rate in the subjects undergoing abdominal insufflation than in the control group. The mean change over 2 h in the insufflated group was 15% compared to 34% in the control group (p = 0.02). This difference indicates decreased absorption of CSF in the insufflated group.

CONCLUSIONS

These results demonstrate decreased absorption of CSF during abdominal insufflation and support the hypothesis that the increase in ICP pressure occurring during abdominal insufflation is caused, at least in part, by decreased absorption of CSF in the region of the lumbar cistern and the dural sleeves of spinal nerve roots.

Intraabdominal adhesion formation after preperitoneal dissection in the murine model

BACKGROUND

The laparoscopic approach to hernia repair has been advocated by many as a potentially superior method of herniorraphy. Several techniques have been described, each with its own proposed advantages. These techniques involve different anatomic approaches, the most recent of which is the totally extraperitoneal approach (TEPA). One presumed advantage of the extraperitoneal approach is the avoidance of adhesion formation because the peritoneum is not entered and mesh is not placed in direct contact with intra-abdominal structures. We hypothesize, however, that when the peritoneum is dissected from the abdominal wall, it is partially devascularized, leading to scar formation and potential adhesion formation. This would suggest that the TEPA method of herniorraphy may not completely avoid the risks of intra-abdominal adhesion formation.

METHODS

After appropriate approval was obtained, 88 male Sprague-Dawley rats were divided into two equal groups. One group underwent laparotomy followed by careful blunt dissection of the peritoneum from the left abdominal wall. The control group underwent laparotomy without manipulation of the peritoneum. All animals were re-explored 14 days later, and the abdominal cavity was examined for adhesions. The type and location of any adhesion was recorded.

RESULTS

Adhesion formation occurred in 10 of 44 (23%) subjects in the peritoneal dissection group, compared with 3 of 44 (7%) in the nondissection group (p < 0.05).

CONCLUSIONS

Dissection of the peritoneum from the overlying abdominal wall in the murine model leads to intra-abdominal adhesion formation. This suggests that peritoneal dissection in the TEPA method of herniorraphy may lead to intra-abdominal adhesion formation.

Endoscopic axillary exploration and sentinel lymphadenectomy

BACKGROUND

Minimally invasive approaches have changed the practice of surgery in several specialties. The purpose of this study was to develop a reproducible endoscopic technique for the evaluation of the axilla in breast cancer patients.

METHODS

A total of 23 patients with biopsy-proven breast carcinoma were enrolled. Patients were positioned in the supine position with the ipsilateral arm abducted at 90 degrees. A 1-cm skin incision was made at the superior aspect of the axilla. Dissection was carried bluntly to the lateral border of the pectoralis major. A balloon distention device was inserted into the tract and distended under endoscopic vision to create a working space. Insufflation was initiated up to a pressure of 8 mmHg. A 30 degrees laparoscope was introduced for visualization of axillary contents. One or two additional 5-mm cannulas were placed as needed under direct visualization. Manipulation of axillary contents was performed, and in 19 patients a sentinel node identification technique was applied.

RESULTS

In all patients, using insufflation and minimal instrument dissection, the axillary vein, long thoracic, and thoracodorsal nerves were found in their usual anatomical locations. Utilizing blunt and sharp dissection, the axilla was thoroughly inspected, and individual lymph nodes were easily identified and extracted. In 11 of 19 patients, a sentinel node or blue dye was identified using isosulfan blue. There was a procedure concordance of 84%, and there were no complications.

CONCLUSIONS

We describe a novel endoscopic technique for the evaluation of the axilla in breast cancer patients. This technique allows (a) creation of a minimally invasive working space within the axilla, (b) recognition of key axillary anatomic landmarks, and (c) instrument manipulation within the axilla to identify and extract lymph nodes, and apply the sentinel node technique. This is the first report of a minimally invasive approach to axillary exploration to employ sentinel lymph node mapping.

A method of objectively evaluating improvements in laparoscopic skills

BACKGROUND

In this paper, we explored a quick and inexpensive method to evaluate the improvement in laparoscopic skills gained by residents after attending a formal training course in laparoscopy.

METHODS

Surgical residents attending an endoscopic workshop were randomly selected to perform tasks in a training simulator. Each was evaluated qualitatively and quantitatively before and after the workshop. A control group of six residents who did not attend the workshop were selected to perform the same tasks twice in succession.

RESULTS

The total mean time improvement for all tasks in the study group was 34.3% and in the control group 7.3% (p = 0.0001). When the data was separated for each task, statistically significant improvement was demonstrated in five of the six tasks.

CONCLUSIONS

Residents who attend a formal workshop in endoscopy can gain significant improvement in skills. The methods described in this study can be used to quantitatively measure this improvement throughout a resident's training.

Utility of insufflation filters in laparoscopic surgery

OBJECTIVES

To determine whether filters, regularly used as part of the insufflator tubing during laparoscopic surgery, trap microbial and particulate matter from CO2 tanks, thus preventing passage from one patient to another.

METHODS

A total of 67 used filters were collected from 17 CO2 tanks and six insufflation machines at three local hospitals, and sterile unused filters were used as controls. The used filters were distributed equally and sequentially into three groups: Group I-viewed under a dissecting microscope for particulate matter; group II-examined by mass spectrometry for contamination with oils and other impurities; group III-incubated on sheep blood agar plates and evaluated for growth of microorganisms.

RESULTS

Negative. Used filters were indistinguishable by all parameters from controls.

CONCLUSIONS

This limited study suggests filters now used in laparoscopic surgery fail to trap microbes or particulate matter. The question remains whether tank waste is absent or these filters fail to trap waste matter.

Gastric adenocarcinoma associated with isolated granulomatous gastritis

BACKGROUND

Granulomatous gastritis is a rarely observed pathological diagnosis. This condition often mimics gastric adenocarcinoma clinically, resulting in gastric resection. However, granulomatous gastritis has long been viewed as a benign process not observed in association with adenocarcinoma of the stomach. This article describes a patient with granulomatous gastritis occurring in close proximity to an area of superficially invading gastric adenocarcinoma.

METHODS

Acid-fast stains, fungal stains, standard cultures, tuberculosis cultures, and a VDRL serum test were all obtained. Both upper endoscopy and colonoscopy were performed. Chest radiographs were taken and pulmonary consultation was obtained.

RESULTS

The gastric samples obtained from resection showed no evidence of foreign body reaction. The acid-fast stains, fungal stains, cultures, and VDRL were all negative. Endoscopic exams did not show granulomatous inflammation in any other part of the gastrointestinal tract. No pulmonary disease was evident on radiographic or pulmonary exam.

CONCLUSION

Isolated granulomatous gastritis is a diagnosis of exclusion. The findings in this patient do not support a diagnosis of Crohn's disease, tuberculosis, sarcoidosis, syphilis, histoplasmosis, berylliosis, or foreign-body reaction. This is a unique case suggesting an association between isolated granulomatous gastritis and metaplastic mucosal changes.

Splenosis of the mesoappendix: case report and review of the literature

The development of splenosis is a known consequence of splenic rupture. A case is presented of acute appendicitis in a patient with a past history of abdominal trauma who required laparotomy for unknown reasons. During appendicectomy a mass was found in the mesoappendix which proved to be evidence of splenosis.

Common bile duct T-tubes. A caveat and recommendations for management

Operations on the common bile duct can result in severe long-term consequences. To prevent some of these complications, it is common practice to drain the biliary tree with a T-tube. The T-tube is usually removed 2 weeks after it was placed. There have been numerous reports of bile leak following T-tube removal in the literature. These leaks can result in bile ascites, biloma, or bile peritonitis. Control of bile leaks can be accomplished in a number of ways, including endoscopically or radiologically placed stents or drains and radiologic techniques to drain the fluid collections. We describe a novel technique that can be utilized at the time of T-tube removal that will allow immediate control of the bile leak and prevent the complications of bile accumulation within the peritoneal cavity. We have performed fluoroscopic removal of T-tubes on two patients and found no complications with the technique. We have successfully visualized the T-tube tract in both patients. The T-tube tract can be visualized at the time of T-tube removal in an effort to prevent the complications of tract disruption and subsequent bile leak.

Laparoscopic versus open Nissen fundoplication: outcome of surgery in monozygotic twins

Differences in outcome and cost of laparoscopic and open surgery are continuously being evaluated. Two-year-old monozygotic twin boys with a previous history of prematurity, severe gastroesophageal reflux disease, and intractable reactive airway disease were each scheduled to undergo a laparoscopic Nissen fundoplication (LNF) on the same day. Current medications for both patients included albuterol, cromolyn sodium, dexamethasone, ranitidine, and metoclopramide. In the first case, the laparoscopic procedure was converted to an open Nissen fundoplication (ONF) to gain expeditious control of bleeding from a short gastric vessel close to the spleen. The second patient underwent LNF without complication. Operative time for each patient was 3.5 h. The postoperative length of stay for each patient was 6 days (ONF) and 4 days (LNF). The total hospital charges were $21,931 (ONF) and $19,108 (LNF). The first patient (ONF) was readmitted later on the day of discharge (postoperative day 6) for vomiting and was discharged after 24 h with no further treatment. The subsequent course of each patient was similar. At a 6-week follow-up visit, both patients were tolerating a regular diet with weight gain and dramatic improvement in pulmonary symptoms.

The investigation of symptomatic inguinal hernia: a complication of barium enema

The controversy surrounding the value of performing screening barium enema in patients with inguinal hernia persists. It was Myers & Zollinger who, in 1942, reviewed 200 consecutive cases of inguinal hernia and noted that 18%; of patients complained of gastrointestinal symptoms. Of these, two cases of adenocarcinoma were discovered on further evaluation. Subsequently, many authors have reported a low diagnostic yield of barium enema in patients with inguinal hernia unless specific colonic symptoms were present. We present a case in which this investigation was indicated, but led to irreducibility.

Incidental detection of cystic neoplasms of the pancreas

Cystic neoplasms of the pancreas are rare, accounting for less than 1% of all pancreatic tumors Since the advent of computerized tomography (CT), an increasing number of these lesions are being discovered incidentally. Compagno and Oertel were the first to thoroughly describe and differentiate the benign serous cystadenoma from the potentially or overtly malignant mucinous cystadenoma/cystadenocarcinoma spectrum. At present, our ability to definitively differentiate between these two classes of cystic neoplasms is limited. Because of this, controversy exists as to their appropriate surgical management. A case report is presented and followed by a review of the literature on incidentally detected cystic neoplasms of the pancreas.

Determination of the learning curve of the AESOP robot

BACKGROUND

As the variety of procedures performed with laparoscopic technology increases, the skill levels and equipment demands also increase. Laparoscopic appendectomy, hernia repair, colon resection, and Nissen fundoplication all require someone whose only responsibility is to control the laparoscope and therefore the operative field. This is usually the most inexperienced person on the operating team. The Automated Endoscope System for Optimal Positioning (AESOP) robot provides a means to eliminate the need for the camera person, returns control of the camera and operative field to the operating surgeon, and enhances human performance. The purpose of this study was to evaluate the acquisition of skills to control the laparoscope in a satisfactory fashion.

METHODS

We selected medical students as our study group because they have no prior experience in laparoscopic procedures. They performed a readily reproducible task in a pelvic trainer with hand control and with the AESOP robot. Their initial times are compared, as is the improvement in their times after 10 min of practice with the AESOP robot.

RESULTS

These data show that in this study group use of the AESOP robot was not as fast as hand control but the skill to use it was learned as quickly. Additional features of the robut such as a steady view and the ability to acquire images and return to them reliably are other advantages.

CONCLUSION

The AESOP robotic arm provides a stable support for the laparoscope during laparoscopic procedures which can be manipulated by the surgeon. We found that the time required to learn control of the laparoscope manually and with the AESOP robot is equal.

Management of colorectal foreign bodies

Colorectal foreign bodies (CFBs) present a serious dilemma regarding extraction and management. In an 11-year period ending March 1994, 48 patients presented to the University of California, San Diego Medical Center and Hammersmith Hospital London with CFBs. Identified patients charts were reviewed in a retrospective manner and the medical literature was reviewed. A wide variety of CFBs were identified and all were extracted transanally. Circumstances surrounding CFB insertion was most commonly sexual stimulation (78%), but included sexual assault (10%). Extraction in the emergency department was successful in 31 (63%) patients. Operating room extraction was performed in 18 (37%) patients; in 12 cases the CFBs were simply extracted under anaesthesia, five patients required primary repair and diverting colostomy for rectal perforation and one required primary repair of an external anal sphincter laceration. Post-extraction observation following simple extraction ranged from immediate discharge to 72 h (mean 13.1 h) and there were no reported complications. A thorough history is essential in order to identify those cases that have resulted from assaults. With adequate sedation, most CFBs can be extracted transanally either in the emergency department or operative suite under direct vision. Sigmoidoscopy is required following extraction to evaluate mucosal injury or perforation. After effortless extraction of a smooth object, with no evidence of mucosal injury, the patient can be discharged after a short period of observation. Rectal perforation can be treated with primary repair and diverting colostomy with low morbidity. This is a relatively common surgical dilemma that requires a thorough history, physical examination, radiographs inventiveness to treat. Additionally, the physician should demonstrate a caring attitude and not subject the patient who is suffering pain and embarrassment to ridicule.

Digital ischemia and occult malignancy

Since the early transcript by Raynaud and Trousseau, there has been wide acceptance of the association of occult malignancy and peripheral vascular disease. Recently, there have been a few case reports of acute onset monophasic digital ischemia heralding an occult malignancy. It appears that the site and tumor types seem unimportant in the development of ischemia; tumor resection however, usually results in rapid improvement of the affected digit. The mechanism remains to be established.

New applications of laparoscopy in gastrointestinal surgery

Although laparoscopy has been available since the turn of the century, the technique did not become widely accepted for gastrointestinal surgery until it was used in cholecystectomy. Since then, various gastrointestinal operations have been performed using laparoscopic guidance. Laparoscopic operations must conform to principles for open general surgery, especially in cases of oncologic resection. Procedures for treatment of conditions such as hiatal hernia, gastroesophageal reflux, intractable peptic ulcer disease, bypass for malignant pancreatic obstruction and repair of rectal prolapse have received immediate acceptance. Other procedures, such as Whipple's operation and colectomy for cancer, have met with a more guarded response.

Comparison of serum C-reactive protein concentrations for laparoscopic versus open cholecystectomy

In an attempt to quantify the difference in tissue damage between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC), we have compared in a prospective manner the pre- and post-operative concentrations of serum C-reactive protein (CRP) in 17 patients undergoing LC and 13 patients undergoing OC. In addition, we measured the pre- and postoperative white blood cell counts (WBC), the postoperative body temperature, and the postoperative duration of hospitalization. There were no differences in the preoperative serum CRP concentrations--5.9 +/- 2.62 mg/l (mean +/- SD) for the LC group and 6.12 +/- 2.38 mg/l for the OC group. Serum CRP rose markedly following OC compared to that of patients who underwent LC (128.6 +/- 45.1 mg/l vs 26.8 +/- 10.5 mg/l) (P < 0.001). There were also significant differences in the postoperative WBC count (14,000 +/- 2,900 cells for the OC group vs 10,600 +/- 3,000 cells for the LC group), the postoperative body temperature (37.5 +/- 0.3 degrees C vs 37.0 +/- 0.3 degrees C), and the postoperative hospital stay (5.5 +/- 1.5 days vs 1.9 +/- 0.9 days). There was no correlation between serum CRP concentrations and the other postoperative parameters. These results provide us with biochemical evidence supporting the clinical observation that LC is far less traumatic to the patient than OC.

Phantoms and pixels, apparitions and apparatus: image guided general surgery

As eloquently stated by Dr. Richard Bucholz in his introduction to the first edition of this journal, "the concept of image guidance in surgery may initially be deemed a non-sequitur: by definition, we use images perceived by our optic systems to lead us to our surgical decisions and actions." However, the thrust of this journal is to define the relationships between Homo sapiens and the technology that is now an interface between surgeon and patient. In this article I will discuss how such technology effects the general surgeon, including devices and designs currently in use and those that are mere speculation. A leader in this field, Colonel Richard Satava, has stated succinctly, "Predicting the future-trends in any profession jeopardizes the credibility of the author." I have been guilty of such speculation and it is amazing how rapidly concepts move from probability to possibility to implausibility. This is another reason why a journal in this electronic format is so appealing.

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

Biofragmentable anastomosis ring for laparoscopic bowel surgery

Laparoscopic surgery is now being applied for colonic resection, and one of the key challenges is fashioning a sound anastomosis. The biofragmentable anastomosis ring, a modern version of the Murphy Button, has been utilized in a series of experiments to develop and evaluate laparoscopic anatomotic techniques. A series of purpose-built devices were used to fashion left and right simulated colectomies as well as for a variety of other anastomoses. Survival animal experiments were performed and demonstrate the feasibility of this technique.

Clinical and laboratory evaluation of an electrosurgical laparoscopic trocar

Electrosurgical energy may be utilized as an adjunct to mechanical force for insertion of laparoscopic trocars. The advantage of this approach may be better operator control of insertion, with less risk of intraperitoneal and retroperitoneal injury. To assess the safety and efficacy of electrosurgical trocars, we compared them to mechanical trocars in clinical and animal trials. During 100 trocar introductions in 25 laparoscopic cholecystectomies, insertion force was measured. In contrast to mechanical trocars, which required progressively more force to insert as size increased, electrosurgical trocars required the same low insertion force regardless of size. No wound complications occurred. In animal experiments, wound healing (measured histologically and by bursting strength) was normal and equivalent for mechanical and electrosurgical insertions. We conclude that electrosurgical trocars require less force for insertion and do not impair wound healing. Electrosurgical trocars may thus offer important safety advantages over mechanical trocars.

Is there a dilemma in adequately training surgeons in both open and laparoscopic biliary surgery?

It is apparent that no inherent dilemma exists in training surgeons in both open and laparoscopic techniques. The important point is that surgeons are trained: a solid foundation in the basic sciences, well-developed technical skills, a large clinical experience on which to base future decisions, and the insight to know when one's skills require improvement. The principles of biliary surgery should be adhered to, and in one's haste to become proficient at laparoscopic techniques, one must not abandon the most basic of these-the unequivocal identification of all structures before ligating, dividing, clipping, or otherwise sacrificing tissues.

Laparoscopic surgery: surgical education in the People's Republic of China

In 1991, because of the international emphasis on laparoscopic surgery, a large contingency of surgeons took on the task of introducing laparoscopy to the People's Republic of China. This trip was a technological feat, since all of the equipment and instrumentation had to be carried into the country. This necessitated a major coordinated effort among professional teaching staff and industry representatives with their transported equipment. This unique educational opportunity is detailed in this article, which highlights, in particular, the contrast between the new "high-tech" surgery and the reality of a developing country.

Are elevated liver enzymes and bilirubin levels significant after laparoscopic cholecystectomy in the absence of bile duct injury?

OBJECTIVE

Increased aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin levels were noted incidentally after a laparoscopic cholecystectomy. The percentage in which such elevation occurs and its clinical significance in the absence of bile duct injury were investigated.

SUMMARY BACKGROUND DATA

Bile duct injury is the most feared complication of laparoscopic cholecystectomy. Some laboratory tests may be indicative of this complication, such as increases in liver enzyme (AST, ALT, and alkaline phosphatase [ALP]) and bilirubin. These parameters have not been investigated in patients who had laparoscopic cholecystectomy and in whom no damage to the bile duct was noted.

METHODS

Sixty-seven patients with normal results of preoperative liver function test were entered into the study. Blood was collected 24 hours after laparoscopic cholecystectomy, and AST, ALT, ALP, and bilirubin levels were measured.

RESULTS

A mean 1.8-fold increase in AST occurred in 73% of patients; 82% showed a 2.2-fold increase in ALT. A statistically nonsignificant increase was noted in 53% of patients (ALP remained within normal limits), and in 14% of patients bilirubin levels were increased (they were primarily of the unconjugated type).

CONCLUSIONS

In many patients a significant increase in AST and ALT levels occurred after laparoscopic cholecystectomy, but they returned to normal values within 72 hours. The cause of this is unclear, and these elevations appear to have no clinical significance.

Laparoscopic fixation and guiding devices

Since the new advances in video technology in the mid 1980's and the couplmg of the video camera to the laparoscope the surgeon no longer needs to control the laparoscope with his own hands. The advantage of this new development in laparoscopic surgery is that (1) it is not as tiring to perform (i.e., he no longer had to bend over the patient to look through the laparoscope's ocular), (2) the whole operating team could follow the progress of the surgery (for better or worse), and (3) that the surgeon is then enabled to operate with two hands, a new skill which must be learned since it is one of the keys to being more effective and efficient under the laparoscope. One of these advanced skills, intracorporeal suturing, is an especially demanding skill and requires a well-centered, and steady camera support for the technique to be performed efficiently. The disadvantage is that he must give oral commands to the individual who is now charged with guiding the laparoscope within the operative field and this disadvantage alone is sometimes thought the tip the balance in the wrong direction.

Training in laparoscopic cholecystectomy. Quantifying the learning curve

There is no clear consensus on the best way to train general surgeons to perform laparoscopic cholecystectomy (LC). We attempted to quantify the "learning curve" for 86 surgeons attending eight consecutive 3-day, three-pig courses in LC. Each step of the operation was scored by the instructor for successful performance: Uncomplicated pneumoperitoneum (p), cystic duct and artery dissection (cd), artery and duct clipping (cc), operative cholangiography (oc), gallbladder dissection without holes (gd), liver bed hemostasis (h), gallbladder removal in one piece (i), and no abdominal organ injury (in). As well, operative time, method of dissection, and contact Nd: YAG or electrocautery were recorded. The percentage of students successfully completing each task for the first and third pigs on which they acted as surgeon was as follows: [table: see text] The operative time for the first and third pigs was 1.3 +/- 0.56 and 0.70 +/- 0.34 (mean +/- SD) h, respectively (P < 0.01). When students were trained with the contact Nd: YAG laser there was more blood loss than with electrosurgery (P < 0.001). Statistically significant improvement could only be demonstrated in the most difficult task, gallbladder dissection without perforation, but that task had not been mastered by the end of 3 days. The flat portion of the laparoscopic cholecystectomy "training curve" had not been reached by the end of the program.

Robotically assisted laparoscopic surgery. From concept to development

The evolution of laparoscopy from a monocular view to the video screen has enabled all in the operating room to see the procedure. This has meant the surgeon must rely on an assistant to hold the scope, which has many drawbacks. Robotic enhancement technology creates a symbiotic relationship between the surgeon and robot and leads to great improvement in the performance of the case.

Laparoscopy in the trauma patient

The first laparoscopic exam of the abdominal viscera was done by Keillng in 1902. Since that time, laparoscopy has been used more extensively in abdominal and pelvic disorders by gynecologists and gastroenterologists than general surgeons. However, since the introduction of laparoscopic cholecystectomy in the 1980s by Mouret in France and Muhe in Germany, laparoscopy has been embraced by the general surgeon and has exponentially increased in number and types of procedures being done. New technology, such as the enhancement of video image along with better instrumentation, has further accelerated the acceptance of "minimally invasive" surgery in all surgical specialties.

Laparoscopic cecopexy for cecal volvulus. Case report and a review of the literature

A case of intermittent cecal volvulus in an immunocompromised patient is presented. This patient, whose bowel was viable, was managed successfully by laparoscopic cecopexy. As a clinical entity, cecal volvulus usually presents as either an unrelenting process, culminating in gangrenous bowel, or as an intermittent, recurrent condition with spontaneous resolution but which also may lead to loss of intestinal viability. Surgical management is required in almost every case; however, a review of the literature reveals considerable controversy as to what constitutes the best operation for cases in which the bowel is viable. The most appropriate operation is usually dictated by the clinical circumstances, and in many settings cecopexy is a satisfactory choice of procedure; resection is obviated, bowel need not be opened, and the operation can be performed laparoscopically relatively rapidly.

Laparoscopic endocorporeal mobilization followed by extracorporeal sutureless anastomosis for the treatment of carcinoma of the left colon

Surgery has become progressively more reliant on technology. The technique of colonic anastomosis utilizing the biofragmentable anastomotic ring (BAR) is one such example. The benefits of therapeutic laparoscopy have been applied to the arena of colorectal surgery. A case is presented that combines these two modalities in a patient with colon cancer, laparoscopic mobilization of the large bowel, exteriorized resection, and BAR anastomosis.