Management of lateral abdominal hernias

PURPOSE

Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates.

METHODS

A retrospective review of all patients who underwent lateral hernia repair at our institution was performed.

RESULTS

Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm² (range 36-625 cm²). The median operative time was 185 min (range 133-282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days.

CONCLUSIONS

Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.

Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up

PURPOSE

Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR.

METHODS

All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications.

RESULTS

A total of five patients underwent the procedure, with a mean age of 48.6 ± 7.9 years. The mean length of stay was 9.2 ± 5.4 days, and follow-up was 12.3 ± 6.8 months. The mean defect size was 175.8 ± 56.2 cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60 %) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures.

CONCLUSIONS

Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.

Obesity should not influence the management of appendicitis

BACKGROUND

Obesity implies an adverse effect on outcome after appendectomy. This study aimed to determine whether obese patients with appendicitis should be managed differently than nonobese patients.

METHODS

After appendectomy, all patients were enrolled in a prospective clinical pathway and followed from initial presentation to full outpatient recovery.

RESULTS

In 1 year, 272 adults underwent appendectomy, 55 (22%) of whom were obese. The obese patients were slightly older (35 vs 33 years; p < 0.001). The time to diagnosis (8.5 vs 8.6 h), and the need for computed tomography (CT) scanning (40% vs 49%) was similar in both populations. The obese patients had similar rates of perforation (35% vs 35%) and laparoscopy (47% vs 41%). The median hospital length of stay (LOS) (2 days) and complications, including wound complications (9.1% vs 10.9%) and intraabdominal abscesses (3.6% vs 3.1%), were similar. Subgroup analysis showed a longer LOS for the obese patients with perforation than for the nonobese patients (6 vs 5.5 days; p = 0.036).

CONCLUSION

Obese patients had no greater delay in diagnosis, had no greater need for CT scan, gained no additional benefit from laparoscopy, and did not incur significantly worse outcomes after appendectomy except for an increased LOS among those with perforation.

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis

INTRODUCTION

Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study.

OBJECTIVE

To study the effects of LA vs open appendectomy (OA) among adults with appendicitis.

METHODS

In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS).

RESULTS

Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis.

CONCLUSIONS

The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Laparoscopic splenectomy

PURPOSE

To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with hematologic disorders requiring surgical intervention.

PATIENTS AND METHODS

A series of 103 consecutive adult patients underwent LS between 1992 and 1997 at our teaching hospital. Data were collected prospectively. The indications for splenectomy included idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, and thrombotic thrombocytopenic purpura.

RESULTS

The mean spleen size was 14 cm (range 8.5-24 cm) and the mean weight was 263 g (range 40-210 g). Accessory spleens were detected in 12 patients with ITP and 17 patients in the study overall. In 12 patients, LS was combined with a laparoscopic cholecystectomy for gallstones. There were four conversions to open splenectomy, all for hemorrhage and all occurred in the first 50 patients. We have not converted a single patient in the last 2 years. The mean operative time was 161 minutes and was greater in the first 10 cases than the last 10. There were no deaths. Postoperative complications occurred in six patients, one necessitating a second procedure for a small-bowel obstruction. The average length of stay in the hospital was 2.5 days. After surgery, thrombocytopenia resolved in 84% of patients with ITP and anemia resolved in 92% of the patients with hereditary spherocytosis. After a mean follow-up of 38 months (range 2-565 months), four patients (6%) showed a relapse of ITP, three within 12 months of surgery.

CONCLUSIONS

Laparoscopic splenectomy can be performed safely and effectively in a teaching institution. LS in comparison with open surgery offers the same efficacy in the control of hematologic disease with the additional benefits of a minimally invasive approach. Laparoscopic splenectomy should therefore be considered the technique of choice and should prompt earlier consideration of surgery for patients with selected hematologic disorders.

Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model

BACKGROUND

Minimally invasive surgical techniques have become routinely applied to the evaluation and treatment of patients with isolated diaphragmatic injuries due to penetrating trauma. The objective of the study was to compare the healing of diaphragm injuries as determined by macroscopic inspection, histologic appearance, and tensile strength following repair by open suturing, laparoscopic suturing, and laparoscopic stapling techniques in an animal model.

METHODS

Using a pig model, three injuries were created and repaired in each hemidiaphragm of five animals, for a total of 30 lacerations. These injuries were repaired using single-layer open repair, single-layer laparoscopic repair, or laparoscopic stapling. After a 6-week healing period the animals were sacrificed. The gross integrity, histologic appearance using H+E and trichrome satins, and tensile strength of each repair were assessed.

RESULTS

All injuries were grossly intact without dehiscence or herniation. Histologic examination revealed no difference in the collagen deposition between the three groups. The tensile strengths of each type of repair were similar.

CONCLUSION

Laparoscopic techniques used to repair diaphragmatic injuries allow for adequate healing equivalent to open sutured repairs. Simple approximation of the peritoneum with laparoscopic staples allows full-thickness healing of these injuries.

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE

To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds.

SUMMARY BACKGROUND DATA

Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds.

METHODS

The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed.

RESULTS

Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study.

CONCLUSION

Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

Predictors of response after laparoscopic splenectomy for immune thrombocytopenic purpura

BACKGROUND

Splenectomy has been shown to produce long term remission in patients with immune thrombocytopenic purpura (ITP). With the development of laparoscopic splenectomy, there is renewed interest in the surgical treatment of ITP. The aim of this study was to identify factors that are predictive of outcome after laparoscopic splenectomy for ITP.

METHODS

A case series of 67 consecutive patients with ITP undergoing laparoscopic splenectomy was reviewed. A positive response was defined as a postoperative platelet count greater than 150,000/ml requiring no maintenance medical therapy on follow-up evaluation. A chi-square test and a stepwise logistic regression analysis were performed for the following variables: age, gender, preoperative response to steroids, duration of disease, severity of preoperative bleeding, accessory spleens, and thrombocytosis on discharge.

RESULTS

At a median follow-up period of 38 months (range, 2-56 months), 52 patients (78%) had a positive response to laparoscopic splenectomy. Of the 15 patients (22%) who did not have a positive response, 11 were refractory and 4 relapsed. All relapses occurred in patients with a platelet count less than 150,000/microl at discharge. Patient age was the most significant predictive factor for success or failure of the operation. The median age of the responders (31 years; range, 19-71 years) was significantly lower than the median age of the nonresponders (49 years; range, 24-62; p < 0.001). Only 5.6% of those younger than 40 years did not have a positive response, compared with 42% of patients older than 40 years (p < 0.05). Patient age was significantly associated with outcome on univariable chi-square analysis (p = 0.001), and was the only significant factor on multivariable analysis (odds ratio, 2.65; 95% confidence interval, 1.71-4.1). Other significant predictors of outcome on univariable analysis were preoperative response to corticosteroids and platelet count on discharge.

CONCLUSIONS

A long-lasting response after splenectomy for ITP is more likely to occur in patients younger than 40 years of age. To avoid the long-term side effects of corticosteroid use, early surgical referral of younger patients with ITP should be considered.

Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair

OBJECTIVE

To evaluate the efficacy of mesh fixation with fibrin sealant (FS) in laparoscopic preperitoneal inguinal hernia repair and to compare it with stapled fixation.

SUMMARY BACKGROUND DATA

Laparoscopic hernia repair involves the fixation of the prosthetic mesh in the preperitoneal space with staples to avoid displacement leading to recurrence. The use of staples is associated with a small but significant number of complications, mainly nerve injury and hematomas. FS (Tisseel) is a biodegradable adhesive obtained by a combination of human-derived fibrinogen and thrombin, duplicating the last step of the coagulation cascade. It can be used as an alternative method of fixation.

METHODS

A prosthetic mesh was placed laparoscopically into the preperitoneal space in both groins in 25 female pigs and fixed with either FS or staples or left without fixation. The method of fixation was chosen by randomization. The pigs were killed after 12 days to assess early graft incorporation. The following outcome measures were evaluated: macroscopic findings, including graft alignment and motion, tensile strength between the grafts and surrounding tissues, and histologic findings (fibrous reaction and inflammatory response).

RESULTS

The procedures were completed laparoscopically in 49 sites. Eighteen grafts were fixed with FS and 16 with staples; 15 were not fixed. There was no significant difference in graft motion between the FS and stapled groups, but the nonfixed mesh had significantly more graft motion than in either of the fixed groups. There was no significant difference in median tensile strength between the FS and stapled groups. The tensile strength in the nonfixed group was significantly lower than the other two groups. FS triggered a significantly stronger fibrous reaction and inflammatory response than in the stapled and control groups. No infection related to method of fixation was observed in any group.

CONCLUSION

An adequate mesh fixation in the extraperitoneal inguinal area can be accomplished using FS. This method is mechanically equivalent to the fixation achieved by staples and superior to nonfixed grafts. Biologic soft fixation with FS will prevent early graft migration and will avoid the complications associated with staple use.

Intraabdominal abscess rate after laparoscopic appendectomy

BACKGROUND

Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution.

METHODS

Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA.

RESULTS

In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service (P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group.

CONCLUSION

IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Laparoscopic repair of chronic intrathoracic gastric volvulus

BACKGROUND

Totally intrathoracic gastric volvulus is an uncommon presentation of hiatal hernia, in which the stomach undergoes organoaxial torsion predisposing the herniated stomach to strangulation and necrosis. This may occur as a surgical emergency, but some patients present with only chronic, non-specific symptoms and can be treated electively. The aim of this study is to describe a comprehensive approach to laparoscopic repair of chronic intrathoracic gastric volvulus and to critically assess the pre-operative work-up.

METHODS

Eight patients (median age, 71 years) underwent complete laparoscopic repair of chronic intrathoracic gastric volvulus. Symptoms of epigastric pain and early satiety were universally present. Five patients had reflux symptoms. The diagnostic evaluation included a video esophagogram, upper endoscopy, 24-hour pH measurement, and esophageal manometry in all patients. Operative results and postoperative outcome were recorded and follow-up at 1 year included a barium swallow in all patients.

RESULTS

All patients had documented intrathoracic stomach. Five of 8 patients had a structurally normal lower esophageal sphincter. All 4 patients with reflux esophagitis on upper endoscopy had a positive 24-hour pH study, and 2 of these patients had a structurally defective lower esophageal sphincter on manometry. None of the patients had preoperative evidence of esophageal shortening. All procedures were completed laparoscopically. The procedure included reduction of the stomach into the abdomen, primary closure of the diaphragmatic defect, and the construction of a short, floppy Nissen fundoplication. There were no major complications. One patient required repair of a trocar site hernia 6 months postoperatively. At 1-year follow-up, there were no radiologic recurrences of the volvulus. One patient complained of temporary swallowing discomfort and another had recurrent gastroesophageal reflux disease (GERD) symptoms caused by a breakdown of the wrap. All other patients remained asymptomatic during follow-up.

CONCLUSIONS

The repair of chronic gastric volvulus can be accomplished successfully with a laparoscopic approach. A preoperative endoscopy and esophagogram are crucial to detect esophageal stricture or shortening, and manometry is needed to access esophageal motility; pH measurements do not affect operative strategy. The procedure should include a Nissen fundoplication to treat preoperative GERD, to prevent possible postoperative GERD, and to secure the stomach in the abdomen. The procedure is safe but technically challenging, requiring previous laparoscopic foregut surgical expertise.

Laparoscopic management of benign cystic lesions of the liver

We present our experience in the laparoscopic management of benign liver cysts. The aim of the study was to analyze the technical feasibility of such management and to evaluate safety and outcome on follow-up. Between September 1990 and October 1997, 31 patients underwent laparoscopic liver surgery for benign cystic lesions. Indications were: solitary giant liver cysts (n = 16); polycystic liver disease (PLD; n = 9); and hydatid cysts (n = 6). All giant solitary liver cysts were considered for laparoscopy. Only patients with PLD and large dominant cysts located in anterior liver segments, and patients with large hydatid cysts, regardless of segment or small partially calcified cysts in a safe laparoscopic segment, were included. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. The procedures were completed laparoscopically in 29 patients. The median size of the solitary liver cysts was 14 cm (range, 7-22 cm). Conversion to laparotomy occurred in 2 patients (6.4%), to control bleeding. The median operative time was 141 min (range, 94-165 min) for patients with PLD and 179 min (range, 88-211 min) for patients with hydatid cysts. All solitary liver cysts were fenestrated in less than 1 h. There were no deaths. Complications occurred in 6 patients (19%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. Three patients were transfused. The median length of hospital stay was 1.3 days (range, 1-3 days), 3 days (range, 2-7 days), and 5 days (range, 2-17 days) for solitary cyst, PLD, and hydatid cysts, respectively. Median follow-up was 30 months (range, 3-78 months). There was no recurrence of solitary liver cyst or hydatid cysts. One patient with PLD presented with symptomatic recurrent cysts at 6 months, requiring laparotomy. We conclude that laparoscopic liver surgery can be accomplished safely in patients with giant solitary cysts, regardless of location. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.

Possibilities of laparoscopic liver resection

The aim of this study was to report the results of our experience in liver surgery by laparoscopy. From 1989 to 1996, 30 patients (20 women, 10 men; age, 23-88 years; mean age, 53.9 years) underwent laparoscopic liver surgery at our Institute for the following pathology: 10 for biliary cysts, 7 for polycystic diseases, 8 for benign tumors, 3 for hydatid cysts, 1 for chronic abscess, and 1 for metastasis. The locations of these lesions were: 19 in the left lobe, 4 in the right lobe, and 7 in both lobes. Their average size was 8. 45 cm (range, 2.5-22 cm). The largest lesions were biliary cysts; among benign tumors, the maximum diameter was 8 cm. Surgical treatment was as follows: 17 deroofings, 3 pericystectomies, 7 tumorectomies, and 3 left lobectomies. The mean operative time was 79 min (range, 45-527 min). Three of the 30 laparoscopic procedures (10%) were converted to open surgery, because of bleeding in 2 patients with polycystic disease and because it was impossible to carry out the dissection in 1 patient with liver-cell adenoma adjacent to the left portal branch. There were no deaths in this series and 6 patients showed morbidity: 2 patients with polycystic disease developed ascites and required intensive care unit recovery, 1 patient had phlebitis, 1 had infection of the urinary tract, and 2 had local septic complications. Preliminary findings show that the laparoscopic approach to liver lesions may represent safe and effective treatment in selected patients, on condition that several technical details are respected. Of fundamental importance are the surgical equipment, the presence of two experienced operators to do four-hands surgery, and the careful selection of indications, reserving laparoscopic treatment only for those lesions located in easily accessible areas, mainly in the lateral and anterior hepatic segments.

Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

OBJECTIVE

To evaluate the authors' experience with periduodenal perforations to define a systematic management approach.

SUMMARY BACKGROUND DATA

Traditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines.

METHODS

A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome.

RESULTS

Fourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV.

CONCLUSIONS

Clinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.

Laparoscopic splenectomy

Laparoscopic splenectomy can be taught and performed safely. It presents less significant morbidity than does open surgery, and efficacy in the control of hematologic disease is comparable while offering the proven benefits of the minimally invasive approach. Laparoscopic splenectomy for selected hematologic disorders should replace open splenectomy as the technique of choice and prompt earlier consideration of surgery when it is indicated.

Laparoscopic management of benign liver disease

Minimally invasive techniques may be used for treating a variety of benign hepatic lesions in selected patients. The size of the lesions is less important than the anatomic location in anterolateral regions. Laparoscopic unroofing of solitary liver cysts is the surgery of choice for this indication. The laparoscopic management of patients with PLD should be reserved for patients with a few, large, anteriorly located, symptomatic cysts. Active hydatid cysts present technical difficulties because of their complex biliovascular connections and the inherent nature of the parasite. The authors' results do not support the widespread use of laparoscopy in these cases. Uncomplicated benign liver tumors located in the left lobe or in the anterior segments of the right lobe can be resected safely using a four-hand technique. Open surgery is the treatment of choice when primary tumors are malignant, located posteriorly, or in proximity to major hepatic vasculature. Laparoscopic resection of liver metastases with a safety margin of 1 cm, when the total number is less than four, is not unreasonable and can be offered to patients without evidence of extrahepatic disease.

Visual identification of the cystic duct-CBD junction during laparoscopic cholecystectomy (visual cholangiography): an additional step for prevention of CBD injuries

Despite advances in technical skills, common bile duct (CBD) injury during laparoscopic cholecystectomy is not an uncommon major complication. We describe a technical step that can be taken during the dissection of the triangle of Calot to allow the junction between the cystic duct and CBD to be clearly visualized. This is a safe and simple maneuver that mimics the one done in open surgery. Its routine application serves as an additional safety measure to prevent injury to the common bile duct.

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND

Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease.

METHODS

Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations.

RESULTS

Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group.

CONCLUSIONS

Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.

Laparoscopic extraperitoneal inguinal hernia repair. A safe approach based on the understanding of rectus sheath anatomy

We have devised a reproducible approach to the preperitoneal space for laparoscopic repair of inguinal hernias that is based on an understanding of the abdominal wall anatomy. Laparoscopic totally extraperitoneal herniorrhaphy was performed on 99 hernias in 90 patients at the Los Angeles County-University of Southern California Medical Center, using a standardized approach to the preperitoneal space. Operative times, morbidity, and recurrence rates were recorded prospectively. The median operative time was 37 min (range, 28-60) for unilateral hernias and 46 min (range, 35-73) for bilateral hernias. There were no conversions to open repair, and there was only one conversion to a laparoscopic transabdominal approach. Complications were limited to urinary retention in two patients, pneumoscrotum in one patient, and postoperative pain requiring a large dose of analgesics in one patient. All patients were discharged within 23 h. There were no recurrences or neuralgias on follow-up at 2 years. A standardized approach to the preperitoneal space based on a thorough understanding of the abdominal wall anatomy is essential to a satisfactory outcome in hernia repair.

Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients

HYPOTHESIS

Laparoscopic management of perforated duodenal ulcers is safe and effective.

DESIGN

Prospective nonrandomized controlled trial.

SETTING

Tertiary care academic center.

PATIENTS AND METHODS

Between October 1993 and October 1997, 30 patients underwent laparoscopic Graham patch repair of perforated duodenal ulcers and 16 had an open repair.

MAIN OUTCOME MEASURES

Morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work.

RESULTS

There was no difference in morbidity between the 2 groups. Operating time was longer in the laparoscopy group (106 vs. 63 minutes; P = .001). Patients with shock on admission or symptoms for more than 24 hours had a higher conversion rate (P<.05). The laparoscopy group required fewer analgesics, had a shorter stay, and a quicker recovery.

CONCLUSIONS

Laparoscopic repair for perforated ulcers is safe and maintains benefits of the minimally invasive approach. Laparoscopy is not beneficial in patients with shock.

A new form of access for endo-organ surgery. The initial experience with percutaneous endoscopic gastrostomy

BACKGROUND

Intraluminal gastric surgery provides a new treatment option for various disease processes. This study assesses the safety of a new large-diameter percutaneous endoscopic gastrostomy (PEG) for intraluminal surgery.

METHODS

Investigators at six institutions were asked to complete a standard questionnaire to assess the difficulties associated with the assembly and introduction of the PEG, plus intraoperative and postoperative problems related to placement of the device.

RESULTS

In terms of assembly; 1.9% of respondents reported difficulty obtaining complete vacuum of the balloon tip, and 3.8% had difficulty fitting the graduated dilator to the balloon-tipped cannula. Difficulties associated with introduction of the PEG included disengagement of the dilator from the balloon-tipped cannula (0%), extraction of the dilator-port assembly (0%), difficult PEG pullout (1.9%), abdominal wall bleeding (0%), and difficult PEG dilator separation (7.5%). Intraoperatively, 7.5% of respondents reported inadequate skin bolster fitting, 1.9% had CO(2) leakage into the peritoneal cavity, 0% had inadvertent PEG extraction, and 0% reported injury to the esophagus, colon, or small intestine. Postoperatively, there was a 9.4% rate of wound infection, a 1.9% rate of gastrocutaneous fistula, and a 1.9% rate of esophageal, colon, or small intestine injury.

CONCLUSIONS

The large-diameter PEG is safe and effective for endo-organ surgery. Additional preventive measures for PEG site infection should be investigated.

Laparoscopic management of benign solid and cystic lesions of the liver

OBJECTIVE

The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome.

SUMMARY BACKGROUND DATA

Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined.

METHODS

Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively.

RESULTS

The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy.

CONCLUSION

Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.

Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients

OBJECTIVE

To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders.

SUMMARY BACKGROUND DATA

The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce.

METHODS

One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients.

RESULTS

Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months.

CONCLUSIONS

LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.

An improved technique for laparoscopic highly selective vagotomy using harmonic shears

BACKGROUND

Results from classic highly selective vagotomy (HSV) are technique dependent because an incomplete operation will result in early recurrence of duodenal ulcer. Few reports describe laparoscopic completion of the procedure. All techniques use clips for division of neurovascular branches, making the laparoscopic approach tedious and thus the results, uncertain.

METHODS

Ten patients with intractable duodenal ulcer and negative Helicobacter pylori status underwent an extended HSV. All procedures were performed laparoscopically using a new surgical tool, the harmonic shears.

RESULTS

All procedures were completed laparoscopically and took approximately 1 h. There were no deaths and no postoperative complications. Patients were discharged the next day. Follow-up endoscopy at 2 months showed healing of duodenal ulcer in all cases, and postoperative acid secretion studies demonstrated a decrease in basal acid output (BAO) by 74% (8.2 meq/h to 2.16 meq/h) and maximal acid output (MAO) by pentagastrin stimulation by 79.2% (40 to 8.32).

CONCLUSIONS

Harmonic shears expedite laparoscopic HSV. The operation can be taught safely, yields good results in early follow-up, and represents an acceptable option in patients with intractable duodenal ulcers who are H. pylori negative.

Laparoscopic liver surgery. A report on 28 patients

BACKGROUND

An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery.

METHODS

Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one).

RESULTS

Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1-67 months with one asymptomatic recurrence.

CONCLUSIONS

Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the "four-hands technique" for simultaneous dissection and control of bleeding and bile ducts during resections.

Unresolved issues in laparoscopic splenectomy

BACKGROUND

Laparoscopy is now expanding to surgery of intra-abdominal solid organs such as splenectomy for hematologic diseases. The purpose of this study is to further demonstrate that laparoscopic splenectomy is feasible for the surgeon, teachable for the resident, and beneficial to the patient and to revise prior contraindications to this minimally invasive approach.

METHODS

Thirty-three consecutive cases of laparoscopic splenectomy were performed between May 1992 and March 1996. The series included 21 females and 12 males with a median age of 42 years (range 19-79) and a median weight of 73 kg (range 36-115). Indications included: immune thrombocytopenic purpura (20), hemolytic anemia (5), hereditary spherocytosis (4), infarction with abscess (1), Hodgkin's lymphoma (1), Gaucher's disease (1), and AIDS-related thrombocytopenia (1). Dissection was predominately performed with a new surgical instrument, the harmonic shears, and main vessels were controlled with clips.

RESULTS

Thirty-two (97%) of the cases were completed laparoscopically, with 1 (3%) conversion to control hilar bleeding. Four patients underwent simultaneous cholecystectomy. The median spleen size was 13 cm (range 8-28) and median weight was 256 g (range 40-2100). Median operating time was 242 minutes (range 85-515). Morbidity occurred in 2 (6%) patients: ileus and small bowel obstruction. Median hospital stay was 4 days (range 2-14). There was no mortality in our series. Median follow-up was 20 months (range 1-46) with no evidence of late surgical complication or recurrent disease.

CONCLUSION

Laparoscopic splenectomy may be successful in cases previously considered contraindicated, particularly splenomegaly and splenic infarct with abscess. It is a procedure that can be learned under appropriate guidance in academic centers.

Totally extraperitoneal laparoscopic lumbar sympathectomy: an initial case report

A 27-year-old man with a diagnosis of Buerger's disease presented with vasospastic symptoms of coldness and pain at rest of his right foot. Physical examination of his affected limb revealed absent popliteal pulse, cool skin hyperhidrosis and dry gangrene of the big toe. He had been operated on for a ruptured liver and liver abscess 20 years ago. He was scheduled for totally extraperitoneal laparoscopic lumbar sympathectomy on July 26, 1994. The technique was performed under general anesthesia and the patient was put in a supine position with slight extension between the rib and the iliac crest. The working space was created by digital blunt dissection and direct insufflation of carbon dioxide. The right sympathetic trunk was found between the medial edge of the psoas muscle and inferior vena cava. The L2, L3, L4 sympathetic ganglia were identified above the vertebral column and meticulously dissected cephalocaudally. Based on the concept of traditional approach, we believe that this laparoscopic technique is relatively safe and should become the procedure of choice in the future.

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries

BACKGROUND

General surgeons' recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma.

METHODS

Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared.

RESULTS

Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs.

CONCLUSIONS

DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.

Laparoscopic management of complications of peptic ulcer disease

Laparoscopic treatment of intractable duodenal ulcers is intended for the treatment of patients who do not heal after a trial of intensive regimen of medication such as H2 blockers and/or therapy aimed at eradication of Helicobacter pylori. Patients in a category who are Helicobacter-negative can be offered a laparoscopic treatment of their ulcer by vagotomy. Patients who have early relapses on stopping medical treatment are also candidates for vagotomy. Complications of the disease, such as bleeding or pyloric outlet obstruction, represent valid indications in 1995 for performing surgery in patients with duodenal ulcer disease.

Laparoscopic splenectomy

Several indications for laparoscopic splenectomy are represented mainly by hematological disorders such as Idiopatic Thrombopenic Purpura (ITP) or hereditary spherocytosis. Patients with ITP who do not respond, have relapses of the disease under steroid treatment, or need a gradually increased dose of steroids, represent an excellent indication for laparoscopic splenectomy, as the spleen is not enlarged. Patients are usually small, thin, young females, making the procedure much easier. The size of the spleen in hereditary spherocytosis varies, sometimes making the procedure a little more difficult, especially as those patients have pigmented gallbladder stones necessitating a concurrent laparoscopic cholecystectomy. Other indications are represented by staging of Hodgkin's disease, lymphoma of the spleen, and splenic infarcts without abscesses. Some patients with autoimmune hemolytic anemia might benefit from laparoscopic splenectomy, but hypersplenism due to cirrhosis is strongly contraindicated, as the risk of intraoperative hemorrhage is great and not usually managed easily laparoscopically.

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.

Peptic ulcer surgery in 1994

Despite successful medical treatment of peptic ulcer disease regarding both acid reduction and eradication of Helicobacter pylori, there is still an increasing number of emergency operations for complications and no decrease of mortality. Elective surgery after complete physiologic work-up can improve the results for a certain group of patients. In cases requiring acid reduction only, laparoscopic procedures such as posterior truncal vagotomy and anterior seromyotomy can be offered. The minimal invasive approach--as we have experienced in other procedures-increases patient acceptance of surgical treatment.

Laparoscopic posterior vagotomy and anterior seromyotomy

Laparoscopic truncal vagotomy with anterior seromyotomy, as described by Taylor, is our operation of choice in open surgery for elective treatment of chronic duodenal ulcer because it is a rapid, reliable and efficacious procedure. This procedure also does not have the variability of highly selective vagotomy in relation to the surgeon who is performing the operation. The technique is standardised and the results on 90 patients showed minimal morbidity and no mortality with a recurrence rate of 4.2% after a follow-up of 2-41 months. These results are very similar to those obtained in open surgery and compare favorably with the recurrence results after medical treatment. The procedure is therefore effective and safe and should be included in the armamentarium of treatment of chronic duodenal ulcer resistant to a thorough medical treatment.

Laparoscopic rossetti fundoplication

A fundal wrap of the abdominal segment of the esophagus, transposed from the Rossetti modification of the classic Nissen fundopfication, is the operation of choice for surgical treatment of gastroesophageal reflux refractory to medical therapy. Previously validated by open anti-reflux surgery, fundoplication has also proven reliable, effective, and reproducible when performed by laparoscopy, a technique the authors have used routinely since 1989 thanks to the experience gained in vagotomy by a trans hiatal approach.

Laparoscopic treatment of peptic ulcer disease and its complications

Peptic ulcer disease will eventually affect more than 3-4% of the Occidental population. The medical management of this disease, including H2 Blockers, proton pump inhibitors and antihelicobacter therapy, has been well defined and has been very successful. However, the treatment of chronic duodenal ulcer disease has been less successful, thus subjecting these patients to long term disability. It is with chronic duodenal ulcer disease as well as with its complications, such as bleeding, obstruction or perforation, where the surgeon can impact, using laparoscopic surgical techniques as an added therapeutic option.

Laparoscopic surgery of the liver

The liver, with its multiple metabolic, detoxifying, and filtering functions plays a key role in the field of oncology, as it is the site of both metastatic and primary cancers. This phenomenon occurs because of two factors, namely the proximity of the liver to other intra-abdominal organs as well as the extensive portal vein and lymphatic drainage systems. The lobular structure of the liver represents a barrier to cancer cells which ultimately flourish by producing either synchronous or metachronous hepatic lesions. The size of these metastasizes varies greatly and obeys the laws of expediential tumor growth, thus implying that some lesions will be too small to be detected by conventional methods.

Laparoscopy-assisted aortobifemoral bypass

Therapeutic laparoscopy has substantially simplified the postoperative course of patients suffering from hepatobiliary, gastric, or colonic disease. One important advantage of this modality is the decrease in postoperative pain, which diminishes the potential for cardiopulmonary problems. Patients with aortoiliac atherosclerotic disease are at high risk for postoperative complications, and a minimally invasive procedure may favorably affect their postoperative recovery. We describe here the first patient on whom we performed a laparoscopy-assisted aortobifemoral bypass. Under the pneumoperitoneum, seven 10-mm trocars were inserted to permit aortic dissection and creation of retroperitoneal tunnels to the femoral regions. After evacuation of the pneumoperitoneum, an 8-cm midline incision was made to allow a side-to-end aortic anastomosis. The patient's postoperative period was uncomplicated by any cardiopulmonary problems despite his history of three myocardial infarctions; the patient had minimal pain that allowed for a quick return to ambulation. This procedure is minimally invasive and appeared to simplify the postoperative period in our patient. It could become the procedure of choice for certain patients with aortoiliac disease.

Laparoscopic treatment of inguinal hernias. A personal approach

Laparoscopic hernia repair has suffered from a lack of careful anatomical appreciation and the application of sound surgical principles. Key anatomical landmarks which must be clearly identified in every hernia repair are Cooper's ligament, the umbilical artery and the epigastric vessels. The preperitoneal transabdominal mesh repair is the technique advocated by the authors. Between January 1991 and February 1993, 180 hernias were repaired. One hernia has recurred. Morbidity was minimal, with no major complication. The hospital stay was 1.3 days and the majority of patients returned rapidly to full activity. The best indications for laparoscopic hernia repair are recurrent hernias, a large hernia in patients with a weak muscular abdominal wall and bilateral hernias, for which the technique is considered ideal.

[Dissection of the Calot's triangle by the celioscopic approach]

Laparoscopy seems to increase the frequency of post-cholecystectomy biliary complications. Irrespective of the instruments and techniques utilized, dissection of Calot's triangle must be performed in compliance with the classical rules of bile duct surgery. These rules are: always keep in contact with the gallbladder; completely dissect the Calot's triangle area which must not contain more than one biliary tract element; never dissect the cystic duct beyond the right border of the hepatic choledochus; never section an element that is not identified with certainty; systematically perform a peroperative transcystic cholangiography, in particular to detect the anatomical variants of the extra-hepatic biliary ducts.

Laparoscopic vagotomy for chronic duodenal ulcer disease

Two laparoscopic procedures for treatment of chronic duodenal ulcer are described: bilateral truncal vagotomy with balloon pyloric dilatation and posterior truncal vagotomy with anterior lesser curve seromyotomy. The first procedure is simple to perform and easily reproducible, but the latter is preferred because it respects the physiology of the stomach. Thirty-six patients were operated on over a period of 18 months with good results comparable to those with open surgery. The indications for surgery were intractable chronic duodenal ulcers resistant to optimal medical therapy. There was no perioperative morbidity or mortality, and recurrent ulcers have not been demonstrated during early postoperative follow-up. The proper role of laparoscopic surgery in the arsenal of treatment of duodenal ulcers is unclear. The method of laparoscopic vagotomy requires rigorous experimental evaluation in specialized centers before widespread clinical application. Future multicentric prospective studies with long-term follow-up are necessary to assess the results of this innovative therapy of acid-peptic disease.