[Colo-rectal surgery, through laparoscopic approach. Considerations concerning a personal experience of 613 cases]

The start of colo-rectal laparoscopic surgery, after an initial period of enthusiasm tempered by predictable technical difficulties, was finally slowed down by the risk of port site metastases. However, this kind of surgery continued to be used for benign colonic pathology, allowing the achievement of surgical skill. Some well-trained teams reported comparable loco-regional relapse rate and 5-years survival in both laparoscopic and conventional trials. The some good results concern also mortality and morbidity in both kind of trials. Based on 613 personal cases, the authors reveal this surgery's peculiarities, justifying a predictable development.

[The capacity of preoperative ultrasonography in predicting technical challenges in laparoscopic cholecystectomy]

Ultrasonography is a nonsophisticated, cheap and safe exploration, that makes it the most used non-invasive method in the diagnosis of biliary diseases. Present study aims to evaluate preoperative ultrasonography's capacity of predicting technical challanges in laparoscopic cholecystectomy (LC).

MATERIAL AND METHOD

The trial is represented by a sequence of 100 patients undergoing LC in 2001. The conversions to open procedure were excluded. Patients with certified lithaisis were re-examined by ultrasonography the day before surgery. The sonographic features as size, volume (scleroatrophic gallbladder), function (distension, contraction), wall thickness, hydrops, number and size of stones, infundibular position (impactation) of the stones, perivesicular liquid collections hepatic and pancreatic aspects, main bile duct caliber were registered. During LC, the difficulty in performing the procedure was measured using a 10 points-score of following parameters: 1 peritoneal and perivesicular adhesions; 2. Difficult grasping of the gallbladder; 3. Cystic duct's dissection; 4. Cystic artery; 5. Liver bed; 6. Difficult cystic stappling; 7. Gallbladder's wall efraction; 8. Need for intraoperative cholangiography; 9. operative bleeding; 10. Operative time.

RESULTS

Gallbladder's and the number, the size and infundibular impactation of the stones was significantly associated to ultraoperative difficulties (p < 0.05), the other parameters having not a sensitive influence upon LC procedure.

CONCLUSION

Preoperative ultrasonography is able to furnish valuable data in predicting LC challenges.

[Conversion in laparoscopic surgery]

AIM

The conversion causes evaluation in dynamics.

METHODOLOGY

The study is a retrospective analysis of the conversion to open surgery in 1993-2001 period, indifferently of the moment and the determinant cause. The yearly dynamics of the conversions was divided by operation types and surgeons. There were also analysed the moment and the cause of the conversion.

RESULTS

There were realised 3961 laparoscopic operations (by 7 experienced surgeons and a lot of young surgeons), with 244 conversions (6.2%), percentage variable depending of the operation (3.3% in hernioraphies, 5.3% in cholecystectomies, 8.2% in gynecologic procedures, 12.1% in appendectomies, 33% in abdominal esophagus procedures, 33% in splenectomies) and on surgeon (until 0% and 8%); the differences until the surgeons don't depend on their experience and for the same surgeon, the experience accumulation doesn't reduce the conversion rate. The most conversions happen after a simple inspection or a minimal dissection (73.1% in cholecystectomy) caused by the existence of plastron, the discovery of a difficult anatomic situation or of another pathology; more rarely, the conversion happens in the principal time (23.4% in cholecystectomy), doing to hemorrhage, impossible dissection, visceral injury or even at the end of the operation (3.5% in cholecystectomy), doing to hemorrhage, loss piece or calculs.

CONCLUSIONS

The conversion rate depends especially on the correctness of the indication of laparoscopic approach and not on the surgeon experience, what proves that it is a moment of surgical maturity. Decide from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication, modifies neither the morbidity, nor the much discussed hospital stay.

[Analysis of 3100 laparoscopic cholecystectomies]

AIM

To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period.

PATIENTS AND METHODS

First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%).

RESULTS

Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8.

CONCLUSIONS

To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.