Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe

Laparoscopic ultrasonography is a novel technique which may be useful in screening for choledocholithiasis during laparoscopic cholecystectomy. Following concerns regarding the learning curve and accuracy associated with the adoption of this user-dependent technology, we have prospectively evaluated a commercially available 90° sector scanning laparoscopic ultrasound probe during elective laparoscopic cholecystectomy. Laparoscopic ultrasonography was performed in 60 patients and identified common duct stones in nine patients (one false positive and one false negative), and previously unsuspected duct stones were defined in three out of four patients. The gallbladder and portal vein were constantly defined anatomical landmarks throughout the study, whereas the suprapancreatic bile duct, intrapancreatic bile duct, and pancreatic duct were identified in 100%, 80%, and 85% of patients in the third consecutive group of 20 patients examined. Laparoscopic ultrasonography has the potential to accurately identify common duct stones during laparoscopic cholecystectomy and thereby implement a policy of superselective operative cholangiography. However, adequate training for surgeons unfamiliar with this technology is recommended.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Bile leak from the liver bed following laparoscopic cholecystectomy

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the ducts of Luschka. Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.     

Construct validity

Background: This study was undertaken to establish construct validity of the Xitact LS500, a virtual reality laparoscopic cholecystectomy simulator. The primary research statement is: The clip-and-cut task on the Xitact LS500 virtual reality laparoscopic cholecystectomy simulator mimics the surgical procedure of the clipping and cutting of the cystic duct and artery during the laparoscopic cholecystectomy adequately. Methods: According to the level of experience of the surgeon, an expert group opinion was formed resulting from 37 surgeons having performed over 100 laparoscopic cholecystectomies, and a novice group opinion was formed resulting of 37 surgeons having no experience at all with performing laparoscopic cholecystectomy. Participants received an instructed hands-on tour on the Xitact simulator and performed three formal simulation runs. Results: The novice group is younger and more surgeons are female. Performance scores in the expert group are significantly higher on the second (p value 0.011) and third (p value 0.005) run, compared to the novices scores. Experts are significantly faster on completion of all three runs. There is an increase in score over runs in both groups, which is statistically significant in the expert group. Less than one-third of surgeons in either group are able to correctly predict their performance score as generated by Xitact. Both experts and novices feel it is useful to train with Xitact LS500 in the surgical curriculum. Conclusions: Three hypotheses, formulated to operationalize the primary research statement, could be answered affirmatively. Although further validation studies are needed, the Xitact LS500 simulator seems to be able to discriminate between expert and novice surgeons in this research setting, and thus the construct for this setting is considered to be valid.     

The Mexican experience with laparoscopic cholecystectomy and common bile duct exploration

We present here the initial data collected since the first laparoscopic cholecystectomy (LC) was performed in our country (June 1990). Twenty-one centers were surveyed (2,399 patients). The most frequent indication for LC was chronic gallstone disease (76.2%). The female population predominated (69.4%). Seven centers always perform the laparoscopic approach. Antibiotic prophylaxis is the rule, and most centers use nasogastric tube and urinary catheterization. Perioperative cholangiography is done selectively. The instrument of choice to dissect the gallbladder is the electrosurgical hook-knife. General anesthesia is preferred (97%). The complication rate was 8.87%. Injury to the bile duct and bowel perforation occurred in 0.25% and common duct stone retention occurred in 0.29% of patients. Mortality rate reached 0.12%. It is our hope that this study will help in defining the situation of LC in developing countries and that it also can serve as a first step in the organization of minimally invasive surgery groups in Mexico. Participating institutions: Clínica Florida, Satélite, Edo. de México; CMN Siglo XXI, IMSS, México D.F.; Hospital Santiago Ramón y Cajal, ISSSTE, Durango; Hospital ABC, México D.F.; Hospital Angeles del Pedregal, México D.F.; Hospital Betania, Puebla; Hospital General Dr. Fernando Quiróz, ISSSTE, México D.F.; Hospital General Dr. Manuel Gea González, SSA, México D.F.; Hospital General 10 de Octubre, ISSSTE, México D.F.; Hospital General de Zona #8, IMSS, México D.F.; Hospital General de Zona, IMSS, Tijuana, B.C.; Hospital General Regional Vincente Guerrero, IMSS, Acapulco, Guerrero; Hospital General Regional #1, IMSS, Culiacán, Sinaloa; Hospital Muguerza, Monterrey, N.L.; Hospital Privado, Guadalajara, Jalisco; Hospital Privado, Hermosillo, Sonora; Sanatorio Moderno, León Guanajuato     

Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation

Background Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes.Methods A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized.Results The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were round. Remaining nodes were oblong. All nodes had a hyperechoic center with a hypoechoic rim.Conclusion In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.     

The intercollegiate Basic Surgical Skills Course

Objective: This study was undertaken to establish residents progress in minimal access surgery (MAS) after attending the Intercollegiate Basic Surgical Skills Course (BSSC) by means of the Xitact LS500 laparoscopy simulator assessment program. Methods: Twenty-five surgical residents attended the BSSC in Leiden and Eindhoven, The Netherlands. Before and after the course, participants performed three runs on the Xitact LS500, featuring a standardized laparoscopic cholecystectomy clip-and-cut task. A control group of 25 interns not attending the course also performed two sessions of three runs. Parameters of interest were score and time for completion of task. Results: No significant differences were found within the resident group for the parameters time and score when comparing outcomes pre- and post-BSSC. No significant differences were found comparing time and score between residents and interns on each of the six runs, except for time in run 2. Over six runs, both residents and interns became significantly faster. Conclusions: The Xitact LS500 cholecystectomy simulator did not detect significant improvement in MAS performance among a group of surgical residents attending the BSSC.     

Injury to the diaphragm and its repair during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has now become the gold standard for the treatment of gallstone disease. Parallel with the conversion from the open to the laparoscopic technique, some complications peculiar to the laparoscopic approach have been experienced. Such a technique-related complication, resulting in an injury to the diaphragm and its repair during laparoscopic cholecystectomy is presented.     

The distribution of extracellular matrix vesicles in healing of rat tibial bone three days after intramedullary injury

Summary The distribution of extracellular matrix vesicles on the third day of bone healing was studied by morphometric analysis of transmission electron micrographs. Detection and grouping of the vesicles was performed according to type, diameter, and distance from the calcified front. The different types were selected as follows: vesicles with electron-lucent contents (empty), vesicles with amorphous electron-opaque contents (amorphic), vesicles containing crystalline depositions (crystal), and vesicles containing crystalline structures with ruptured membranes (rupture). The majority of vesicles were between 0.07 µm and 0.12 m in diameter and were located at less than 3 m from the calcified front. The distribution of the empty, amorphic, crystal, and rupture vesicles was 23.2%, 74%, 2.5%, and 0.3% respectively. Their sequence of arrangement according to diameter was as follows: empty, amorphic, crystal, and rupture, the empty vesicles constituting the smallest and the rupture the largest type. Distances from the calcified front were similar for the empty, amorphic, and crystal vesicles, while the rupture type was located nearest to the front. The present observations support the widely acknowledged hypothesis on the role of extracellular matrix vesicles in mineralization. It is thought that the secretion of empty vesicles from the cell is followed by intravscular accumulation of amorphous Ca and Pi to form a hydroxyapatite crystal that, in turn, ruptures the vesicle's membrane. The maturation process is accompanied by an increase of the vesicular diameter and its approximation to the calcifying front.     

Experience with laparoscopic double gallbladder removal

Double gallbladder is a rare congenital anomaly and an encounter with it while performing cholecystectomy laparoscopically is a challenge to the laparoscopic surgeon. A 28-year-old man complaining of epigastric pain was evaluated at Teikyo University Hospital, Mizonokuchi, Japan. There were no abnormal laboratory findings. Ultrasonography revealed an acoustic shadow in each compartment without any inflammatory changes in the gallbladder. No lesions were endoscopically noted in the stomach. CT scan could not demonstrate the anomaly. ERCP revealed a duplication of the gallbladder shadow with a stone in each vesicle and also the confluence of two cystic ducts from both the gallbladders draining into the common bile duct (CBD). Laparoscopic cholecystectomy was performed successfully in this case. This paper presents this particular case because of double gallbladder's rarity in the literature and to emphasize the importance of preoperative cholangiographic evaluation for double gallbladder. The laparoscopic surgeon is given an idea of the meticulous dissection at the hepatocystic triangle due to the various other vascular and other congenital anomalies associated with it. An account of the classification of this congenital abnormality and its various types is also discussed here.     

A patient with early gallbladder cancer derived from a Rokitanski-Aschoff sinus

We present herein a case of a 40-year-old male with early gallbladder cancer derived from a Rokitanski-Aschoff sinus (RAS). The patient originally presented at our hospital with epigastric discomfort, following which a diagnosis of adenomyomatosis (ADM) of the gallbladder was made, and a cholecystectomy performed. Histopathological examination of the resected specimen revealed a 7-mm well-differentiated papillo-tubular adenocarcinoma in the RAS epithelium in the body of the gallbladder. The RAS extended to the pm layer but the adenocarcinoma was an in situ lesion localized within the RAS epithelium. Considering the difficulties in making an early diagnosis of gallbladder cancer, active surgery should be performed for patients in whom ADM is seen in the gallbladder.     

Pattern of elevation of urine catecholamines in intracerebral haemorrhage

Summary Autonomic nervous system dysfunction is a common complication of severe intracranial disease. The aim of this study was to reveal the autonomic changes in patients suffering from acute intracerebral haemorrhage (ICH). 25 patients with spontaneous ICH within 24 hours of onset of symptoms were included. All patients were treated with standardised medical management and the meta- and normetanephrines were detected by high performance liquid chromatography (HPLC) in 24-hour urine every day.The mean level of normetanephrine (709±579 g/day) and metanephrine (244±161 mg/day) were significantly elevated in comparison with a control group, p0,01. The norepinephrine elevation was of greater diagnostic and prognostic importance. Maximum urinary catecholamine metabolite levels occurred between day 3 to 10 after the bleeding.Normetanephrines correlated with the prognosis and the complications of ICH: intraventricular involvement resulted in significantly elevated normetanephrine levels (896±520 g/day versus 311±78 g/day) p0,01. Patients with a great volume of haematoma developed severe autonomic dysregulation (normetanephrines 1114±493 g/day), whereas patients with smaller haematoma did not (339±125 g/day) p0,0001; patients with bad outcome (1014±620 mg/day) had higher levels of normetanephrines than those with a good prognosis (322±110 g/day) p0,001. A close relationship to elevated intracranial pressure was established.This study demonstrated the feasibility of detecting autonomic nervous system dysfunction in neurological intensive care patients by means of examination of the metabolites of the catecholamines in the urine. The pattern of elevation in ICH and the relation to the clinical situation is presented. Norepinephrine offers the chance of simple and feasible monitoring of autonomic dysfunction.     

Experimental study of drainage and granulation in response to the intra-articular injection of particles in rat knee joints

Reactive granulation and drainage of intraarticularly injected plastic particles in rat knee joints was examined by light and electron microscopy. The knee joints and associated iliac lymph nodes were excised at various intervals after the injection of latex beads (1 m) or fluoresbrite particles (0.2 m or 10 m) from 5 min until 3 months after the injection. Particles in the lymphatic or blood vessels were successfully demonstrated by an enzyme-histochemical method (5-nucleotidase staining). Five min after the injection, most of the particles were scattered on the surface of the synovial membrane, and some particles were phagocytosed by synovial lining cells. After 5 h, neutrophils had phagocytosed particles which adhered to fibrin in the joint cavity. Twelve h after the injection, after the neutrophils had died, those same particles were phagocytosed by macrophages in the joint cavity. One day after the injection, Fluoresbrite particles (0.2 m) phagocytosed by macrophages were found in the iliac lymph nodes, while latex particles (1 m) were detected in the iliac lymph nodes 3 days after the injection. Some Fluoresbrite particles (10 m) were seen in the 5-nucleotidase-positive lymphatic vessels in the synovial membrane. Three months after the injection, many macrophages filled with particles had formed granulation tissue in the synovial membrane, and macrophages containing phagocytosed particles were also seen increasingly in the iliac lymph nodes. Our findings suggested that neutrophils and macrophages phagocytosed injected particles in the joint cavity, and that the macrophages brought the particles into the deep layer of the synovial membrane. Phagocytic macrophages also carried the particles to the iliac lymph nodes through lymphatic vessels in the synovial membrane. There were no morphological differences in the processes of granulation and drainage between the two different sized plastic particles (1 m and 0.2 m), except for the behavior of the macrophages phagocytosing the particles.     

Laparoscopic cholecystectomy for gallbladder volvulus

Torsion of the gallbladder is a rare entity. Approximately 300 cases have been reported since it was first described in 1898 by Wendel (Ann. Surg. 1898; 27:199). The condition occurs most often in the elderly. Although the etiology is unknown, a constant finding is the presence of the gallbladder on a mobile mesentery (floating gallbladder). Torsion, or volvulus, of the gallbladder occurs when this gallbladder twists axially, with subsequent occlusion of bile and/or blood flow.We present a case of gallbladder volvulus diagnosed and treated laparoscopically. This is the first reported laparoscopic cholecystectomy for volvulus of the gallbladder.     

Role of TGFβ in the anti-estrogen response/resistance of human breast cancer

Transforming growth factor (TGF) has potent inhibitory effects upon epithelial proliferation and malignant progression may be associated with breakdown of the autocrine and paracrine inhibitory loops in which TGF participates. The therapeutic effects of anti-estrogens may be partially attributable to boosting of local endogenous levels of TGF. This article reviews the evidence in support of TGF being a proximate effector in mediation of the anti-neoplastic effects of anti-estrogens. Both the conventional estrogen receptor (ER)³ dependent and ER independent mechanisms of action are likely to be involved. Evidence for preferential stromal induction of TGF by anti-estrogens is emphasized, together with the therapeutic potential of this strategy for improving outcome in early breast cancer irrespective of ER status.     

82. Fragen der chirurgischen Weiterbildung: Gegenwärtiger Stand

Zusammenfassung Weiterbildung — die Einführung eines approbierten Arztes in ein anerkanntes Fachgebiet — ist im Begriff und System von Ausbildung (des Studenten) und lebenslanger Fortbildung (des fertigen Arztes) zu unterscheiden. Sie schafft das Fundament, auf dem sich Wissen und Können der Angehörigen einer Disziplin aufbauen, und setzt damit Wertmaßstäbe im eigenen Land und über die Grenzen hinaus. Weiterbildungsordnung (WO) und als Richtlinien bezeichnete Ausführungsbestimmungen regeln den Ablauf der Weiterbildung (W). Neu ist im wesentlichen die Verlängerung der Weiterbildungszeit von 5 auf 6 Jahre, die Einführung von Teilgebieten (in der Chirurgie Teilgebiet Kinder-Chirurgie und Teilgebiet Unfall-Chirurgie) mit dem Ziel, abgerundeten Subspezialitäten im Rahmen des Gesamt-Fachgebiets eine Autonomie zu geben, sowie ein umfangreicher Operations-Katalog. Die WO ist damit richtungweisend für die weitere Entwicklung des Fachgebietes und begründet erhebliche Anforderungen sowohl an den Facharzt-Aspiranten als auch an den Erfahrenen, der die W leitet. Die Einführung eines Befähigungsnachweises als einer in der ausschließlichen Kompetenz der ärztlichen Selbstverwaltung gelegenen Abschlußkontrolle wird befürwortet.

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Summary Postgraduate medical education in an approved specialty by definition and set-up differs from both undergraduate medical education and the life-long continuing medical education after completion of training. Postgraduate education in medicine is the basis for the knowledge and proficiency of a specialist and sets standards at home and abroad. Postgraduate education is laid down in principle in the Weiterbildungsordnung and regulated by the Richtlinien. Major innovations are a prolongation of training from 5 to 6 years, the introduction of subspecialties (pediatric surgery, traumatology), in order to give these established groups autonomy within the field of surgery and finally a sizable list of operations to be performed. The new Weiterbildungsordnung will guide the future development of surgery and imposes demands both on those in training and those responsible for it. An examination as "proof of competence"' is recommended, but should remain within the competence of the medical profession.

     

Moderne Konzepte der Pharmakokinetik intravenöser Anästhetika

Zusammenfassung Aus pharmakologisch/pharmakokinetischer Sicht beschäftigt sich der Anästhesist mit der Sicherstellung des richtigen zeitlichen Verlaufs der Wirkung von Anästhetika. Herkömmliche Parameter wie Verteilungsvolumen, Clearance und Halbwertszeit beschreiben die Pharmakokinetik vieler Substanzen im Mehrkompartimentmodell nur unzureichend. Begriffe wie die kontextsensitive Halbwertszeit, relevant decrement time, das Konzept des Wirkortkompartimentes oder die Spitzenkonzentration am Wirkort tragen wesentlich mehr zum Verständnis bei und spielen teilweise eine Rolle als Prädiktoren für den Wirkeintritt oder Wirkverlust einer Substanz. Das Prinzip der target controlled infusion- (TCI-)Systeme dient als praktische Anwendung dazu, die gewünschte Wirkung schnell zu erreichen und die Zielkonzentration konstant zu halten. Dieser Weiterbildungsartikel beschäftigt sich mit den pharmakokinetischen Grundlagen, die für das Verständnis des zeitlichen Verlaufes einer Medikamentenwirkung notwendig sind, und darauf aufbauend werden neuere pharmakokinetische Konzepte und Anwendungen eingeführt.     

Sectorial posterior rhizotomy,a new technique of surgical treatment for spasticity

Summary After their experience of Foerster's operation and its technical modifications in 80 cases the authors report a new concept of analysis and treatment of spasticity in lower limbs.Spasticity of the different muscle groups is classified either as useful spasticity or handicapping spasticity. The first has to be preserved, the second must be reduced.In order to achieve this purpose a new technique is presented, based on operative sectorial identification of the posterior rootlets subserving the handicapping spasticity by electrophysiological stimulation, muscle testing, and B.M.G. studies.The conus medullaris and cauda equina are exposed by T 11-L 1 laminectomy, performed in the lateral position. The clinical and E.M.G. evaluation of responses to stimulation enables the surgeon to establish a map of rootlet groups which are marked with coloured threads. Selective resection of handicapping posterior rootlets is then performed after several tests of the mapping. The rootlets subserving useful spasticity are carefully preserved.Ten cases are reported, comprising five cases of cerebral palsy operated upon since 1974 and five cases of posttraumatic spastic paraplegia from the same period. Pre and postoperative findings are summarized.The technical features of this procedure are discussed and compared with other surgical procedures. The problem of the rootlet reflex arch is considered in the light of the effects of stimulation of anterior and posterior rootlets at the same level.     

Validity and interobserver agreement of a new radiographic grading system for intervertebral disc degeneration: Part II. Cervical spine

A new radiographic grading system for a more objective assessment of lumbar intervertebral disc degeneration has been described and tested in Part I of this study. The aim of the present Part II of the study was to adapt this system to the cervical spine, and to test it for validity and interobserver agreement. Some modifications of the grading system described in Part I were necessary to make it applicable to the cervical spine. Its basic structure, however, stayed untouched. The three variables Height Loss, Osteophyte Formation and Diffuse Sclerosis first have to be graded individually. Then, the Overall Degree of Degeneration is assigned on a four-point scale from 0 (no degeneration) to 3 (severe degeneration). For validation, the radiographic degrees of degeneration of 28 cervical discs were compared to the respective macroscopic ones, which were defined as real degrees of degeneration. The interobserver agreement was determined between one experienced and one unexperienced observer using the radiographs of 57 cervical discs. Quadratic weighted Kappa coefficients () with 95% confidence limits (95% CL) were used for statistical evaluation. The validation of the new version of the radiographic grading system showed a moderate agreement with the real, macroscopic overall degree of degeneration (=0.599, 95% CL 0.421–0.786). In 64% of all discs the real overall degree of degeneration was underestimated but never overestimated. This underestimation, however, was much less pronounced and the Kappa coefficients were significantly higher for the three variables: Height Loss, Osteophyte Formation, and Diffuse Sclerosis separately. The agreement between the radiographic ratings of the experienced and the unexperienced observer was substantial for the overall degree of degeneration (=0.688, 95% CL 0.580–0.796), almost perfect for the variable, Height Loss, moderate for Osteophyte Formation and fair for Diffuse Sclerosis. In conclusion, we believe that the new version of the radiographic grading system is a sufficiently valid and reliable tool to quantify the degree of degeneration of individual cervical intervertebral discs. In comparison to the version for the lumbar spine described in Part I, however, a slightly higher tendency to underestimate the real overall degree of degeneration and somewhat higher interobserver differences have to be expected.Part I of this article can be found at http://dx.doi.org/10.1007/s00586-005-1029-9     

34. Akute und chronische Pankreatitis. Morphologische Grundlagen

Zusammenfassung Die akute Pankreatitis zeigt mit der jauchigen Nekrose und der Vielfalt der Fettgewebsnekrosen ein eindrucksvolles Bild. Dennoch sind einige Teilaspekte wenig bekannt und für das Verständnis der Krankheit wichtig, z. B. die häufige Aussparung des Kerns der Drüse. Die anatomischen Äquivalente von Schock, Schmerz, Ileus werden erläutert, auf das Krankheitsbild Pankreatitis ohne Pankreatitis wird kurz eingegangen. Als Komplikationen werden die Chronifizierung und die Pseudocysten dargestellt. Die chronische Pankreatitis bis zur ausgebrannten Drüse mit Stein, Diabetes und möglicherweise Carcinom wird in ihrer Entstehung anatomisch gezeigt.

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Fundamental morphological aspects of acute and chronic pancreatitis

Summary Acute pancreatitis presents an impressive picture, with autodigestic necrosis and various types of necrosis of fat tissue. Nevertheless, some side aspects are little known, although they are important to the understanding of the disease, e.g. the frequent sparing of the kernel of the gland. The anatomical equivalents of shock, pain, ileus are exvlained, and the syndrome of pancreatitis without pancreatitis will be briefly discussed. The complications of progression to a chronic state and of pseudocysts will be shown. The development of chronic pancreatitis leading to the burnt out gland with stones, diabetes and possibly carcinoma will be shown anatomically.

     

Telerobotic-assisted laparoscopic cholecystectomy: our experience on 29 patients

Background/Purpose The role of computer-assisted surgery (CAS) is still debated and not clearly defined.Methods The authors report their initial experience with CAS, comparing 29 patients submitted to cholecystectomy, using a Zeus remote-controlled robot and an Aesop remote voice-activated endoscope robot, with 29 patients submitted to standard laparoscopic cholecystectomy (LC). The surgical field and the arms of the robot were under the direct and real-time control of the surgeon, who stayed at the workstation and maneuvered the Zeus, using joysticks. The workstation was in the same room as the patient.Results Twenty-nine patients underwent telerobotic-assisted cholecystectomy (TLAC); 1 procedure was converted to standard LC and 1 to open cholecystectomy. The conversions were due to choledocholithiasis and cholecystitis. During TLAC, the mean operating time and transition time (from the induction of anesthesia to incision of the skin) were, respectively, 75min (range, 60–170min) and 45min (range, 25–60min). We did not observe any complications related to TLAC. The limitations of TLAC were the lack of tactile feedback, the increase in surgical time, and the expensive cost of the procedure to reach the same result as that of LC.Conclusions After this initial experience, we believe that TLAC could be considered only for training in CAS, but that it is without advantages in terms of its higher cost compared with LC.