Laparoscopic adrenalectomy for large tumors

AIM OF THE STUDY: To analyze indications and results of laparoscopic adrenalectomy for large tumors (> 6 cm). METHODS: It is a retrospective study including patients between January 1994 and December 2003 operated on for large adrenal lesions > or =6 cm. The size was given by the pathologist. All the patients had a flank transperitoneal approach. Analysed Parameters were: operative difficulties; operative time; conversion rate; postoperative morbidity, follow-up and histologic data. RESULTS: Fourteen patients (10 female and 4 male) were included. Mean age at the time of the diagnosis was 52 years (range: 17-79). Mean size of the lesions was 7 cm (range: 6-10 cm). Mean operative time was 132 mn (range: 120-240 mn). None of the patients experienced surgical complications. Two conversions were needed (for vena cava attachments in one case and because of a retrocava localization in the other case). Three patients had morbidity: one intraperitoneal hemorrhage occurring at the second postoperative day and needing laparotomy; one left pneumopathy; and one case of neuralgia due to a port insertion. Mean hospital stay was 4,5 days. Histologic data showed: five ganglioneuromas, three pheochromocytomas, three adenomas, two adrenocortical carcinomas, and one postpancreatitis cytosteatonecrosis. CONCLUSION: Laparoscopic adrenalectomy is feasible for large lesions > or =6 cm when no evidence of malignity is demonstrated neither by the preoperative imaging study nor by the surgical exploration.     

Pancréatectomies sous laparoscopie : une série de 22 patients

Introduction. - Laparoscopic pancreatic surgery underwent many changes in the last few years. Current indications include staging laparoscopy for pancreatic neoplasms, palliative treatment of non-resectable tumors, and pseudocysts drainage. Pancreatic tail resection or pancreatic enucleation have also been reported, but are currently under investigation. We report our experience in this domain.Material and methods. - Retrospective study of patients who had a pancreatic tail resection or pancreatic enucleation, in a single institution.Results. - From November 1993 to June 2002, a laparoscopic pancreatic resection was attempted in 22 patients. Nineteen patients were operated by laparoscopy (86%), two patients had conversion to laparotomy (9%), and one had conversion to a “hand-assisted” technique (4%). There was 17 left pancreatectomies and five enucleations. Median operating time was 4.1 hours (range 1.6 to 6.6 hours). There were no deaths in the first 30 post-operative days. Global morbidity rate was 31.8% (N =7), including four pancreatic fistulas (18%), one superficial phlebitis, one prolonged ileus, and one peri-pancreatic fluid collection. Median hospital stay was six days (1 to 26 days).Conclusion. - Pancreatic tail resections and enucleations are feasible by laparoscopy, with a mortality and morbidity rate similar to open surgery. The potential advantages of laparoscopy (reduced post-operative pain, hospital stay and recovery time) should be balanced with a potential increase in pancreatic fistula rate. That risk should be addressed before laparoscopy is generalized for pancreatic resections.     

Laparoscopic treatment of ventral hernias

The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.     

Laparoscopic pancreatic resections

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.     

Mobilisation de l’angle colique gauche par cœlioscopie : technique opératoire

The clue of the mobilization of the splenic flexure is a complete division of the root of the transverse mesocolon along the pancreas. After the section of the terminal part of the inferior mesenteric vein, the retrogastric cavity is opened and the root of the mesocolon is cut from the right to the left onto the parieto-colic attachment. Thereafter the coloepiploic attachments are divided. The retromesocolic dissection is continued from top to bottom without opening the Gerota's fascia.     

超声与ERCP检查在腹腔镜胆囊切除术前对Calot三角区粘连的诊断价值

目的探讨二维基波、自然组织谐波和彩色多普勒超声条件下，结合ERCP检查在腹腔镜胆囊切除（LC）术前诊断Calot三角区粘连的应用价值。 方法对310例实施LC患者，术前经超声与内窥镜逆行胰胆管造影术（ERCP）检查，对Calot三角区粘连，进行手术病理对照，回顾性分析声像图特征，评估其诊断效果。 结果310例LC患者，术前超声检查Calot三角区粘连。超声检出率86．5％（268／310）。ERCP检出率96．1％（298／310）。其中1度粘连185例，占59．7％（185／310）；Ⅱ度粘连者115例，占37．1％（115／310）；Ⅲ度粘连者10例，占3．2％（10／310）；全部病例均经手术病理证实。 结论术前超声与ERCP检查Calot三角区粘连，对LC的适应证、禁忌证的选择，预测手术难易程度及防止手术中胆道损伤、出血、胆漏等并发症，具有重要临床应用价值。     

腹腔镜手术治疗巨大卵巢囊肿46例临床分析

目的探讨腹腔镜手术治疗巨大卵巢囊肿的可行性。方法对46例巨大卵巢囊肿行腹腔镜下囊肿剥除术或附件切除术,将第2或第3个trocar（多为肿瘤侧）直接刺入囊肿内,吸引器吸净囊液,并将囊肿提至切口处,同时将切口扩大至20mm,切除囊肿。结果除1例因术中快速病理证实为交界性肿瘤并转开腹外,余45例均在腹腔镜下完成手术。术中出血70～130ml,手术时间30-100分钟。结论腹腔镜手术治疗巨大卵巢囊肿安全可行。     

Laparoscopic pyeloplasty

Ureteropelvic junction (UPJ) obstruction in adults is usually symptomatic, secondary, and it tends to progress. Surgical correction of obstructed UPJ is necessary to preserve the renal function of the affected kidney. Pyeloplasty as a surgical management for UPJ obstruction in adults has proven its efficacy with high success rates on long-term results. Laparoscopic pyeloplasty in the management of primary or secondary UPJ obstruction in adults technically duplicate the open surgical technique. Laparoscopic pyeloplasty has developed to match success, morbidity and complication rates of open surgical pyeloplasty. However it was shown that laparoscopy had consistently a shorter convalescence than open surgery. Endopyelotomy is utilized to manage UPJ obstruction. Early results for endopyelotomy were promising but long-term results were not encouraging. In the management of UPJ obstruction in adults, long-term success rates for laparoscopic pyeloplasty were found to be superior to those of endopyelotomy. Therefore we believe that laparoscopic pyeloplasty will become as a standard management for UPJ obstruction in adults.