Techniques for difficult cases of laparoscopic cholecystectomy

Our basic techniques for the management of difficult cases of laparoscopic cholecystectomy (LC) are presented in this article. If access to Calot's triangle cannot be gained safely, dissection should be started at the fundus or body of the gallbladder (GB), rather than the neck (fundus-first method). In cases with a short and wide cystic duct, a transfixing suture should be applied for ligation instead of clipping. EndoGIA is useful for ligating and transecting this case to avoid a subsequent stricture caused by normal method of ligation. Intraoperative cholangiography should be performed near the neck of the GB in cases in which orientation is lost during dissection. More dissection should be performed in the direction of the junction of the bile ducts after orientation is regained. In cases with GB filled with stones accompanied by severe fibrosis, part of the GB is incised to remove the stones and expose the lumen of the GB. Confluence stones can be removed by placing an incision on the GB side of the junction of the duct. The incised part is closed with suture. A cystic tube (C-tube) is placed in the common bile duct through the cystic duct for decompression. In more difficult cases in which dissection cannot be started safely at any location, the body and the fundus of the GB are excised, and a drain is placed at the neck of the GB. Dissection can be carried out from the main surgeon's or the assistant's side depending on the situation, and cooperation between the two surgeons is mandatory to achieve safe LC in difficult cases. When performing the LC, one must have a low threshold for converting to open surgery if injuries cannot be managed safely.     

Gastro-oesophageal reflux disease: Medical or surgical treatment? Report of an interactive workshop

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. With the introduction of proton pump inhibitors medical treatment of GERD has been significantly improved. However, the development of laparoscopic antireflux surgery resulted in an increasing interest of surgeons in this disease. An interactive meeting was organized in order to develop an agreement between gastoenterologists and surgeons regarding therapeutic decisions and this is the main topic of this paper.     

Laparoscopic (vs. Open) Live Donor Nephrectomy: A UNOS Database Analysis of Early Graft Function and Survival

The impact of laparoscopic (lap) live donor nephrectomy on early graft function and survival remains controversial. We compared 2734 kidney transplants (tx) from lap donors and 2576 tx from open donors reported to the U.S. United Network for Organ Sharing from 11/1999 to 12/2000. Early function quality (>40 mL urine and/or serum creatinine [creat] decline >25% during the first 24 h post-tx) and delayed function incidence were similar for both groups. Significantly more lap (vs. open) txs, however, had discharge creats greater than 1.4 mg/dL (49.2% vs. 44.9%, p = 0.002) and 2.0 mg/dL (21.8% vs. 19.5%, p = 0.04). But all later creats, early and late rejection, as well as graft survival at 1 year (94.4%, lap tx vs. 94.1%, open tx) were similar for lap and open recipients. Our data suggests that lap nephrectomy is associated with slower early graft function. Rejection rates and short-term graft survival, however, were similar for lap and open graft recipients. Further prospective studies with longer follow up are necessary to assess the potential impact of the laparoscopic procurement mode on early graft function and long-term outcome.     

LAPAROSCOPIC INGUINAL HERNIORRHAPHY IS NOT A VALID PROCEDURE

Laparoscopic inguinal herniorrhaphy with or without application of mesh does not correct the basic problem. Unless the dense fascial and bony margins of the posterior inguinal canal wall are palpated under direct vision for suture of the mesh, fortification is not possible and recurrence is invited. The many neural structures cannot be seen with the laparoscope, and their stapling is a prominent hazard. The procedure should not be accepted or approved.     

PERCUTANEOUS LAPAROSCOPIC CHOLECYSTECTOMY: INDICATIONS,CONTRAINDICATIONS AND COMPLICATIONS

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.     

INGUINAL HERNIA REPAIR BY LAPAROSCOPIC SURGEONS: EARLY EXPERIENCE AND ATTITUDES

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%). 74 were from laparoscopic surgeons. 26 of whom had performed 564 (201 public. 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR. and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons. the extraperitoneal technique by eight (31%), and the tronsabdominal onlny technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies. seven (1.2%) conversions, four (0.7%) miijor perforations. and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results. 14 (54%) considered that the optimal technique had not been established. 13 (50%) were concerned about the unique complications associated with LIHR. 11 (42%) were less enthusiastic about performing LIHR than previously. 10 (38%) were doubtful about its advantages, and six (23%,) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.     

LAPAROSCOPIC TREATMENT FOR PERFORATED APPENDICITIS WITH PELVIC ABSCESS

We performed laparoscopic appendectomy and drainage to treat panperitonitis due to perforated appendicitis that occurred in a 28‐year‐old woman. We believe this is an appropriate procedure to treat perforated appendicitis because it is safe and minimally invasive, and faster recovery can be expected than after conventional open appendectomy.     

Laparoscopic splenectomy for isolated parenchymal splenic metastasis of ovarian cancer

Metastatic carcinoma of the spleen occurs in a setting of widespread malignant disease. Solitary parenchymal splenic metastasis of ovarian carcinoma is rare. We report a case of a 59-year-old woman who presented with an elevated serum CA125 level due to a solitary splenic metastasis after a long disease-free period. She was treated with laparoscopic splenectomy followed by chemotherapy. The literature contains 16 cases of solitary parenchymal splenic metastasis of ovarian carcinoma. Our case is the third case that was treated with laparoscopic splenectomy. We review the literature, and we focus on the laparoscopic approach in managing these cases.     

腹腔镜治疗老年人急性胆囊炎的体会

目的探讨老年人急性胆囊炎的腹腔镜治疗特点。方法将我院2001年4月～2006年4月收治的164例LC老年病例分为早期组(85例,急性发作48h内)与延期组(79例,急性发作48h后)进行比较分析。同时,将老年人组(164例)与非老年人组(164例)进行比较分析。结果延期组较早期组LC手术时间和平均住院时间明显延长;老年人组较非老年人组LC手术时间延长,术中出血量及术后并发症明显增多。结论老年急性胆囊炎病人宜早期施行LC。老年女性常因妇科炎症且腹腔内粘连,使LC难度增加,术中、术后并发症的发生率增高。     

腹腔镜辅助远端胃癌根治术的临床应用

目的探讨腹腔镜远端胃癌根治术的可行性及手术方法。方法行腹腔镜远端胃癌根治术15例,D1清扫3例,D2/D2 12例。全部病例均行毕Ⅱ式胃空肠吻合。结果15例成功进行腹腔镜手术。手术时间平均(218.6±31.6)min,术中出血量平均(132.4±21.3)ml,清扫淋巴结平均(33.4±13.6)个。肿瘤近端切缘(6.6±0.9)cm,远端切缘(5.4±0.6)cm,术后肛门排气时间平均(3.5±0.6)d,无手术死亡,无吻合口漏,术后并发肺部感染1例,经治疗后痊愈。术后随访1~10个月,无肿瘤复发或转移。结论腹腔镜远端胃癌根治术能达到与开腹胃癌标准根治术(D2)的淋巴结清扫范围及肿瘤切缘,且具有创伤小、出血少、术后恢复快等优点。