Early laparoscopic cholecystectomy for acute cholecystitis

Background: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. Methods: One hundred ninety-four patients with acute cholecystitis were reviewed. The conversion rates for the various number of days of symptoms before surgery were analyzed. The conversion rate dramatically increased from 3.6% for those patients with 4 days of symptoms to 26% for those patients with 5 days of symptoms. The mean number of days of symptoms prior to surgery in those patients who underwent successful laparoscopic cholecystectomy was 4.1 as compared to 8.0 in those patients who required open cholecystectomy (p < 0.0001). Based on this data the patients were divided into two groups. Group 1 consisted of 109 patients who underwent laparoscopic cholecystectomy within 4 days of onset of symptoms and group 2 consisted of 85 patients who underwent laparoscopic cholecystectomy after more than 4 days following onset of symptoms. Results: The conversion rate from laparoscopic to open cholecystectomy was 15%. The conversion rate for group 1 was 1.8% as compared to 31.7% for group 2 (p < 0.0001). Indications for conversion were inability to identify the anatomy secondary to inflammatory adhesions (68%), cholecystoduodenal fistula (18%), and bleeding (14%). The major complication rate for group 1 was 2.7% as compared to 13% for group 2 (p= 0.007). The mortality rate for all patients with attempted laparoscopic cholecystectomy for acute cholecystitis was 1.5%. The average procedure time for group 1 was 100 ± 37 min vs 120 ± 55 min in group 2. The average number of postoperative hospital days in group 1 was 5.5 ± 2.7 days as compared to 10.8 ± 2.7 days in group 2. Conclusions: We advocate early laparoscopic cholecystectomy within 4 days of onset of symptoms to decrease major complications and conversion rates. This decreased conversion rate results in decreased length of procedure and hospital stay. Received: 28 March 1996/Accepted: 12 September 1996     

Cost and benefit of the trained laparoscopic team

Background: In spite of the emergence of laparoscopic cholecystectomy as the gold standard for treatment of symptomatic gallstones, questions still remain regarding its overall cost effectiveness, especially at low-volume centers where operating room (OR) time and operative complications are higher. We hypothesize that the presence of a well-organized, dedicated laparoscopic OR team will improve surgical outcomes for this procedure. This study compares the operative results of an advanced and a basic laparoscopic surgeon using either a designated laparoscopic operating team or a nondesignated team. Methods: The hospital records for 71 elective laparoscopic cholecystectomies with cholangiograms were retrospectively reviewed and anesthesia times and conversion rates were analyzed. Procedures were performed either at a hospital with a dedicated laparoscopy team or a hospital with nondedicated OR personnel. All procedures were done by an advanced laparoscopic surgeon or a basic laparoscopic surgeon. Results: Case characteristics were evenly matched between sites and surgeons. The mean total anesthesia time at the dedicated site was 120.8 min, compared to 152.3 min at the nondedicated site with a mean difference of 31.5 min (p= 0.001). A 12% conversion rate was documented at the nondedicated site. There were no conversions at the site with a dedicated laparoscopy team. No major complications were encountered in this series. Conclusion: This study demonstrates that having a designated laparoscopic trained team provides a time savings to both advanced and basic laparoscopic surgeons. Although no major complications were encountered, there was a significant conversion rate for the less experienced surgeon operating without the support of a trained team. The end result from having a dedicated team in endoscopic surgery is decreased operative time, an improvement in patient care, and decreased costs to the patient and institution. Received: 5 July 1996/Accepted: 9 January 1997     

Development of gallstone surgery in Germany

Background: The aim of this study was to evaluate the development and outcome of laparoscopic gallstone surgery in Germany in a nationwide representative survey. Methods: A written questionnaire, which included 111 structured items about diagnostic and therapeutic approaches, number of procedures, complications, and mortality, was sent to 449 randomly selected German surgeons (20% of the registered German general surgeons) annually from 1991 to 1994. Results: A total number of 72,455 operations for gallstone disease was reported. The frequency of laparoscopic cholecystectomies increased from 24.9% in 1991 to 65.3% in 1993. In 1994, 92% of the polled surgeons were using the laparoscopic approach as compared with 10% in 1991. The results demonstrated significantly lower morbidity (6% vs. 9%) and mortality figures (0.14–0.45%) than for the open procedure. The percentage of common bile duct (CBD) injuries was significantly higher for the laparoscopic group than for the open treatment group (0.7% vs. 0.4%). In 1993 the data shows a significant decrease in surgical complications such as bleeding, CBD injuries, and relaparotomy rate for the laparoscopic procedures. No changes were seen in the mortality rate. Conclusions: These results show learning curves that project a positive trend in the overall risk incurred by laparoscopic cholecystectomy in Germany during the past few years. This can be seen as an effect of better training and experience. Obviously, CBD injuries and technical problems especially have passed their peak of incidence. Received: 24 October 1997/Accepted: 28 August 1998     

Laparoscopic cholecystectomy in the elderly

Background: Advanced age with its concomitant comorbid conditions may be associated with increased postoperative laparoscsopic cholecystectomy (LC) complications and more frequent conversion to open cholecystectomy (OC). The purpose of this study was to evaluate the outcome of LC in patients age 65 and older. Methods: Ninety consecutive patients were studied age 65 and older, of whom 39 (43%) were males and 51 (57%) were females, mean age 74 years (range 65–98), with 20 patients (22%) ≥ 80. Indications for surgery included biliary colic 55 (61%), acute cholecystitis 22 (24%), pancreatitis 10 (11%), and cholangitis 3 (4%). Seventeen patients (19%) had preoperative ERCP, 12 of which were normal; five had sphincterotomy with stone extraction. Comorbid conditions included hypertension (44%), CAD (17%), cardiac arrhythmias (18), CHF (9%), and COPD (7%). Results: Operative time—mean 1 h 51 min ± SD 43 min. Conversion to OC—three patients (3%). Length of stay—mean 5 days (range 1–26). Mortality—two patients (2%) >80 years old, one patient with septicemia and multiorgan failure whose comorbid diseases included CAD, C.F., COPPED, and elevated BP, one patient with MI postsurgery, morbid diseases included DM and CAD. Complications—five patients (5%): bile leak from cystic duct stump (one), postsurgery MI (two), incarcerated incisional hernia (one), septicemia (one). Conclusion: Morbidity rates for LC in the elderly population are not different from that reported for patients less than 65 years of age. (5% vs 6%, Fried et al., Surg Clin North Am 1994;74 [2]: 375–387). Our 2% mortality rate is statistically different from previously reported in a series of patients of all ages (0.6%, Fried et al.). The 3% rate of conversion to OC in this older population is not significantly different from the patients in Fried et al. series (4%). Received: 17 September 1996/Accepted: 14 October 1996     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

Background: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. Methods: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. Results: Indications for endoscopic adrenalectomy were pheochromocytoma (n= 17), primary hyperaldosteronism (n= 15), Cushing's adenoma or disease (n= 7), nonsecreting adenoma (n= 7), single metastasis from adenocarcinoma (n= 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n= 3), and ACTH-secreting metastases from a thymoma (n= 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5–12), median operation duration was 80 min (range 59–360), and median postoperative stay was 4 days (range 2–13). One patient required blood transfusion. Conclusions: Endoscopic adrenalectomy can safely be performed—even sporadically—by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery. Received: 25 March 1997/Accepted: 16 May 1997     

Delayed diagnosis of malignant tumors missed at laparoscopic cholecystectomy

Background: The aim of this study was to compare the significance of routine examinations prior to laparoscopic cholecystectomy (LC) with intraoperative abdominal investigation. Preoperative evaluation becomes increasingly important when laparoscopic procedures are performed for the removal of gallstones because other intraabdominal diseases may coexist in these patients, mimicking biliary tract disease. Methods: Over the last 6 years, we treated 816 patients with symptomatic cholecystolithiasis using LC. Prior to surgery, routine tests such as upper abdominal ultrasonography, chest radiography, and standard laboratory blood tests were carried out. Results: Despite these routine tests, coexisting colonic cancers escaped detection in four out of 816 cases. This indicates a risk of more ``missed pathologies' during the course of laparoscopic operations compared to standard laparotomy. Conclusion: The risk of missing coexisting diseases during laparoscopic operations has to be minimized by placing additional emphasis on careful evaluation of anamnesis. Physical examination and additional laboratory tests—such as analysis of tumor markers and blood in the stool—combined with complete abdominal ultrasonography, gastroscopy, and/or complete colonoscopy should be performed prior to LC. Received: 6 October 1996/Accepted: 19 February 1997     

The outcome of major biliary tract injury with leakage in laparoscopic cholecystectomy

Background: Concern has been expressed regarding the increased rates of biliary tract injury (BTI) at laparoscopic cholecystectomy. The aim of the present investigation was to analyze the outcome of laparoscopic biliary tract injury with leakage. Methods: Sixteen patients having major laparoscopic BTI with leakage were treated. Thirteen of them were referred to our institution for further treatment. The follow-up was complete and focused on clinical outcome and biochemical analysis. Results: Eight BTI were identified at the time of laparoscopic cholecystectomy, and the procedure was converted to a laparotomy. In eight additional patients, BTI was recognized postoperatively. In this group one patient died because of lately diagnosed biliary peritonitis, whereas in the seven surviving patients nine attempts to repair the BTI and eight other interventions were performed. In the conversion group 14 attempts to repair the BTI and 11 other interventions were needed to completely solve the problems. Final restoration of the BTI was done by Roux-en-Y hepaticojejunostomy in 11 patients and suture repair with T-tube drainage of the bile duct in 4. During a median follow-up time of 63 months, three patients suffered from recurrent segmental cholangitis. In the other patients, neither clinical nor biochemical evidence of biliary disease has been found up to this writing. Conclusions: Laparoscopic BTI has a high morbidity and mortality rate that seems comparable to BTI at open cholecystectomy. The number of attempts to repair the BTI as well as additional interventions is too high, but in this patient series the final outcome seemed to be similar after BTI recognized during and after laparoscopic cholecystectomy. Received: 3 December 1997/Accepted: 28 May 1998     

Successfully establishing laparoscopic surgery programs in developing countries

Background: Laparoscopic surgery has not been widely established in developing countries due to the lack of access to training and lack of money. We describe our experience using on-site training programs to efficiently teach and propagate laparoscopic surgery in Leon, Nicaragua; La Paz, Bolivia; and Santa Cruz, Bolivia. Methods: A group of well-trained and motivated local surgeons was identified in each country as the initial target for teaching. Participants were taught basic and advanced laparoscopic surgery during on-site didactics, animal laboratories, and proctoring sessions. Follow-up courses were held until the target group of surgeons was capable of independently teaching and supervising laparoscopic surgery among other surgeons in each country. Results: Multiple technical and logistic difficulties were encountered. In Leon, Nicaragua, and La Paz, Bolivia, a total of eight surgeons were fully trained and proctored in laparoscopic cholecystectomy. In La Paz and Santa Cruz, Bolivia, a total of seven surgeons were instructed in advanced laparoscopic procedures. To date, over 180 patients have undergone laparoscopic cholecystectomy or advanced procedures with a morbidity similar to that reported in literature series in the United States. Conclusions: Our experience demonstrates that in spite of numerous limitations, basic and laparoscopic surgery can be efficiently and safely taught in developing countries. Many lessons were learned in how to safely and efficiently use laparoscopic equipment and instruments within strict financial constraints. Received: 20 March 1996/Accepted: 15 May 1996     

Early international results of laparoscopic gastrectomies

Background: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. Methods: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. Results: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. Conclusions: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience. Received: 7 August 1996/Accepted: 28 October 1996     

Biliary tract complications in laparoscopic cholecystectomy

Background: The higher risk of biliary tract injury is considered the most significant disadvantage of laparoscopic cholecystectomy. Methods: A national multicenter retrospective study was performed to determine the frequency, etiology, and treatment of biliary tract injuries between January 1, 1991, and December 31, 1994. Follow-up was by questionnaire. Results: Some 148 biliary tract complications were observed during 26,440 laparoscopic cholecystectomies. There was no significant correlation found between the number of LCs performed in one institute and the incidence of biliary tract injuries and postoperative bile leakage, but in the 2nd year of practice, the incidence of both complications decreased. In institutes with more conversions, more cases of bile leakage were also observed. A significant positive relationship was found between biliary tract injuries and postoperative bile leaks. There was no significant relationship between usage of intravenous and intraoperative cholangiography and ERCP. In univariant analysis of the type of injury, the primary treatment modality did not affect the outcome of injury or entail the necessity of reoperation. Obscure anatomy leads to significantly more main bile duct injuries. According to multivariant analysis, the outcome is significantly influenced unfavorably by the necessity of repeated interventions and advanced age. Conclusions: The definitely higher risk of bile duct injury mentioned in early studies was not confirmed. Received: 1 March 1996/Accepted: 26 November 1996     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Laparoscopic cholecystectomy, Calot's triangle, and variations in cystic arterial supply

Background: The extrahepatic biliary tree with the exact anatomic features of the arterial supply observed by laparoscopic means has not been described heretofore. Iatrogenic injuries of the extrahepatic biliary tree and neighboring blood vessels are not rare. Accidents involving vessels or the common bile duct during laparoscopic cholecystectomy, with or without choledocotomy, can be avoided by careful dissection of Calot's triangle and the hepatoduodenal ligament. Methods: We performed 244 laparoscopic cholecystectomies over a 2-year period between January 1, 1995 and January 1, 1997. Results: In 187 of 244 consecutive cases (76.6%), we found a typical arterial supply anteromedial to the cystic duct, near the sentinel cystic lymph node. In the other cases, there was an atypical arterial supply, and 27 of these cases (11.1%) had no cystic artery in Calot's triangle. A typical blood supply and accessory arteries were observed in 18 cases (7.4%). Conclusion: Young surgeons who are not yet familiar with the handling of an anatomically abnormal cystic blood supply need to be more aware of the precise anatomy of the extrahepatic biliary tree. Received: 1 November 1998/Accepted: 22 March 1999     

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

Incisional hernias after laparoscopic vs open cholecystectomy

Background: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. Methods: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n= 142) or open cholecystectomy (OC group, n= 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. Results: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. Conclusions: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure. Received: 16 July 1998/Accepted: 27 November 1998     

Prospective randomized comparison of laparoscopic ultrasonography using a flexible-tip ultrasound probe and intraoperative dynamic cholangiography during laparoscopic cholecystectomy

Background: We performed a prospective randomized comparison of laparoscopic intraoperative ultrasonography (LIOU) and dynamic intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). Methods: LIOU and IOC were attempted in 518 consecutive patients scheduled for laparoscopic cholecystectomy. The order in which the diagnostic procedures were performed was randomly assigned. Results: LIOU failed in two patients (0.4%), and there were 41 (7.9%) failed IOC. The common bile duct (CBD) was visualized reliably with both methods. Our patients showed sensitivities of 83.3% and 100% and specificities of 100% and 98.9%, with an overall accuracy of 99.2% and 98.9% for LIOU as compared to IOC for identifying unsuspected common bile duct stones. The time necessary for the examination was significantly shorter in LIOU than in IOC (7 versus 16 min). Conclusion: LIOU performed by experienced surgeons is a good and effective method to assess the CBD, including the neighboring structures of hepatoduodenal ligament. Using powerful, flexible-tip ultrasound probes, CBD exploration can be done in a longitudinal fashion, which is necessary for good anatomical clarity. A lack of adverse effects, shorter examination times, and lower costs are some of the advantages of this method. The most important advantage is the possibility of unlimited repetition, especially if there is difficulty identifying anatomic structures. In addition, there are some indications that LIOU has the potential to recognize major iatrogenic bile duct injuries. Received: 19 December 1996/Accepted: 23 April 1997     

Changing management of gallstone disease during pregnancy

Background: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. Methods: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. Results: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6–10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. Conclusions: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients. Received: 3 April 1997/Accepted: 5 July 1997     

Telementoring

Background: Telemedicine offers significant advantages in bringing consulting support to distant colleagues. There is a shortage of surgeons trained in performing advanced laparoscopic operations. Aim: Our aim was to evaluate the role of telementoring in the training of advanced laparoscopic surgical procedures. Methods: Student surgeons received a uniform training format to enhance their laparoscopic skills and intracorporeal suturing techniques and specific procedural training in laparoscopic colonic resections and Nissen fundoplication. Subsequently, operating rooms were equipped with three cameras. Telestrator (teleguidance device), instant replay (to critique errors), and CD-ROM programs (to provide information of reference) were used as intraoperative educational assistance tools. In phase I, four colonic resections were performed with the mentor in the operating room (group A) and four colonic resections were performed with the mentor on the hospital grounds, but not in the operating room (group B). The voice and video signals were received at the mentor's location, using coaxial cable. In phase II, two Nissen fundoplications were performed with the mentors in the operating room (group C) and two Nissen fundoplications were performed with the mentors positioned five miles away from the operating room (group D), using currently existing land lines at the T-1 level. Results: There were no differences in the performances of the surgeons and outcome of the operations between groups A & B and C & D. It was possible to tackle the intraoperative problems effectively. Conclusions: The telementoring concept is potentially a safe and cost-effective option for advanced training in laparoscopic operations. Further investigation is necessary before routine transcontinental patient applications are attempted. Received: 17 May 1996/Accepted: 19 August 1996     

Initial results of a prospective trial of outpatient laparoscopic cholecystectomy

Background: Whether or not laparoscopic cholecystectomy may be performed safely as an outpatient procedure is controversial. In 1993, a protocol for outpatient laparoscopic cholecystectomy was instituted to determine the benefits and safety of discharging patients within several hours of surgery. Methods: The initial 60 outpatient laparoscopic cholecystectomies performed by one surgeon in a hospital-based outpatient teaching facility between February 1993 to June 1996 were prospectively studied. Results: Fifty-eight (97%) patients were discharged successfully after an average stay in the recovery room of 3 h. There were no deaths. Two patients required overnight observation and three patients required readmission. Two patients (3%) had cystic duct leak. The average hospital stay for all patients undergoing laparoscopic cholecystectomy at the institution (inpatient and outpatient) decreased from 3.2 to 1.5 days and the average hospital cost decreased from $7,800 to $4,600 during this period. Conclusion: Laparoscopic cholecystectomy in an outpatient setting is safe and cost-effective in healthy patients. Received: 3 April 1997/Accepted: 10 June 1997     

Laparoscopic cholecystectomy performed by a single surgeon using a visual field tracking camera

Background: This report describes a visual field tracking camera for laparoscopic surgery that allows the visual field to be changed without moving the laparoscope. We also report on our early experience with this camera for single-surgeon laparoscopic cholecystectomy. Methods: The visual field tracking camera has a tracking mechanism (composed of a zoom lens and a charge-coupled device [CCD] slide mechanism) built into the camera head. The 80° visual field observed with the laparoscope can be expanded using the zoom lens, and the field can be shifted by changing the size of the area being viewed by the CCD. This is accomplished by pushing a switch on the forceps or by verbal command. Cholecystectomy was carried out on 12 patients with gallstones using this camera. The operations were performed by either a single surgeon or two surgeons. Forceps held with a forceps holder were inserted through the right port to lift the fundus of the gallbladder. The single surgeon used the other two ports to resect the gallbladder by the two-handed technique. Results: In all cases, cholecystectomy was completed without any need to move the laparoscope at any point during the operation. Seven operations were performed by a single surgeon. Mainly for education purposes, five other operations were performed by a pair of surgeons. The mean time required for surgery was 76 ± 17 min. This time did not differ from that of laparoscopic cholecystectomy performed during the same period on 22 patients by teams of three surgeons using conventional cameras. Conclusions: Using the visual field tracking camera, laparoscopic cholecystectomy can be performed without any need to touch the laparoscope. This camera allowed laparoscopic cholecystectomy to be performed by a single surgeon. Received: 30 April 1999/Accepted: 10 January 2000/Online publication: 4 August 2000     

Laparoscopic management of acute cholecystitis

Background: Laparoscopic cholecystectomy for acute cholecystitis is considered feasible and safe, but it is associated with a higher rate of conversion to laparotomy than elective cholecystectomy because of technical reasons and anatomical changes related to the inflammatory process. The value of several factors that might influence its successful completion has not been studied completely yet, including the role of residents in operating such cases under attending-surgeon surveillance. Methods: In a retrospective nonrandomized study, the medical charts of 182 patients that were operated for acute cholecystitis (94 of whom via the laparoscopic approach) were studied. The study was also conducted to study the effect of residents as operators. Results: Male sex, duration of right upper abdominal pain, and the severity of the inflammatory process have all been significantly and independently correlated with increased conversion rate to laparotomy. Operation time was not longer than that of the open approach, and hospital stay and complication rate were lower. Operations performed by residents were associated with twofold conversion rate to laparotomy, without increased complication rate (p < 0.012). Conclusions: Laparoscopic management of acute cholecystitis is feasible and safe. Considering the factors discussed above, lowering the threshold for conversion is necessary in selected cases to maintain low morbidity rate. Integrating laparoscopic cholecystectomy for acute cholecystitis into surgical residency should be studied. Received 5 January 1996/Accepted 22 April 1996