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1.
Laparoscopic surgery for diverticulitis 总被引:11,自引:3,他引:8
M. E. Sher F. Agachan M. Bortul J. J. Nogueras E. G. Weiss S. D. Wexner 《Surgical endoscopy》1997,11(3):264-267
Background: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and
any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the
results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and
possibly a subset of patients who may benefit from a laparoscopic approach.
Methods: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey
classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with
a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were
62.8 and 67.1 years, respectively (p= NS).
Results: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions
were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had
a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed
without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative
morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length
of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic
approach (6 days vs 10 days, p < 0.05).
Conclusion: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey
I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease,
and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization
associated with laparoscopic treatment.
Received: 25 March 1996/Accepted: 17 July 1996 相似文献
2.
Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in
need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we
designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results
with those achieved with open techniques.
Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging
and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were
done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass,
seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of
14 matched patients who had conventional palliative procedures.
Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery
(p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03).
Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass
surgery—i.e., high morbidity, high mortality, and long hospital stay.
Received: 24 February 1999/Accepted: 13 May 1999 相似文献
3.
Early laparoscopic cholecystectomy for acute cholecystitis 总被引:4,自引:0,他引:4
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 相似文献
4.
Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery
and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic
bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear.
Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients
who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically
for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with
success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression
was used to assess for independent variables.
Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary
in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and
postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of
surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation
(p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications.
Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach.
Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion.
No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon
is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable
alternative to conventional surgery in the management of acute small bowel obstruction.
Received: 20 July 1999/Accepted: 22 November 1999/Online publication: 17 April 2000 相似文献
5.
A prospective multicenter study on laparoscopic treatment of gastroesophageal reflux disease in Italy 总被引:4,自引:0,他引:4
Background: A national survey was undertaken by the Italian Society for Laparoscopic Surgery to investigate the prevalence, indications,
conversion rate, mortality, morbidity, and early results of laparoscopic antireflux surgery.
Methods: Beginning on January 1, 1996, all of the centers taking part in this study were asked to complete a questionnaire on each
patient. The questionnaire was divided into four parts and covered such areas as indications for surgery and preoperative
workup, type of operation performed and certain aspects of the surgical technique, conversions and their causes, intraoperative
and postoperative complications (within 4 weeks), and details of the postoperative course. The last part of the questionnaire
focused on the follow-up period and was designed to gather data on recurrence of preoperative symptoms, postoperative symptoms
(dysphagia, gas bloat), and postoperative test findings.
Results: As of June 30 1998, 21 centers were taking part in the study and 621 patients were enrolled, with a median of 27 patients
per center (less than one patient/month). The most popular technique was the Nissen-Rossetti (52%), followed by the Nissen
(33%) and Toupet procedures (13%). Other techniques, such as the Dor and Lortat-Jacob, were used in the remainder of cases.
Patients who received a Toupet procedure had a higher incidence of defective peristalsis (p < 0.05). The conversion rate to open surgery was 2.9%. The most common causes of conversion were inability to reduce the
hiatus hernia or distal esophagus in the abdomen and adhesions from previous surgery. Perforation of the stomach and esophagus
occurred in <1% of patients. Mortality was nil. Postoperative complications were observed in 7.3% of cases. The most common
complication was acute dysphagia (19 patients), which required reoperation in 10 patients. No differences in the incidence
of acute dysphagia were found for the different surgical techniques employed. Follow-up data were obtained for 319 patients
(53%): 91.5% of the patients remained GERD symptom–free; severe esophagitis (grade 2–3) healed in 95% of the patients; lower
esophageal sphincter (LES) manometric characteristics (pressure, abdominal length, and overall length) improved significantly
after surgery (p < 0.005); and acid exposure of the distal esophagus decreased.
Conclusions: Laparoscopic antireflux surgery has no mortality and a low morbidity. Symptoms and esophagitis are resolved in >90% of patients.
Despite these favorable results, however, this type of surgery is not yet as widely employed in Italy as in other countries.
Received: 12 February 1999/Accepted: 8 June 1999 相似文献
6.
J. D. F. Allendorf M. Bessler K. D. Horvath M. R. Marvin D. A. Laird R. L. Whelan 《Surgical endoscopy》1998,12(8):1035-1038
Background: Surgery can suppress immune function and facilitate tumor growth. Several studies have demonstrated better preservation of
immune function following laparoscopic procedures. Our laboratory has also shown that tumors are more easily established and
grow larger after sham laparotomy than after pneumoperitoneum in mice. The purpose of this study was to determine if the previously
reported differences in tumor establishment and growth would persist in the setting of an intraabdominal manipulation.
Methods: Syngeneic mice received intradermal injections of tumor cells and underwent either an open or laparoscopic cecal resection.
In study 1, the incidence of tumor development was observed after a low dose inoculum; whereas in study 2, tumor mass was
compared on postoperative day 12 after a high-dose inoculum.
Results: In study 1, tumors were established in 5% of control mice, 30% of laparoscopy mice, and 83% of open surgery mice (p < 0.01 for all comparisons). In study 2, open surgery group tumors were 1.5 times as large as laparoscopy group tumors (p < 0.01), which were 1.5 times as large as control group tumors (p < 0.02).
Conclusion: We conclude that tumors are more easily established and grow larger after open laparoscopic bowel resection in mice.
Received: 27 October 1997/Accepted: 19 January 1998 相似文献
7.
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 相似文献
8.
Duration of postlaparoscopic pneumoperitoneum 总被引:4,自引:0,他引:4
Background: Patients who present with abdominal pain after recent laparoscopic surgery present a diagnostic dilemma when pneumoperitoneum
is present. Previous studies do not define the duration of postlaparoscopic pneumoperitoneum. In this study, we attempted
to define the duration of laparoscopic pneumoperitoneum and to identify factors which affect resolution time.
Methods: We followed 57 patients who underwent laparoscopic cholecystectomy (34), inguinal herniorraphy (20), or appendectomy (three).
Serial abdominal films were taken until all residual gas was resolved.
Results: Thirty patients resolved their pneumoperitoneum within 24 h; 16 patients resolved between 24 h and 3 days; nine patients
resolved between 3 and 7 days; two patients resolved between 7 and 9 days. Mean resolution time for all patients was 2.6 ±
2.1 days. There was no apparent difference in resolution time between the three types of procedures; however, the sample size
may be insufficient. Duration of the pneumoperitoneum did not correlate with gender, age, weight, initial volume of CO2 used, length of time for the procedure, or postoperative complications. Sixteen patients had bile spillage during cholecystectomy
which significantly reduced the duration of postoperative pneumoperitoneum (p < 0.008), resulting in a mean resolution time of 1.3 ± 0.9 days. While 14 patients reported postoperative shoulder pain,
no correlation was found between the presence or duration of shoulder pain and the extent or duration of pneumoperitoneum.
Conclusions: We conclude that the residual pneumoperitoneum following laparoscopic surgery resolves within 3 days in 81% of patients and
within 7 days in 96% of patients. The resolution time was significantly less in patients sustaining intraoperative bile spillage
during cholecystectomy. There was no correlation found between postoperative shoulder pain and the presence or duration of
the pneumoperitoneum.
Received: 22 March 1996/Accepted: 12 July 1996 相似文献
9.
Laparoscopic creation of stomas 总被引:5,自引:0,他引:5
Background: Some indications for laparoscopic bowel surgery are still controversial. However, the use of laparoscopic techniques for
the treatment of benign disorders is less often challenged. Moreover, the morbidity of nonresectional procedures is less than
that encountered with resectional cases. Therefore, stoma creation seems ideally suited to laparoscopy. The aim of our study
was to assess the outcome of laparoscopic stoma creation.
Methods: All patients who underwent laparoscopic intestinal diversion were evaluated; parameters included age, gender, indication
for the procedure, history of previous surgery, operative time, length of hospitalization, recovery of bowel function, and
postoperative complications.
Results: Between March 1993 and January 1996, 32 patients of a mean age of 42.2 (range 19–72) years (14 males, 18 females) underwent
elective laparoscopic fecal diversion (25 loop ileostomy, four loop colostomy, three end colostomy). Indications for fecal
diversion were fecal incontinence (n= 11), Crohn's disease (n= 6), unresectable rectal cancer (n= 4), pouch vaginal fistula (n= 3), rectovaginal fistula (n= 2), colonic inertia (n= 2), radiation proctitis (n= 1), anal stenosis (n= 1), Kaposi's sarcoma of the rectum (n= 1), and tuberculous fistula (n= 1). Conversion was required in five patients (15.6%) due to the presence of adhesions (three), enterotomy (one), or colotomy
(one). All of these five patients had undergone previous abdominal surgery and were operated on early in our experience. Major
postoperative complications occurred in two patients (6%) and in both cases consisted of stoma outlet obstruction after construction
of a loop ileostomy. One of the two patients had undergone prior surgery. This patient required reoperation, at which time
a rotation of the terminal ileum at the stoma site was found. The other patient had a narrow fascial opening which was successfully
managed with 2 weeks of self-intubation of the stoma. The mean operative time was 76 (range 30–210) min; mean length of hospitalization
was 6.2 (range 2–13) days; stoma function started after a mean of 3.1 (range 1–6) days. Patients with previous abdominal surgery
had a longer mean operative time (14/32; 117 min) compared to patients who had no previous surgery (18/32; 55 min) (p < 0.0002). These longer operative times and hospital stay were attributable to extensive enterolysis, which was required
in some cases.
Conclusion: In conclusion, laparoscopic creation of intestinal stomas is safe, feasible, and effective. Although the length of the procedure
is longer in patients who have had prior surgery, previous surgery is not a contraindication, and even in these cases, a laparotomy
can be avoided in the majority of patients. Lastly, care must be taken to ensure adequate fascial opening and correct limb
orientation.
Received: 25 March 1996/Accepted: 21 May 1996 相似文献
10.
Microlaparoscopic cholecystectomy 总被引:11,自引:4,他引:7
Background: We set out to compare a prospective evaluation of microlaparoscopic cholesystectomy (MLC) using 5-mm ports for the scope
and operating ports and two 2-mm ports for retracting to the historic results of standard laparoscopic cholecystectomy (SLC).
Methods: Fifty-six consecutive patients were operated electively for symptomatic gallstones between June 1997 and July 1998. Demographics,
history of prior abdominal surgery, operative time, resident level, need to convert, length of stay, and postoperative analgesia
were recorded for each case. In all, 43 women and 13 men aged 21 to 89 (average, 51 years) underwent MLC. Average weight was
78 kg (range, 48–119) and average height was 163 cm.
Results: Operative time for MLC was 72 ± 25 min (range, 35–140), somewhat less than the referenced standard of 79 ± 27 min (p= 0.1). The skin-to-trocar time (6 ± 2 vs 13 ± 77 min) and intraoperative cholangiogram time (9 ± 8 vs 11 ± 6 min) were significantly
shorter (p < 0.01 and p < 0.05, respectively) for MLC. Other partial times were not significantly different. PGY2 residents averaged 74 ± 21 min
(range, 44–118) compared to 75 ± 27 min (range, 35–140) for PGY3 and 53 ± 5 (range, 43–59) for PGY5. Patient weight influenced
time. Patients <65 kg averaged 56 ± 12 min; 66–80 kg, 72 ± 24 min; 81–95 kg, 78 ± 26 min; and >95 kg, 85 ± 22 min. Previous
abdominal surgery did not affect operative time. Nine patients (16%) required conversion from 2- to 5-mm ports because of
adhesions, wall thickening, or need for better retraction. Time in these patients was 95 ± 26 min vs 68 ± 21 min in other
patients (p < 0.01). No patient was converted to an open procedure. Three patients (5%) had a positive cholangiogram and common bile
duct exploration that required placement of an extra 5-mm trocar. Five patients (9%) required insertion of an additional 2-mm
port. All patients received patient-controlled analgesia (PCA). Morphine use was 0.21 ± 0.19 mg/kg (range, 0–0.8). Hospital
stay was 1.31 days (range, 0.5–4). Subjective satisfaction was excellent because of smaller incisions. No additional morbidity
was seen with MLC.
Conclusion: MLC is a feasible and safe approach that provides similar times to SLC with better cosmesis, a less painful recovery, and
possibly an earlier return to normal activity.
Received: 16 February 1999/Accepted: 8 October 1999 相似文献
11.
Background: Between February 1995 and June 1998, 30 laparoscopic Duhamel pull-through procedures were performed in our department.
Methods: Our main aim was to prove the feasibility of the laparoscopic abdominal Duhamel procedure for different localizations of
Hirschsprung disease. We used one camera port and three working ports. The sigmoid colon and posterior rectum were mobilized
laparoscopically. A standard posterior colo-anal anastomosis was fashioned and a stapler was used for the anterior anastomosis.
The top of the rectum was then closed by endo stapler under laparoscopic vision.
Results: Thirty patients underwent laparoscopic surgery for this procedure. Three laparoscopic procedures were converted because of
technical difficulties. The operative time was 100–330 mn. Oral feeding was started at a mean postoperative time of 2.5 days.
Mean postoperative hospitalization was 9 days. Early postoperative complications included 1 anastomotic leak, 1 retrorectal
abscess, 2 urinary infections, and 1 evisceration (after conversion). No enterocolitis or enterocolitis-like symptoms were
noted. All patients now have daily spontaneous bowel movements.
Conclusion: The laparoscopic Duhamel procedure can be performed safely, giving good results.
Received: 6 November 1998/Accepted: 12 February 1999 相似文献
12.
Background: The use of minimally invasive techniques in the surgical treatment of pheochromocytoma is controversial because of possible
intraoperative excessive hormone release resulting in cardiovascular instabilities.
Methods: Laparoscopic adrenalectomy was performed in nine patients with a total of 10 pheochromocytomas. Conversion was required in
two cases. The relevant data were prospectively documented and compared with a historical group of nine patients who had undergone
conventional transabdominal adrenalectomy for unilateral pheochromocytoma.
Results: The laparoscopic operations lasted significantly longer than the conventional procedures (median 243 min vs. 100 min, p < 0.01). Intraoperative cardiovascular instabilities (tachycardia, hypertension) occurred in seven laparoscopically and eight
conventionally treated patients. All were easily controlled. Blood transfusions were necessary in four patients in the conventional
and one patient in the laparoscopic group. Postoperative hospital stay and duration of analgetic treatment were significantly
shorter after laparoscopic adrenalectomy.
Conclusions: Laparoscopic adrenalectomy is a safe procedure for patients with pheochromocytoma.
Received: 11 May 1997/Accepted: 20 March 1998 相似文献
13.
Resection rectopexy for rectal prolapse 总被引:6,自引:0,他引:6
E. Xynos E. Chrysos J. Tsiaoussis E. Epanomeritakis J.-S. Vassilakis 《Surgical endoscopy》1999,13(9):862-864
Background: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse.
Methods: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results
were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment
included anorectal manometry, defecography, and measurement of large-bowel transit.
Results: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze
pressures and rectal compliance increased significantly in both groups of patients (p= 0.007, p= 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p= 0.007). In addition, sampling events were observed more commonly (p= 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in
four of them after rectopexy (two LAP and two OPEN).
Conclusions: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of
shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained
with both procedures.
Received: 16 February 1998/Accepted: 2 September 1998 相似文献
14.
Intracorporeal vs laparoscopic-assisted resection for uncomplicated diverticulitis of the sigmoid 总被引:1,自引:0,他引:1
Background: Minimally invasive surgery for uncomplicated diverticulitis of the sigmoid (UDS) may be performed either as an intracorporeal
procedure (LICR) or as laparoscopically assisted colon resection (LACR).
Methods: Prospectively collected data of 40 selected patients who had undergone LICR for UDS between 1992 and 1994 were compared retrospectively
with those of 34 diagnosis-matched LACR controls operated on at the same hospital between 1995 and 1996 to assess the short-term
outcome.
Results: There were no mortalities. LICR and LACR patients were well matched for age, gender, weight, American Society of Anesthesiologists
(ASA) grade, duration of symptoms, and number of previous admissions. There were no significant differences in conversions
(one vs three), mobilization of splenic flexure (11:29 vs 9:25), anastomotic distance from anal verge (12 vs 13 cm), estimated
blood loss (270 vs 285 ml), passage of flatus (3.1 vs 3.8 days), operating room (OR) costs ($3,040 vs $2,820), and total hospital
costs ($9,250 vs $10,050) in LICR and LACR patients, respectively. Suprapubic skin-incision length (36 vs 60 mm, p << 0.01), size of circular stapler 28:31 mm (1:39 vs 6:28, p= 0.03), specimen length (21 vs 11 cm, p << 0.01), complication rates (6 vs 5, p= 0.02), OR time (180 vs 244 min, p < 0.001), resumption of oral solid food intake (3.2 vs 5.8 days, p < 0.001), hospital stay (4.6 vs 9.9 days, p < 0.001), and ward costs ($2,360 vs $4,950, p < 0.001) were significantly different in LICR and LACR patients, respectively.
Conclusion: The immediately recognizable advantages of LICR over LACR surmised from this study need further evaluation in a prospective
randomized setting. LICR remains a procedure of considerable technical complexity requiring high surgical skills.
Received: 20 May 1999/Accepted: 23 November 1999/Online publication: 17 April 2000 相似文献
15.
Adhesion formation is reduced after laparoscopic surgery 总被引:15,自引:4,他引:11
C. L. Garrard R. H. Clements L. Nanney J. M. Davidson W. O. Richards 《Surgical endoscopy》1999,13(1):10-13
Background: Adhesion formation after abdominal operations causes significant morbidity.
Methods: Adhesion formation in pigs was compared after placement of prosthetic mesh during celiotomy (group 1), laparoscopy with large
incision (group 2), and laparoscopy (group 3). After peritoneum was excised, polypropylene mesh was fixed to the abdominal
wall, then to the opposite abdominal wall in the preperitoneal space followed by peritoneal closure. Adhesion area, grade,
and vascularity were measured.
Results: More adhesions (p < 0.02) covered intraperitoneal mesh (7.57 ± 1.89 cm2) than covered reperitonealized mesh (2.16 ± 1.13 cm2), and adhesion grade was significantly greater (p < 0.02). Adhesion areas were significantly greater in groups 1 and 2 than in group 3 (p= 0.001 and 0.03, respectively). Adhesion grade was significantly greater in groups 1 and 2 than in group 3 (p= 0.02 and p= 0.04, respectively). Groups 1 and 2 had more vascular adhesions than group 3 (p < 0.01 and p= 0.02, respectively)
Conclusions: A foreign body within the peritoneum stimulates more numerous and denser adhesions. Tissue trauma distant from the site of
adhesions increases their formation. A major advantage of laparoscopic surgery is decreased adhesion formation.
Received: 23 January 1998/Accepted: 10 March 1998 相似文献
16.
Immediate and delayed effects of laparoscopic Nissen fundoplication on pulmonary function 总被引:1,自引:1,他引:0
Background: An effort was made to assess the respiratory outcomes of laparoscopic Nissen fundoplication (LNF).
Methods: Prospective follow-up of 69 patients undergoing LNF for gastroesophageal reflux disease. Outcomes included pulmonary function
testing, 24-h pH recording, esophageal manometry, and symptom assessment.
Results: There was an improvement (p < 0.0001) in heartburn and cough scores. There was a significant fall in spirometry (p < 0001), diffusing capacity (p < 0.0001), and respiratory muscle strength (p < 0.0001) 36 h after surgery, which had returned to baseline by 1 month. At 6 months, the patients (n= 16) with impaired preoperative diffusing capacity showed improvement (17.8 ± 3.7 to 19.8 ± 4.6 ml/min/mmHg, p= 0.0245).
Conclusion: Patients undergoing LNF have impaired gas exchange before surgery which tends to improve 6 months after surgery. There is
an early reversible impairment in respiratory function due to diaphragm dysfunction. Patients with a preoperative 1-s forced
expired volume > 1.5, or 50% predicted, are unlikely to develop signficant early respiratory complication.
Received: 22 April 1996/Accepted: 9 July 1996 相似文献
17.
E. Croce M. Golia M. Azzola R. Russo L. Crozzoli S. Olmi C. Pompa M. Borzio 《Surgical endoscopy》1996,10(11):1064-1068
Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described.
Methods: The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations,
and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure
of the main duct. Median duration of surgery was 180 min (range 100–300), including three associated laparoscopic procedures.
Results: There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range
4–14). In May–June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a
successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5–44). Besides
clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography.
Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had
umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative
CBD stricture. At US, CBD was ≤7 mm in 15 patients, 8–10 mm in four patients, and 10–12 mm in three patients. The last group
had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no
change; in nine it decreased; and two had a slight increase (8–10 mm).
Conclusions: We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and
low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of
asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless,
and its specific complications are well known.
Received: 20 October 1995/Accepted: 28 February 1996 相似文献
18.
Intermittent pneumatic sequential compression (ISC) of the lower extremities prevents venous stasis during laparoscopic cholecystectomy 总被引:2,自引:1,他引:1
Background: Fifty patients were included in a prospective randomized trial to evaluate the efficacy of intermittent sequential compression
(ISC) of the lower extremities in preventing venous stasis during laparoscopic cholecystectomy.
Methods: We treated 25 patients with (+ISC) and 25 without (–ISC) intermittent sequential compression. Peak flow velocity (PFV) and
cross-sectional area (CSA) of the right femoral vein were measured by Doppler ultrasound before, during, and after capnopneumoperitoneum
with 14 mm Hg.
Results: PFV was 26.4 (8.4) cm/s and CSA was 1.03 (0.23) cm2 before pneumoperitoneum was induced. During abdominal insufflation, PFV decreased to 61% of the baseline value in the (–ISC)
group but remained unchanged in the (+ISC) group (t = 5.17, df = 42.8, p < 0.01). CSA was 1.06 (0.22) cm2 before insufflation. It increased to 118% of the baseline in the (–ISC) group and to 108% in the (+ISC) group (t =–1.55,
df = 47.1, p= 0.13). PFV and CSA returned to baseline values within 5 min after abdominal desufflation.
Conclusions: ISC effectively neutralizes venous stasis during laparoscopic surgery and may decrease the risk of postoperative thromboembolic
complication. Therefore, it is recommended for all prolonged laparoscopic procedures.
Received: 10 April 1996/Accepted: 24 April 1997 相似文献
19.
Background: Since 1994, 27 patients at our institution have undergone laparoscopic splenectomy for immune thrombocytopenic purpura (ITP).
Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify factors that precluded successful laparoscopic
splenectomy in the remaining 5 patients.
Methods: Retrospective review of 27 patients with ITP undergoing laparoscopic splenectomy was performed at Duke University Medical
Center from August, 1994 to September, 1997.
Results: Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures
were converted to open splenectomy. There was no significant difference in age, ASA score, gender, weight, height, or splenic
size between the converted and laparoscopic groups. However, preoperative and postoperative platelet counts were significantly
higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscopic group than for the converted group (p < 0.001). Adherent adjacent structures, associated comorbidities, and technical errors prohibited laparoscopic completion
in five patients. Technical errors with subsequent bleeding required conversion in two patients. A thickened greater omentum
blanketing the splenic capsule and a densely adherent pancreatic tail extending well into the splenic hilum prevented laparoscopic
completion in two patients. Increased peak airway pressures greater than 60 mmHg after pneumoperitoneum necessitated conversion
in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients
achieved a therapeutic response after splenectomy. Splenectomies completed laparoscopically resulted in a significantly shorter
length of hospital stay (p < 0.01).
Conclusions: Densely adherent adjacent structures, technical errors, and cardiopulmonary instability may preclude successful completion
of laparoscopic splenectomies. Thorough preoperative evaluation with an emphasis on the cardiopulmonary system may elicit
a cohort of individuals with ITP who are unlikely to undergo laparoscopic splenectomy successfully. This cohort also may include
individuals with preoperative platelet counts less than 35,000 mm−3.
Received: 15 April 1998/Received: 15 January 1999 相似文献
20.
Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis 总被引:4,自引:0,他引:4
Background: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged
benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had
relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially
in cases where surgeons are not limited by technical constraints.
Methods: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July
1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy
was performed using a three-trocar technique and the endoscopic stapler.
Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced
length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669;
p= ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom
had perforated appendicitis.
Conclusions: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic
appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.
Received: 3 April 1997/Accepted: 19 August 1997 相似文献