Splenectomy for idiopathic thrombocytopenic purpura

Background: This study aimed to compare the safety, efficacy, and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP). Methods: The results from 14 consecutive patients who underwent LS for ITP were reviewed and compared with the results from patients who underwent OS for the same disease. Demographics, concomitant disease on admission, and platelet counts were evaluated, as were details of the surgical procedure, postoperative physiologic status, and hospital stay. Results: Mean operative time was 88.3 min for OS and 146.4 min in LS group (p < 0.05). The conversion rate to open splenectomy was 7.1. Therapeutic response to splenectomy was 92.8% in the LS group and 86.6% in the OS group. Bowel canalization, return to liquid diet, and length of hospital stay were all significantly delayed in the OS group as compared with those who underwent LS (p= 0.01, p= 0.02, p= 0.005, respectively). In the OS group the morbidity rate was 13.3%, whereas in the LS group it was 7.1%. Conclusions: Laparoscopic splenectomy represents a valid alternative to conventional splenectomy in the treatment of ITP. Received: 10 October 1997/Accepted: 11 March 1998     

Handport-assisted laparoscopic splenectomy in massive splenomegaly

Background: Laparoscopic splenectomy of normal-sized spleens is performed with increasing frequency. By using a handport, which allows the intraperitoneal introduction of one surgeon's hand, massively enlarged spleens may also be extirpated via a laparopscopy-assisted technique. Methods: Seven patients (54–80 years) with massive splenomegaly (3.5–5.8 kg) underwent handport-assisted laparoscopic splenectomy. All patients had spleens that extended beyond the umbilicus, hypersplenism, and discomfort in the upper left quadrant due to intractable hematological malignancy. Results: Both the operation and recovery were uneventful in five of the patients, but one patient had to be converted to an open procedure due to splenic damage and bleeding, and another was reoperated for hemorrhage from a trocar. The handport allowed splenic protection while the trocars were introduced and instruments changed. It also enabled splenic mobilization, particularly prior to stapling of the hilar structures and dissection of the upper splenic pole. Conclusions: Handport-assisted laparoscopic splenectomy seems to be a viable alternative for massive splenomegaly, but it requires further evaluation with respect to safety, efficacy, and indication. Received: 7 September 1999/Accepted: 12 March 2000/Online publication: 20 July 2000     

Laparoscopic splenectomy for ITP

Background: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. Methods: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. Results: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 ± 35 min) significantly shorter than for the first ten (p= 0.01) and also shorter than for OS (103 ± 45 min). Postsurgical hospital stay was 2.9 ± 1.3 days for LS and 6.9 ± 3.0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 ± 0.5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 ± 3,636 for LS and $9,031 ± 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. Conclusions: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS. Received: 26 March 1996/Accepted: 11 May 1996     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

Background: Laparoscopic splenectomy (LS) has rapidly become the preferred surgical treatment for idiopathic thrombocytopenic purpura (ITP), but its long-term efficacy for this disorder is unproved. This report documents the author's 5-year experience with, and long-term follow-up of, LS for ITP. Methods: Between September 1992 and September 1997, 30 patients with clinical ITP and intractable thrombocytopenia were referred as surgical candidates. Two of them (7%) were converted to open, and the other 28 underwent successful LS. The operative approach evolved from a supine lithotomy to right lateral decubitus position, and the harmonic scalpel became the primary dissection tool in the later part of the study. Results: The 28 successful LS patients constituted the study group. Accessory spleens were identified and resected in six patients (21%). Surgical times and blood loss averaged 2.4 h and 170 cc, respectively. The typical hospital stay was 2 days. Initial reversal of thrombocytopenia and ultimate cessation of oral steroids was achieved in 25 of 28 patients (89%). There were no deaths, but two patients had major complications (bleeding and pneumonia). All but two patients experienced a return to full activity and/or employment by 3 weeks post-LS. In the three cases that failed LS, none had residual splenic tissue on subsequent radionuclide scan. Long-term follow-up (2–60 months) was obtained in 22 of 28 patients (79%). The only death (at 13 months) resulted from oncologic disease. Twenty-one patients had lasting clinical remission of ITP. A positive preoperative response to oral steroids was the best predictor of success. Conclusions: This 5-year experience with LS supports its use for the surgical treatment of ITP. The procedure is safe and efficacious, resulting in brief hospitalization, minimal recovery time, and excellent long-term results. Received: 11 October 1998/Accepted: 19 February 1999     

Laparoscopic splenectomy in β-thalassemia major patients

Background: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. Methods: Laparoscopic splenectomy was undertaken in 12 β-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. Results: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3–6 days. Conclusions: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications. Received: 21 March 1997/Accepted: 10 August 1997     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

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     

Laparoscopic vs open splenectomy in the management of hematologic diseases

Background: Laparoscopic splenectomy (LS) is becoming the gold standard in the treatment of several splenic diseases. Shorter postoperative stay and more rapid return to full activity are the primary advantages of LS. Methods: Prospective data collection of 44 consecutive LS (group 1) and comparison with a historical control group of 56 consecutive open splenectomies (OS) (group 2) were performed for hematologic diseases. Results: The LS patients started earlier on an oral diet (p < 0.0001) and left the hospital sooner (p < 0.0002) than OS patients. Less blood transfusion (p < 0.004) and pain medication (p < 0.0001) was required by LS patients. They also had fewer postoperative complications (p < 0.03). Compared by diagnosis, patients with laparoscopic idiopathic thrombocytopenic purpura or Hodgkin's disease started to eat earlier (p < 0.0001) and left the hospital sooner (p < 0.01). Multivariate analysis showed that time to oral diet and postoperative stay was related to operative technique and age. Morbidity and pain medications were related, respectively, to transfusion requirements and type of surgical approach. Conclusions: Used to manage hematologic diseases, LS is feasible, effective, and safe. It offers several advantages over the open approach. The type of surgical approach seems to be the crucial factor in determining the length of the postoperative course. Received: 16 July 1998/Accepted: 20 January 1999     

Posterolateral approach

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports. Received: 24 January 1997/Accepted: 28 October 1997     

Laparoscopic splenectomy

Background: The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University of California, San Francisco. Methods: The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated open splenectomy patients (OS). Results: Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients (mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group (mean $8,939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications occurred. Complication rates and transfusion requirements did not differ between OS and LS patients. Conclusions: Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in patients of all ages. Received: 16 April 1996/Accepted: 5 July 1996     

Port site tumor recurrence rates in a murine model of laparoscopic splenectomy decreased with increased experiencerid=""id=""Presented at the sixth International Congress of the European Association of Endoscopic Surgery (E.A.E.S.), Rome, Italy, 5 June 1998

Background: The etiology of port site tumor recurrences following laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that it is poor surgical technique (i.e., crushing of the tumor) rather than the CO₂ pneumoperitoneum that is responsible for these tumors. However, in that experiment, no intraabdominal procedure was carried out. We subsequently performed a preliminary study in which we compared the rate of port site tumor recurrences after laparoscopic-assisted splenectomy (LAS) vs open splenectomy (OS) using the murine splenic tumor model. In this study, we found significantly more port and incisional tumors after laparoscopic splenectomy. The reasons for this finding are unclear. Further analysis of the data showed that the incidence of port tumors in the LAS group decreased dramatically from the first to the second trial, suggesting that the experience of the surgeon may play a role. The purpose of the current study was to carry out further trials to determine if the lower rate of port tumor recurrence in the laparoscopic group will persist with increased surgical experience. Methods: Splenic tumors were established in female Balb/C mice (n= 128) via a subcapsular injection of a 0.1-cc suspension containing 10⁵ C-26 colon adenocarcinoma cells via a left flank incision at the initial procedure. Seven days later, the animals with isolated splenic tumors (95%) were randomized to one of two groups—open splenectomy (OS) or laparoscopic-assisted splenectomy (LAS). Three ports were placed in similar locations in all animals. The OS mice underwent an open splenectomy via a subcostal incision and anesthesia for 20 min. The LAS mice underwent laparoscopic mobilization of the spleen using a three-port technique, followed by an extracorporeal splenectomy via a subcostal incision. Seven days after splenectomy, the mice were killed and inspected for abdominal wall tumor implants. The experiment was carried out in four separate trials. Results: When the results of the four trials were combined, there was no significant difference in the incidence of animals with at least one port tumor recurrence between the OS vs the LAS group (25% vs 35.2%; p= 0.30, power = 0.91). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic-assisted group than in the open group (18.5% vs 9.5%; p= 0.03). It was noted that the incidence of port tumor recurrence (PTR) in the LAS group dropped significantly from the first to the latter three trials (second, third, and fourth trials combined) (36.1% vs 13.5%; p < 0.006) while it did not change significantly in the OS group. In the latter three trials, there was no significant difference in the number of animals with PTR between the LAS and the OS group (13.5% vs 9.8%; p= 0.43). Conclusions: Overall, there was no significant difference between the OS and the LAS groups in number of animals with port tumor recurrence or subcostal wound tumor recurrence. However, there were more port tumors in the laparoscopic-assisted group. The reasons for these findings are unclear. The laparoscopic mobilization was quite difficult; it required excessive splenic manipulation, which may have liberated tumor cells from the primary lesion and facilitated port tumor formation. With increased experience, less manipulation was required to complete the mobilization. Of note, the incidence of port tumors in the LAS group decreased significantly from the first to the subsequent three trials; therefore, it is possible that surgical technique is a factor in port tumor formation. The CO₂ pneumoperitoneum may also be a factor, but this seems less likely. Received: 10 September 1999/Accepted: 4 April 2000/Online publication: 9 August 2000     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

Background: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. Methods: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). Results: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases—i.e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. Conclusions: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy. Received: 3 April 1997/Accepted: 26 September 1997     

Laparoscopic vs conventional Nissen fundoplication

Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Received: 15 May 1996/Accepted: 10 September 1996     

Resection rectopexy for rectal prolapse

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     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

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     

Laparoscopic surgery for splenic disorders

Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April-1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with ^99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approach's safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted. Received: 29 January 1997/Accepted: 22 May 1997     

Surgical treatment of pheochromocytomas

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     

Effects of laparoscopic vs laparotomy treatment of E. coli peritonitis on hemodynamic responses in a porcine model

Background: Laparoscopic surgery is being used now for increasingly diverse clinical applications, including diagnosis and treatment of appendicitis and bacterial peritonitis. However, some concerns and controversies exist regarding the effectiveness of laparoscopic irrigation of the abdominal cavity compared with that achieved during laparotomy. Of no less importance is concern that establishing a CO₂ pneumoperitoneum in patients with cardiopulmonary insufficiency or endotoxemic shock may compromise hemodynamic function. The objective of this randomized, controlled study was to determine the effects of laparoscopic versus laparotomy intervention on hemodynamic and outcome measurements using a porcine model of Escherichia coli peritonitis. Methods: For this study, 24 specific pathogen-free Hanford pigs underwent surgical placement of carotid, Swan-Ganz, and peritoneal catheters. After a 24-h recovery period, one subset of pigs (n= 12) received a bolus infusion of 9 × 10⁸ CFU/kg E. coli intraperitoneally (septic) and intravenous fluid resuscitation. The remaining 12 pigs were not challenged with E. coli (control). Twenty-four hours later, all 24 pigs underwent either laparoscopic or open peritoneal irrigation with saline, then were reevaluated 48 h after surgical intervention. Standard cardiopulmonary, hematologic, and bacteriologic assessments were obtained both perioperatively and 48 h after surgical intervention. Results: Pigs given E. coli exhibited significantly elevated heart rates and core temperatures and decreased O₂ saturation during the initial 6 h. Within 24 h, these pigs exhibited respiratory alkalosis, altered blood leukocyte profiles, and E. coli–infected peritoneal fluid. Random blood samples from the septic pigs tested negative for E. coli. Mean pulmonary artery and capillary wedge pressures were lower (p < 0.05) in septic than in control pigs before and after surgical intervention. Septic pigs that underwent laparoscopy had significantly lower (p < 0.05) arterial pH and higher arterial pCO₂ levels than septic pigs after laparotomy. Other cardiopulmonary responses were similar irrespective of the surgical modality used. One of six septic pigs from each surgical group still had E. coli growth in its peritoneal fluid 48 h after surgical intervention. Conclusion: Laparoscopic intervention demonstrated effectiveness equal to that of laparotomy for treating acute E. coli peritonitis in pigs without septic shock. Received: 26 June 1998/Accepted: 12 January 1999     

Laparoscopic surgery for diverticulitis

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