Preoperative risk factors for intraabdominal adhesions should not contraindicate surgical laparoscopy for infertility

OBJECTIVE: Abdominal wall adhesions at laparoscopy may predispose infertile patients to access-related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of surgical laparoscopy in infertile patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of intraabdominal adhesions at laparoscopy, a retrospective cohort study was performed. METHODS: All infertile patients who underwent a reproductive laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for intraabdominal adhesions. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. RESULTS: During the study period, 254 infertile patients underwent reproductive surgical laparoscopy, and videotapes on 164 (65%) were available for review. A total of 88 patients (54%) were identified with preoperative risk factors for intraabdominal adhesions (group 1), while 76 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI, range 0.89 to 2.01, P=0.18) when risk factors were identified. There were no differences in the groups regarding patient age, operative time, access technique, conversion to open surgery, or complications. Estimated blood loss was significantly higher in group 2, likely due to the predominance of laparoscopic surgery for ovarian endometriomata and complexity of the cases rather than the presence or absence of intraabdominal adhesion risk factors. CONCLUSIONS: No difference existed in the risk of intraabdominal adhesions in infertile patients with and without identifiable preoperative risk factors. Preoperative risk factors for intraabdominal adhesions should not contraindicate the surgical laparoscopic approach for reproductive procedures.     

Use of transabdominal ultrasound to identify intraabdominal adhesions prior to laparoscopy: a prospective blinded study

OVERVIEW: The aim of the current study was to assess the accuracy of transabdominal ultrasound (TAU) in identifying intra-abdominal adhesions (IAA) prior to laparoscopy in patients with previous abdominal surgery. METHODS: Patients with previous open surgical procedures presenting for laparoscopic gastric bypass (LGB) underwent TAU by 1 radiologist. Attempts were made to identify IAA using TAU. The intended trocar sites were categorized as free movement (no adhesions), chaotic movement (omental adhesions), or no movement (frozen bowel). During LGB, adhesions at the 6 trocar sites were graded by 1 blinded surgeon. RESULTS: A significant degree of agreement was found between the radiologist's predictions and the intraoperative findings with regards to identification of trocar sites free of adhesions versus omental adhesions and frozen bowel. CONCLUSIONS: TAU can accurately identify IAA prior to laparoscopy. Widespread application of this technique may decrease trocar-related injuries during laparoscopic procedures in patients with previous abdominal surgery.     

Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications

BACKGROUND: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery. METHODS: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications. RESULTS: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P=0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6-8% of complications occurring in each of the two groups (P=1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153-723) min respectively, although not statistically significant (P=0.059). CONCLUSION: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.     

The effect of previous abdominal surgery on urological laparoscopy

PURPOSE: Abdominal surgery causes adhesions that may render subsequent laparoscopic access and dissection problematic. We determined the effect of previous surgery on the operative outcome in a large series of patients undergoing urological laparoscopy. MATERIALS AND METHODS: The records of 700 consecutive laparoscopic procedures performed at a single institution from 1995 to 2001 were reviewed. Patient gender, American Society of Anesthesiologists (ASA) patient classification, surgical history, operative time, estimated blood loss, transfusion rate, rate of conversion to an open procedure, complication rate and hospital stay were assessed in each patient. Patients were categorized by anatomical site of previous surgeries and the type of laparoscopic procedure performed. Statistical analysis was performed with 1-way ANOVA, and the chi-square, Fisher exact and Kruskal-Wallis tests. RESULTS: Of the 700 patients 366 (52%) had never undergone surgery, 105 (15%) had a history of abdominal surgery at the same anatomical region and 229 (33%) had a history of abdominal surgery at a different region. Overall previous abdominal surgery of any type was associated with female gender, higher ASA classification, increased age and an increased rate of perioperative transfusion (p = 0.0001). A history of surgery at the same site was associated with increased operative time (p = 0.03) and increased hospital stay (p = 0.02). Differences in operative blood loss (p = 0.3), and the complication (p = 0.11) and conversion (p = 0.08) rates in patients with and without a history of surgery did not attain significance. Outcomes analysis of individual types of surgery showed similar results except for renal biopsy. In these cases previous surgery was not associated with increased age, ASA score or transfusion rate. CONCLUSIONS: Of all patients presenting to a single center for urological laparoscopy 48% had a history of abdominal surgery. Overall compared with patients with no history of surgery those with such a history tended to be older, predominantly female and at significantly higher operative risk. Patients with a history of surgery who underwent nephrectomy or pyeloplasty were also more likely to have received blood transfusion perioperatively, which was probably related to their increased age and higher degree of medical co-morbidity. There were no significant differences in operative blood loss, rate of conversion to open procedure or rate of operative complications. Therefore, previous abdominal surgery does not appear to affect adversely the performance of subsequent urological laparoscopy.     

Acute hemoperitoneum caused by rupture of omentum adhesions after running

The case of a 37-year-old man in whom a massive hemoperitoneum developed a few hours after running is described. The patient disclaimed any trauma and clearly noted that symptoms appeared after running. Findings at laparoscopy showed that the bleeding was caused by the rupture of adhesions between the omentum and left inguinal abdominal wall. These adhesions, which had resulted from a previous laparoscopic transperitoneal bilateral inguinal hernia cure, were resected. Recovery was simple and follow-up assessment was uneventful. Hemoperitoneum secondary to the rupture of intraperitoneal adhesions is very rare in the absence of precipitating trauma. However, the trauma can be trivial. Rupture of intra-abdominal adhesions has been described after sexual intercourse or mobilization of the patient under general anesthesia. Disruption of adhesions by insufflation or mobilization of organs under laparoscopy also is reported. The transperitoneal approach to laparoscopic treatment of inguinal hernia can be responsible for late intestinal obstruction caused by intra-abdominal adhesions, but late hemorrhagic complication has not yet been reported.     

Laparoscopy offers diagnosis and treatment in abdominal stab injuries

PURPOSE: To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). METHODS: Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. RESULTS: From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. CONCLUSIONS: Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.     

经腹腔途径腹腔镜手术141例报告

目的:总结经腹腔途径泌尿外科腹腔镜手术的初期经验。方法:回顾性分析141例经腹腔途径患者的手术结果。结果:138例患者通过腹腔镜完成手术,3例转为开放手术。无需要二次手术患者,无围手术期死亡发生,无大血管及腹腔内脏器损伤等严重并发症。术后远期,1例出现不完全性肠梗阻,1例出现切口疝。结论:初学者进行经腹腔途径的泌尿外科腹腔镜手术是安全可靠的;在手术过程中,对解剖的认识和采取谨慎的态度,是避免严重并发症发生的关键。     

Laparoscopy-assisted aneurysm resection as a minimal invasive alternative in patients unsuitable for endovascular surgery

OBJECTIVE: So far, endovascular surgery has been the only minimal invasive way to treat patients with abdominal aortic aneurysms (AAAs). With hand-assisted laparoscopic surgery (HALS), laparoscopic transperitoneal endoaneurysm repair can be performed through a 6-cm mini-incision only. We wanted to evaluate whether this laparoscopic technique can be offered as a minimal invasive alternative in patients unsuitable for endovascular AAA repair. MATERIAL AND METHODS: Forty patients were referred for endovascular AAA repair. Three patients had to be excluded from the study. Endovascular AAA exclusion was finally performed in 13 patients. Laparoscopic AAA resection was performed in 24 patients. Hand-assisted laparoscopic surgery with transperitoneal access and endoaneurysm repair was accomplished in all patients unsuitable for an endovascular procedure. The outcome after endovascular repair was compared with the outcome of patients who underwent laparoscopy. RESULTS: In the laparoscopic group, conversion to an open procedure was necessary in one case. One patient in this group died (4.1%) postoperatively. There were four complications in each group. In the endovascular group we had one endoleak type II and one graft thrombosis, which required a reoperation. After endovascular treatment, patients were transferred significantly less frequently to the intensive care unit, and they could resume oral feeding earlier. Mobilization and postoperative hospital stay did not differ significantly between the groups. CONCLUSION: Laparoscopic AAA resection with the use of the technique described can be routinely offered to patients unsuitable for endovascular AAA exclusion with excellent long-term results similar to open surgery. A controlled study is clearly indicated to evaluate the role of laparoscopic techniques in aneurysm surgery.     

Laparoscopic assisted placement of peritoneal dialysis catheters for selected patients with previous abdominal operation.

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy

BACKGROUND: There is little evidence in the literature to support a lower incidence of adhesion formation following laparoscopic surgery rather than laparotomy. Adhesion formation after laparotomy has been well studied, but we believe that the decrease or absence of adhesions following laparoscopic surgery is underreported. Therefore, we set out to evaluate adhesion formation following laparoscopic cholecystectomy (LC) compared with open cholecystectomy (OC). METHODS: Group A consisted of 18 patients who underwent a second laparoscopy due to various intraabdominal diseases after an LC had already been performed. Group B consisted of eight patients who underwent laparoscopy due to various intraabdominal diseases after an open cholecystectomy performed at an earlier date. In both groups, the frequency, extent, and thickness of adhesions were evaluated according to a standardized scoring system. RESULTS: Ten patients in group A (55.5%) had no adhesion formation either on the treated side of the previous LC or on the trocar entry sites. Three patients (16.6%) had minimal adhesions on the treated side of the previous LC, but no adhesions were observed at the trocar entry sites. Five patients (27.7%) had loose, easily separable adhesions on the treated site of the previous LC and at the trocar entry sites. All eight patients in group B (100%) had thick and extensive adhesions either on the treated side of the previous open cholecystectomy or the anterior abdominal wall below the surgical incision. CONCLUSION: This comparative clinical study suggests that LC results in less adhesion formation, either on the operative or at the trocar entry sites, than open cholecystectomy.     

Prior abdominal surgery and radiation do not complicate the retroperitoneoscopic approach to the kidney or adrenal gland

PURPOSE: Laparoscopic renal and adrenal surgery is an accepted standard of care. This can be accomplished by a transperitoneal or retroperitoneal approach. In patients with extensive prior intra-abdominal surgery with or without radiation the retroperitoneal laparoscopic approach may avoid bowel adhesions and potential operative complications. We compared clinical outcomes of the laparoscopic retroperitoneal approach in patients with prior open abdominal surgery with or without radiation to outcomes in those with no surgical history. MATERIALS AND METHODS: We evaluated clinical and functional parameters in 78 consecutive patients undergoing retroperitoneoscopic renal or adrenal surgery performed by a single surgeon in a 36-month period, including radical nephrectomy with or without ureterectomy in 50, nerve sparing surgery in 8, ablation in 16 and adrenalectomy in 4. All transperitoneal procedures during the same period were excluded from analysis. Patients were divided into 48 who underwent prior abdominal surgery with or without radiation (group 1) and 30 who did not (group 2). Prior abdominal surgeries in group 1 patients were open and they were major in 42 and/or minor in 39. An additional 6 patients in group 1 received prior abdominal radiation overlapping the planned surgical field. RESULTS: No statistically significant differences were noted between the groups in any parameter assessed, including operative time, blood loss, time to first oral intake, hospital stay or the complication rate (p >0.05). There were no enterotomies in either group. There were no open conversions in group 1, while there were 2 in group 2 (renal vein injury and splenorrhaphy secondary to lymphoma, respectively). Pathological findings showed malignancy in 57 cases (renal cell carcinoma, transitional cell carcinoma, carcinoid disease and metastases) and benign disease in 21 (oncocytoma, adenoma, pyelonephritis and complex cysts). All margins were negative except in 1 group patient with carcinoma in situ at the bladder cuff margin. CONCLUSIONS: The retroperitoneoscopic approach to the kidney and adrenal glands can be used in patients with extensive prior open abdominal surgery and/or radiation without significant increases in morbidity or convalescence.     

William Stewart Halsted: Father of American Modern Surgery

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

Results after laparoscopic lysis of adhesions and placement of seprafilm for intractable abdominal pain

Background: The surgical treatment of patients with chronic abdominal pain resulting from intraabdominal adhesions is controversial. We report our experience with treatment of this challenging patient population using laparoscopic lysis of adhesions (LOA) and placement of Seprafilm (Genzyme, Cambridge, MA, USA). Methods: The participants in this study were 19 consecutive patients (2 men and 17 women) who underwent laparoscopic LOA and placement of Seprafilm between July 1998 and July 2001. Patients with abdominal pain resulting from irritable bowel syndrome, hernias, or endometriosis were excluded. The patients had undergone a mean of 6.4 previous abdominal procedures (range, 1–14) and 2.3 previous LOAs (range, 0–10). They had experienced chronic, intractable abdominal pain for at least 4 months (range, 4–180). Eight patients had preoperative obstructive symptoms. Results: A completely laparoscopic procedure was used to treat 16 patients, whereas the procedure for 3 patients was converted to open surgery because of dense adhesions. Perioperative complications included two patients in whom enterocutaneous fistulae developed and one patient with intraabdominal hematoma. At follow-up (mean, 9.6 months; range, 1–32 months), 14 patients (73.7%) had completely discontinued all pain medications. At this writing, 12 of these patients are completely symptom free. Two patients are taking nonsteroidal antiinflammatory drugs (NSAIDs) as needed, and three patients require round-the-clock narcotics. Three patients were readmitted with small bowel obstruction, which was managed nonoperatively. One patient had diagnostic laparoscopy for recurrent pain 6 months postoperatively, but had no adhesions. Conclusion: Chronic intractable abdominal pain is relieved in most patients via this approach. Repeat laparoscopy in two patients showed no intraabdominal adhesions. Laparoscopic LOA and placement of Seprafilm is an excellent approach to this challenging patient population with symptoms caused by intraabdominal adhesions.     

腹腔镜切口疝修补术中腹腔粘连的诊断、分型及分离技巧

背景与目的 切口疝是腹部手术的常见并发症之一，而患者在经历了腹部手术后常有不同程度的腹腔内粘连，分离粘连是切口疝修补过程中不可回避且有相对难度的工作。术前人工渐进性气腹是腹腔镜切口疝修补术中的重要环节，笔者前期发现，通过对比气腹前后的影像学资料，可评估切口疝患者腹腔内状态，有利于手术预判，提高手术精准度，减少手术风险。本文旨在进一步探讨人工气腹结合腹部CT在伴腹腔粘连切口疝患者的腹腔镜修补术中的应用价值，并总结腹腔粘连的类型和分离粘连的手术技巧。方法 回顾性收集分析2019年4月—2020年5月在中山大学附属第六医院胃肠、疝和腹壁外科行腹腔镜切口疝修补术患者的临床资料和手术录像。通过术前人工气腹前、后腹部CT对比，判断是否存在腹腔粘连。研究者通过手术录像复盘，观察腹腔粘连的分型，总结粘连分离的技巧，记录术中粘连分离时间和并发症，统计观察孔穿刺时副损伤情况，术后并发症与恢复情况。结果 共收集72例行腹腔镜切口疝修补术病例，其中15例术前未建立人工气腹，7例建立人工气腹后术前未复查腹部CT，15例气腹前或气腹后未行疝囊三维CT重建，均予以排除。最终纳入35例患者，均为II型腹壁缺损；复发疝5例；男16例，女19例；年龄（63.26±11.11）岁；体质量指数25.04（23.03~27.34）kg/m²；既往手术术后有腹腔内感染伴切口感染者4例，切口感染者7例；最多手术次数5次。通过人工气腹前、后腹部CT对比，诊断存在腹腔内容物与腹壁粘连者33例（94.29%），无粘连者2例（5.71%）。其中主要粘连物为肠管20例（60.61%），主要粘连物为网膜组织13例（39.39%）。根据粘连的形态可分为：点状粘连，线状粘连，片状粘连及混合型粘连。根据粘连的质地可分为：膜性粘连，瘢痕性粘连及复合型粘连。粘连分离采取层面变峰面，面转化线和点，钝锐结合分离膜性粘连，锐性分离瘢痕性粘连的程序化方法。全组均成功松解分离粘连，分离时间32（4.50~46.50）min。其中5例发生小肠壁浆肌层损伤，予3-0可吸收缝线行浆肌层缝合。在行观察孔穿刺时，均未发生腹腔内脏器损伤。术后1例出现肺部感染，术后恢复排气时间3（2~4）d。结论 术前人工气腹结合腹部CT有助于判断是否存在腹腔粘连及粘连部位，有利于观察孔布局的选择。根据其形态和性质采取程序化的方法有利于简化腹腔粘连的分离。     

Laparoskopie bei Dünndarmileus

Today laparoscopic procedures are routinely performed in patients with intestinal adhesions from previous abdominal surgery. Does laparoscopy have a potential benefit in acute small-bowel obstruction? Theoretically, a lower rate of wound complications and incisional hernias, as well as less subsequent adhesions with a lower incidence of recurrent intestinal obstruction, can be expected. However, laparoscopy is successful in only 50-70% of selected patients, thereby representing the highest rate of conversion in minimally invasive surgery. Laparoscopic management of severe abdominal distension with massively dilated and fragile small-bowel or dense adhesions is extremely difficult even when performed by experienced surgeons. Significantly prolonged operating time, the high risk of bowel injury (> 6-10%) and an increased frequency of early reoperations jeopardize the patient's safe outcome. However, in strictly selected patients the laparoscopic approach may be promising. In acute intestinal obstruction without a history of previous abdominal surgery, laparoscopy is--in the absence of adhesions--an excellent diagnostic tool and may also be a successful therapeutic modality in a variety of bowel-obstruction etiologies. Furthermore, the laparoscopic option should be considered in patients who previously had undergone small laparotomies (e.g., appendectomy) or laparoscopic surgery. We recommend "postlaparoscopic" intestinal obstruction as the ideal case for laparoscopic reexploration. Incarcerated hernias at the site of trocar insertion or adhesions due to peritoneal tears are easily identified as the cause of obstruction and successfully cured with the laparoscope. In conclusion, we advocate the laparoscopic approach in acute small-bowel obstruction exclusively for selected patients. Clinical studies are required to define appropriate surgical indications objectively.     

A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain

Laparoscopic adhesiolysis for chronic abdominal pain is subject for criticism. In this prospective study, we analyze factors that encourage or discourage the indication for therapeutic laparoscopic adhesiolysis. Two hundred twenty-four consecutive patients with chronic abdominal pain underwent diagnostic laparoscopy, and in case of adhesions, they underwent adhesiolysis. Pain relief was assessed, and the individual impact of variables on pain relief was determined. Laparoscopy was performed in 224 patients. Two hundred patients had only adhesions and underwent primary laparoscopic adhesiolysis. Three months after adhesiolysis, 74% of patients were pain-free or had less pain. The remaining 26% of the patients felt no change (22%) or had more pain (4%). Gender, age, and bowel perforation leading to a laparotomy appear to be individual factors significantly influencing pain relief. Laparoscopic adhesiolysis can be done (almost) completely in 92% of patients with adhesions. After laparoscopic adhesiolysis, 74% of patients had good results and 4% had more pain. The complication rate is high.     

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass.

BACKGROUND: To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery. METHODS: A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings. RESULTS: A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up). CONCLUSION: The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.     

Laparoscopic appendectomy for acute appendicitis: indications and current use.

Laparoscopic evaluation was performed in 43 consecutive patients with right lower abdominal pain and preoperative diagnosis of possible appendicitis. Patients with generalized peritonitis and evidence of perforation of the appendix were not considered for laparoscopy. Visualization was sufficient for making a diagnosis in 97.7% of the cases. In 95%, laparoscopic findings were compatible with the pathology report. Thirty-five patients underwent successful laparoscopic appendectomy with neither intraoperative nor postoperative complications. No further surgery was required; slightly elevated temperatures in 6 patients responded to treatment with antibiotics, and there were no wound infections. Laparoscopic appendectomy is minimally invasive and results in less postoperative pain and morbidity and fewer adhesions and other long-term sequelae than conventional laparotomy. It is associated with superior cosmetic results, a shorter hospital stay, and faster return to normal activities. This experience suggests that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best evaluated and treated with laparoscopic technique.     

Laparoscopy for chronic abdominal pain

Background: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. Methods: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. Results: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. Conclusions: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain. Received: 16 April 1996/Accepted: 30 May 1996