Simultaneous laparoscopic biliary and retrocolic gastric bypass in patients with unresectable carcinoma of the pancreas

Background: A substantial number of patients with unresectable pancreatic cancer eventually develop biliary or gastric outlet obstruction. In some cases, they present initially with both complications. These conditions contribute markedly to their discomfort and certainly justify palliative intervention. The purpose of this study was to examine the feasibility and safety of simultaneous laparoscopic biliary and gastric bypass in patients with unresectable carcinoma of the pancreas. Methods: Between August 1995 and July 1998, simultaneous laparoscopic biliary and retrocolic gastric bypass was performed successfully in 12 consecutive patients with unresectable carcinoma of the pancreas. There were eight men and four women. Their median age was 72 years (range, 50–82). In all patients, the indications for gastrointestinal bypass were gastric outlet obstruction and obstructive jaundice. The following parameters were evaluated for each patient: procedure-related morbidity and mortality, operative time, length of hospital stay, overall survival, and ability to sustain oral nutrition during the survival period. Results: All procedures were completed laparoscopically. The mean operative time was 89 ± 29.56 min. There were no intraoperative complications. Postoperative morbidity consisted of wound infection in two patients and pneumonia in one patient. One patient died of multiorgan failure on postoperative day 2. The mean hospital stay was 6.4 ± 1.5 days (range, 5–17). The mean survival time until death from underlying disease was 85 ± 32.46 days (range, 31–260). None of the patients had recurrent jaundice, and all of them were able to maintain oral nutrition. Conclusion: Simultaneous laparoscopic biliary and retrocolic gastric bypass is a safe and effective technique for the treatment of biliary and gastroduodenal obstruction in patients with unresectable pancreatic cancer. Received: 17 December 1998/Accepted: 13 May 1999     

Laparoscopic management of colorectal endometriosis

Background: In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery. The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center. Methods: From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate, length of hospitalization, and complications. Results: In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas. Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases required conversion due to the overall severity of the pelvic disease. For those who did (n= 12) and did not (n= 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90–390) and 110 min (range, 45–355), respectively; the median length of hospitalization was 4 days (range, 3–7) and 1 day (range, 0–4), respectively. A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1–32), 28 patients were improved, and 24 of these had near or total resolution of preoperative symptoms. Conclusions: Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients. Received: 1 April 1998/Accepted: 22 March 1999     

Laparoscopically assisted intestinal resection in 88 patients with Crohn's disease

Background: Experience with 94 resections in 88 patients with Crohn's disease using advanced laparoscopic techniques is reported. Records of patients who underwent intestinal resection for Crohn's disease between August, 1993 and November, 1998 were reviewed. Indications, operative findings, clinicopathologic, and postoperative data were recorded. Methods: In this study, the mean age was 37 years (range, 16–70 years), and 55% of the participants were women. Indications for surgery included obstruction (64 cases), pain (22 cases), peritonitis (1 case) and abscess (1 case). Seventy patients underwent ileocolic resection, 28 of whom had a previous history of one or two ileocolic resections. Eight of these patients had additional procedures including tubal ligation (1), sigmoidectomy (1), cholecystectomy (3 cases), and enterectomy (3 cases). Small bowel resection (13 cases), right hemicolectomy (3 cases), subtotal colectomy (3 cases), anterior rectal resection (2 cases), and sigmoid resection (3 cases) were performed in the remaining patients. All but one procedure were completed laparoscopically with extracorporeal anastomosis. The average length of intestine resected was 33 cm (range, 10–92 cm). Forty-one patients had 58 fistulae between ileum, jejunum, mesentery, colon, abdominal wall, skin, or bladder. Mean blood loss was 168 ml (range, 30–800 ml) and mean operative time was 183 min (range, 96–400 min). Results: More than 85% of the patients were tolerating a liquid diet on the first postoperative day. Average length of hospital stay was 4.2 days (range, 3–11 days). Complications included anastomotic leak necessitating reoperation, stricture requiring endoscopic dilation, hemorrhage treated expectantly, urinary tract infection, pulmonary embolus, line sepsis, and early postoperative intestinal obstruction (7 cases) requiring reoperation in three cases. Conclusions: Experience with both advanced laparoscopic techniques and conventional surgery for inflammatory bowel disease allowed successful laparoscopic management of patients with complicated Crohn's disease. Received: 29 August 1998/Accepted: 22 January 1999     

Robot-assisted laparoscopic surgery of the infrarenal aorta

Background Recently introduced robot-assisted laparoscopic surgery (RALS) facilitates endoscopic surgical manipulation and thereby reduces the learning curve for (advanced) laparoscopic surgery. We present our learning curve with RALS for aortobifemoral bypass grafting as a treatment for aortoiliac occlusive disease. Methods Between February 2002 and May 2005, 17 patients were treated in our institution with robot-assisted laparoscopic aorto-bifemoral bypasses. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Operative time, clamping time, and anastomosis time, as well as blood loss and hospital stay, were used as parameters to evaluate the results and to compare the first eight (group 1) and the last nine patients (group2). Results Total median operative, clamping, and anastomosis times were 365 min (range: 225–589 min), 86 min (range: 25–205 min), and 41 min (range: 22–110 min), respectively. Total median blood loss was 1,000 ml (range: 100–5,800 ml). Median hospital stay was 4 days (range: 3–57 days). In this series 16/18 anastomoses were completed with the use of the robotic system. Three patients were converted (two in group 1, one in group 2), and one patient died postoperatively (group 1). Median clamping and anastomosis times were significantly different between groups 1 and 2 (111 min [range: 85–205 min] versus 57.5 min [range: 25–130 min], p < 0.01 and 74 min [range: 40–110 min] versus 36 min [range: 22–69 min], p < 0.01, respectively) Total operative time, blood loss, and hospital stay showed no significant difference between groups 1 and 2. Conclusions Robot-assisted aortic anastomosis was shown to have a steep learning curve with considerable reduction of clamping and anastomosis times. However, due to a longer learning curve for laparoscopic dissection of the abdominal aorta, operation times were not significantly shortened. Even with robotic assistance, laparoscopic aortoiliac surgery remains a complex procedure. Presented at SAGES 2006, April 26–29 2006, Dallas, Texas, USA An erratum to this article can be found at     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Laparoscopic treatment of hydatid cysts of the liver and spleen

Background: The short-term results from laparoscopic treatment of hydatid cysts of the liver and spleen were reported previously. The procedure was shown to be feasible and safe, offering the advantages of laparoscopic surgery. This is the first report on the long-term follow-up of this operation in a large group of patients. Methods: In this study, 108 hydatid cysts of the liver and spleen in 83 consecutive patients (43 males [52%] and 40 females [48%]) were approached laparoscopically. The mean age of the patients was 40 years (range, 13–85 years). There were 104 liver cysts and 4 spleen cysts. The liver cysts were located in the right lobe in 42 patients (53%), in the left lobe in 21 patients (26%) and in both lobes in 16 patients (21%). Of the 104 cysts, 44 (42%) were uniloculated and 60 (58%) were multiloculated. Results: All cysts were approached laparoscopically. The mean operative time was 80 min (range, 40–180 min). The conversion rate was 3%. The mean hospital stay was 3 days (range, 2–7 days). There were no mortalities, and complications occurred in nine patients (11%). All were managed conservatively except one patient in whom a laparotomy was needed. All patients were followed up for a mean period of 30 months (range, 4–54 months) with serological testing and ultrasonography if needed. In three patients (3.6%) recurrence of the disease developed. Conclusion: The laparoscopic approach to uncomplicated hydatid cysts of the liver and spleen is a safe and effective option with favorable long-term results. Received: 27 August 1998/Accepted: 13 July 1999     

Microlaparoscopic cholecystectomy

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     

Newly designed retraction devices for intestine control during laparoscopic aortic surgery

Background: Recent clinical studies have demonstrated the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease. However, transperitoneal aortic access is compromised by poor exposure in the operative field from uncontrolled bowel. The retractors that are currently available are inadequate for this task. The development of new retractors would help to facilitate laparoscopic aortic surgery. Methods: Six female piglets (28–30 kg) in each group underwent laparoscopy with pneumoperitoneum (12 mmHg). Exposure of the infrarenal aorta and cross-clamping were undertaken through a transperitoneal approach. Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Aortotomy and suturing were performed to mimic a vascular procedure. After bleeding was controlled, the intraabdominal pressure (IAP) was lowered to 6 mmHg, and retraction was assessed for 30 min. The main outcome measures were time to deploy the retractors, time to perform the vascular procedure, time to withdraw the devices, and total procedural time. Blood loss and frequency of retraction failure were also recorded. Results: Mean time to deploy the device was 22 ± 12 min in group A and 36 ± 34 min in group B (n.s.). Vascular surgery time averaged 60 ± 24 min in group A and 68 ± 16 min in group B (n.s.). The times to withdraw the nets were 3.6 ± 1.2 min and 13.5 ± 8.2 min, respectively (p < 0.05). Total surgery time was 155 ± 41 min vs 174 ± 49 min (n.s.). There were six retraction failures, five in group A and one in group B. When lower IAP was used, there was only one failure in each study group. Mean blood loss was <150 ml in both groups. There were no major complications. Conclusions: Both methods provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar for both groups. The movable device proved more usable and, at lower IAP, more effective. The results of this study demonstrate effective bowel retraction for laparoscopic aortic surgery. Received: 10 December 1998/Accepted: 13 May 1999     

Laparoscopic treatment of lymphocele after kidney transplantation

Background: Laparoscopic treatment of pelvic lymphocele secondary to kidney transplant has gained popularity in the last few years, although lesions of the urinary tract (ureter, renal pelvis, and bladder) have been reported frequently. To evaluate the result of this treatment and the associated risk of urinary tract lesions, we reviewed our experience and reports in the medical literature on open and laparoscopic surgery. Methods: From 1991 to 1999, we laparoscopically treated 12 patients (7 men and 5 women; median age, 43 years; range, 17–59 years) with symptomatic pelvic lymphocele causing a deterioration of renal function because of compression on the ureter in 10 of the 12 patients and lymphocele compression of the iliac vein in the other 2 patients. In nine patients, the lymphocele wall was opened and sutured to the peritoneum to keep the window open. In two patients, an omentoplasty was performed, and in the remaining patient, both techniques were used. All patients were followed up clinically with ultrasound and biochemistry for a median period of 33 months (range, 1–96 months). Using Medline, we reviewed the medical literature from 1980 to 1998 and collected 252 cases in which operations had been performed to drain an internal lymphocele secondary to kidney transplantation. Results: Laparoscopic treatment was successful in 11 of the 12 patients. One patient was converted to open surgery because of a lesion in the transplanted ureter. One patient needed repeat laparoscopy 24 hours after the operation because of bleeding from the peritoneal window. The median duration of the operation was 120 min (range, 70–200 min), and the median postoperative hospital stay was 5 days (range, 2–12 days). None of the patients needed to discontinue oral cyclosporine assumption. The serum creatinine level dropped significantly after surgery (p < 0.05). No symptomatic recurrences were observed. Of the 252 patients found in the medical literature, in 129 the procedure was performed with open surgery and in 123 laparoscopically (our 12 patients included). The prevalence of iatrogenic lesions to the urinary tract increased threefold with the use of laparoscopic surgery (from 1.6% in open surgery to 7% in laparoscopy). The recurrence rate of symptomatic lymphocele, however, decreased from 15% to 4%. Conclusions: Laparoscopic drainage of posttransplantation lymphocele is a relatively simple method for treating this complication, although it bears the burden of an increased incidence of urinary tract lesions, as confirmed by a review of the literature. The major advantage of the laparoscopic approach is the absence of postoperative ileus with the opportunity to continue the enteral immunosuppressive regimen and a lower recurrence rate. These data suggest that laparoscopic lymphocele treatment might be considered the therapy of choice, provided the iatrogenic lesions of the urinary tract diminish as more experience with this technique is gained. Received: 1 March 1999/Accepted: 1 July 1999     

Balloon-tipped cannulas for use in laparoscopic diagnosis and treatment of acute upper GI bleeding

Background: Percutaneous balloon-tipped laparoscopic cannulas designed for preperitoneal hernia repair can be readily used to treat gastric bleeding laparoscopically. Methods: Between 1995 and 1997, we successfully used balloon-tipped cannulas to visualize, biopsy, and suture acutely bleeding gastric lesions in five patients. These case histories are reviewed for this study. Results: Patients received an average of six units of blood preoperatively (range, 0–15). Operative time averaged 207 min (range, 149–270). At surgery, gastrotomies were made for cannula placement under laparoscopic visualization. Operative findings included: lesser curve gastric ulcer, Mallory-Weiss tear, prepyloric ulcer, duodenal ulcer, and angiosarcoma. Three patients had successful percutaneous suture of bleeding gastric lesions. One patient was converted to open surgery. One patient had local resection of an angiosarcoma. Conclusion: The laparoscopic use of balloon-tipped cannulas allows the expeditious diagnosis and treatment of acute gastric hemorrhage. Received: 31 March 1998/Accepted: 26 February 1999     

Laparoscopic repair of rectal prolapse

Background: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. Methods: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. Results: Median operation time was 255 min (range, 180–360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3–15) and median time off work was 14 days (range, 12–21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12–60 months). Conclusions: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated. Received: 30 April 1999/Accepted: 8 July 1999/Online publication: 22 May 2000     

Laparoscopic nephrectomy in childrenrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopic nephrectomy in the adult population is reported with increased frequency. We present our initial experience with laparoscopic nephrectomy in children. Methods: Over a 2-year period, 11 nephrectomies were performed in nine children aged 16 months to 16 years (mean, 6.5 years). All patients were referred due to complications of a nonfunctioning kidney. Seven patients had recurrent urinary tract infections, and two had refractory hypertension. Two patients underwent bilateral laparoscopic nephrectomy. The operation was performed using four access ports measuring 3.5 to 10 mm. Results: All kidneys were removed successfully using a laparoscopic technique. The average length of the operation was 163 min per kidney (range, 90–420). The estimated blood loss was <10–150 ml (mean, 45). No patient required transfusion. Seven patients were discharged home by postoperative day 2. The two patients with the longest operating times were discharged home on postoperative days 4 and 5 due to delay in return of bowel function. Narcotic use was minimal, and all patients enjoyed a rapid return to full activity. Conclusion: Laparoscopic nephrectomy is a viable alternative to open nephrectomy in children. Further experience with this technique is required to establish its efficacy and reduce the operating time Received: 29 April 1999/Accepted: 29 August 1999/Online publication: 17 April 2000     

Laparoscopic colectomy

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

Laparoscopic choledochotomy with primary closure

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     

Measurement of urinary N-acetyl-β-D-glucosaminidase to assess renal ischemia during laparoscopic operations

Background: Oliguria during laparoscopy is a well-documented phenomenon of unknown etiology. Experimental evidence suggests that renal perfusion is reduced during pneumoperitoneum. N-acetyl-β-D-glucosaminidase (NAG), which is present in renal tubular cells, is released into the urine in response to tubular insults. In this study, urinary NAG was measured before and after procedures to assess for ischemic renal injury. Methods: A total of 31 patients underwent laparoscopic procedures while 28 patients had conventional surgery. Urine was obtained first at the time of preoperative Foley catheter placement and later during the recovery room stay. NAG levels were measured and indexed to urinary creatinine. Results: Operative time for the laparoscopy group was 105 min (range, 15–255); for the conventional group, it was 179 min (range, 75–385) (P < 0.05). No differences were noted between pre- and postoperative NAG levels or between the groups. There was no correlation between urinary NAG levels and operative time. Conclusion: Pneumoperitoneum is not associated with a change in the urinary concentration of NAG. This finding suggests that there is no significant renal tubular injury associated with laparoscopic surgery. Accepted: 8 April 1997     

Laparoscopic vs open inguinal hernia repair

Background: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. Methods: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. Results: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p= 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p= 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5–14) days vs 14 (8–19) days (p= 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17–60) days vs 35 (20–56) days (p= 0.25). The return to work was not significantly different, median 14 (8–25) days after laparoscopic repair and 15 (11–21) days after open repair (p= 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. Conclusions. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly. Received: 23 May 1997/Accepted: 1 August 1997     

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

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

Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation

Background: This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia who have persistent or recurrent dysphagia following balloon dilatation. Methods: Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation, and heartburn (0 = none–3 = maximal) and esophageal manometry. Results: Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result, three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative complications. Median (IQR) postoperative stay was 3 (2–4) days. At 3-month reassessment, there was a reduction in the median dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery. Conclusions: Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have had previous balloon dilatation with complication and success rates similar to published results in patients who have not undergone previous dilatation. Received: 7 January 1998/Accepted: 22 June 1998     

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     

The laparoscopic management of post-transplant lymphocele

Background: The management of lymphocele in patients following kidney (KT) and kidney pancreas (KPT) transplants is evolving. Open surgery has been the traditional treatment, but some authors have advocated laparoscopic drainage in selected patients. Methods: We retrospectively reviewed our results in lymphocele treatment since developing a laparoscopic program at our institution. Results: Between May 1994 and June 1995, 186 KTs and 48 KPTs were performed, and 1,354 patients are currently being followed. Eight patients developed symptomatic lymphoceles an average of 26 months (range 4–59) following 6 KTs and 2 KPTs. All patients diagnosed were successfully drained laparoscopically, with no conversions to open surgery. Laparoscopic ultrasound was used to help with localization of the fluid collection. Operative time averaged 59 min, median hospital stay was 1 day (range 1–4), and there were no perioperative complications. Follow-up imaging was obtained on six patients, 3–16 months following their procedures, and no recurrences were noted. A review of the literature demonstrates a 5.3% rate of major complications and a 7% incidence of lymphocele recurrence. Conclusions: Intraoperative laparoscopic ultrasound can help localize fluid collections and prevent organ injuries. Laparoscopic drainage of lymphocele following transplantation results in minimal disability and an acceptable complication rate, although it is higher than with open drainage. Therefore, laparoscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphocele. Received: 15 March 1996/Accepted: 3 July 1996