Laparoscopic adhesiolysis: not for all patients,not for all surgeons,not in all centres

ASBO is a common cause of emergency surgery and the use of laparoscopy for the treatment of these patients is still under debate and conflicting results have been published, in particular regarding the high risk of iatrogenic bowel injury. In fact, although over the last few years there has been an increasing enthusiasm in the surgical community about the advantages and potential better outcomes of laparoscopic management of adhesive small bowel obstruction (ASBO), recently published studies have introduced a significant word of caution. From 2011 in our centre, we have started to systematically approach ASBO in carefully selected patients with a step-by-step standardized laparoscopic procedure, developed and performed by a single operator experienced in emergency laparoscopy, collecting data in a prospective database. Inclusion criteria were: stable patients (without diffuse peritonitis and/or septic shock with suspicion of bowel perforation), CT scan findings consistent with a clear transition point and therefore suspected to have a single obstructing adhesive band. Patients with diffuse SB distension in the absence of a well-defined transition point and suspected to have diffuse matted adhesions (based on their surgical history and radiological findings) should be initially managed conservatively, including gastrografin challenge. Up to date, 83 patients were enrolled in the study. The rate of iatrogenic full-thickness bowel injury was 4/83 (4.8%); two of these cases were managed with simple repair and the other two required bowel resection and anastomosis. Conversion to open was performed in 3/4 of these cases, whereas in one a repair of the full-thickness injury was completed laparoscopically. All the iatrogenic injuries were detected intraoperatively and none of the reoperations that occurred in this series were due to missed bowel injuries. At 30 days follow-up, none reported incisional hernias or SSI or death. With the described accurate selection of patients, the use of such standardized step-by-step technique and in the presence of dedicated operating surgeons with advanced emergency surgery laparoscopic expertise, such procedure can be safe and feasible with multiple advantages in terms of morbidity and LOS. A careful preoperative selection of those patients who might be best candidates for laparoscopic adhesiolysis is needed. The level of laparoscopic expertise can also be highly variable, and not having advanced surgical expertise in the specific subspecialty of emergency laparoscopy, ultimately resulting in performing standardized procedures with proper careful and safe step-by-step technique, is highly recommended.     

Paraoesophageal hiatus hernia: surgery for all ages.

The results of surgery for paraoesophageal hiatus hernia over a 10-year period have been studied. From a group of 26 symptomatic patients, elective repair has been undertaken in 20 (mean age of 65.6 years) and emergency repair in four (mean age of 73.1 years). Emergency surgery was associated with a fivefold increase in mortality, and anatomical repair gave a satisfactory result in 90% (CI 77-100) of survivors. Surgical treatment should be considered for all symptomatic patients with paraoesophageal hiatus hernia.     

老年人急性胆囊炎的腹腔镜手术治疗

目的:探讨腹腔镜手术治疗方法在老年人急性胆囊炎的临床疗效和安全性。方法:将2006年1月—2012年5月138例急性胆囊炎老年患者随机分成两组,分别行腹腔镜胆囊切除术(腔镜组,70例)和剖腹胆囊切除术(开腹组,68例),对比两组患者手术时间、肠功能恢复时间、住院时间、术后并发症。结果:腔镜组手术时间、肠功能恢复时间以及住院时间均短于开腹组(均P<0.05),两组术中出血量差异无统计学意义(P>0.05),腔镜组术后并发症明显少于开腹组(P<0.05)。结论:腹腔镜手术治疗方法在老年人急性胆囊炎中具有理想疗效,手术时机的选择与操作的熟练程度是治疗成功的关键。     

Laparoscopic cholecystectomy in patients with previous abdominal surgery.

BACKGROUND: Laparoscopic cholecystctomy has become the treatment of choice for symptomatic gallstones. The potential risks have dissuaded some surgeons from using the laparoscopic procedure in patients with previous abdominal surgery. Therefore, we aimed to investigate the effect of previous abdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: This study included 600 well-documented patients with gallstones who underwent laparoscopic cholecystctomy at our surgical department between May 2000 and January 2004. The patients were classified into 3 groups: group 1, patients without a history of previous abdominal surgery (n = 408); group 2, patients with a history of upper abdominal surgery (n = 92); group 3, patients with a history of lower abdominal surgery (n = 100). The data were collected and analyzed for open conversion rates, operative times, perioperative and postoperative complications, and hospital stay. RESULTS: Of the 600 study patients, 192 had undergone previous abdominal surgery (92 upper, 100 lower). Conversion rate, hospital stay, and complication rates were similar in each group. Mean operating time was the longest (57 +/- 9.8 min) in patients with previous upper abdominal surgery (P < 0.05). On the other hand, the operative time was similar in groups 1 and 3 (P > 0.05). CONCLUSION: Previous abdominal surgery is not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a prolonged operation time.     

Laparoscopic colon surgery for benign disease: a comparison to open surgery.

BACKGROUNDS AND OBJECTIVES: There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will hopefully answer this question. However, for benign diseases of the colon, we believe laparoscopic surgery offers many advantages including decreased postoperative pain, early discharge from the hospital, and early return to normal activities. We retrospectively reviewed our experience with laparoscopic colectomies for benign disease to see whether these procedures could be done safely and if the proposed advantages could be realized. METHODS: Thirty-eight laparoscopic colon resections performed for benign disease were compared to 39 open colon resections with respect to operating times, length of hospital stay, estimated blood loss, days until first postoperative bowel movement, and complications. RESULTS: The laparoscopic colon resection group had decreased length of stay, less blood loss, earlier return of bowel function, and an equivalent number of complications. Laparoscopic cases did take an average of 24 minutes longer. CONCLUSION: The use of laparoscopic colon surgery for benign disease not only affords the patient the advantage of the laparoscopic approach, but also allows the surgeon to gain experience while awaiting the results of ongoing trials for laparoscopic colon surgery in malignant disease.     

Laparoscopic surgery: an excellent approach in elderly patients

HYPOTHESIS: A review of the literature will show that laparoscopy is safe and effective for the treatment of surgical diseases in elderly patients. DATA SOURCES: An electronic search using the PubMed and MEDLINE databases was performed using the term laparoscopy in elderly patients. Literature published in the English language in the past decade was reviewed. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed. STUDY SELECTION: All relevant studies that could be obtained regardless of the study design were included. DATA EXTRACTION: All studies that contained material applicable to the topic were considered. Data on patient characteristics and surgical outcomes were abstracted. DATA SYNTHESIS: Sixteen studies evaluated laparoscopic cholecystectomy in the elderly. Compared with open cholecystectomy, elderly patients undergoing the laparoscopic procedure had a lower incidence of complications and a shorter hospitalization. In the 4 studies reporting the results of laparoscopic antireflux surgery in the elderly, the morbidity, mortality, and length of hospital stay were similar to those of younger patients. The elderly had equally good postoperative symptom relief. Ten reports of laparoscopic colon resection in the elderly demonstrated earlier return of bowel function, shorter hospitalization, and less cardiopulmonary morbidity. CONCLUSIONS: Despite underlying comorbidities, individuals older than 65 years tolerate laparoscopic procedures extremely well. Complications and hospitalization are lower than in open procedures. Surgeons need to inform primary care physicians of the excellent result of laparoscopic procedures in the elderly to encourage earlier referrals.     

老年人结直肠肿瘤的微创手术治疗

目的探讨腹腔镜结直肠手术治疗70岁以上老年人结直肠肿瘤的安全性与有效性. 方法回顾性总结2003年1～10月腹腔镜辅助与开腹结直肠手术治疗70岁以上老年人结直肠肿瘤的经验.同期比较腹腔镜手术(LAP组)30例与传统开腹手术(OPEN组)71例的手术安全性、并发症、术后恢复情况.结果 LAP组无手术相关死亡病例,OPEN组有2例(2.8%)分别因为术后肺部感染与吻合口瘘而死亡.两组病人随年龄增加ASA(american society of anesthesiology score)分级增高.OPEN组有29例(40.8%)发生术后并发症显著多于LAP组6例(20.0%)(P<0.05).LAP组病人术中出血、排气时间与进食半流质时间分别为(91.7±49.9)mL、(2.3±1.2)d与(4.9±1.8)d,与OPEN组(156.3±118.8)mL、(3.4±2.9)d与(5.8±1.2)d相比差异有显著性意义(P<0.05).两组手术时间与住院天数差异无统计学意义(P>0.05).结论腹腔镜结直肠手术治疗70岁以上老年人结直肠肿瘤安全有效,值得进一步推广应用.     

Laparoscopic surgery for pheochromocytoma

OBJECTIVE: To evaluate the feasibility of laparoscopic adrenalectomy for pheochromocytoma. MATERIAL: Between January 1998 and March 2002, 12 patients aged from 19 to 76 (average age 54 years) underwent 13 adrenalectomies (7 right and 6 left, 1 bilateral) using laparoscopic surgery. A specific anti-hypertensive preparation was begun prior to the operation. Peaks of blood pressure were treated by bolus Nicardipine and sinus tachycardia by bolus Esmolol. Catecholamines were dosed at different times during the intervention. As far as surgery was concerned, the adrenalectomies were performed 11 times using the transperitoneal route and twice using the retroperitoneal route. The adrenal vein was found and ligatured before manipulation of the adrenal gland. RESULTS: Average length of operation was 127 minutes (75 to 195). Average blood loss was 105 ml (0 to 1000). Catecholamines dosed throughout showed a variable increase in plasma rates during peritoneal insufflation and manipulation of the gland. They were responsible for 5 cases of hypertensive bouts and 2 cases of tachycardia which were treated with medication. No surgical conversions were necessary. Average length of hospital stay was 4.18 days (3 to 6); average size of adrenal tumours was 44 mm (30 to 72); average follow-up, 18.4 months. CONCLUSION: This study showed the feasibility of adrenalectomy for pheochromocytoma using laparoscopic surgery, subject to specific medical preparation to reduce the consequences of peroperative bouts of hypertension and sinus tachycardia during peritoneal insufflation and manipulation of the adrenal gland despite initial ligature of the main adrenal vein.     

Laparoscopic surgery for obesity

Bariatrics surgery has been a subject to a noteworthy revolution since the advent of the laparoscopic approach. This overview of the literature highlights on established scientific data in this field and the eventual evidence bases of laparoscopic surgery. Vertical banded gastroplasty and gastric bypass are now recognised as the gold-standards for the surgical treatment of morbid obesity by laparotomy. For the minimally invasive approach, the gastric banding appears now as a validated technique with a good level of evidence. The results of this approach appears to be comparable to those of other techniques (in terms of weight loss). But there is at present no randomized trial comparing the gastric banding with the gold-standards (gastric banding versus vertical banded gastroplasty). Some particular feature of this surgery are discussed (such as the association of a gastroesophageal reflux disease or a cholelithiasis). The criteria of patient's selection, the pre and post-operative management are also detailed in the light of literature data and guidelines of international societies.     

Laparoscopic surgery for female urinary incontinence: prudence shall prevail.

Advances in laparoscopic techniques continue to seek new domains and new indications with the sole objective of providing maximum benefit in a minimally invasive manner. During the last decade, several innovative laparoscopic procedures have evolved for the management of female urinary incontinence. At this juncture, prudence dictates a careful analysis of the principles behind and performance of these procedures so that our treatment recommendations for this common ailment can be based on unbiased scientific pragmatism. In this review, we attempt to analyze the available data and provide constructive criticism and recommendations toward the continued pursuit in this area of development in laparoscopy.     

腹腔镜下胆总管囊肿的手术治疗

目的 探讨在腹腔镜下胆总管囊肿切除、空肠切断及肠肠吻合、胆总管空肠Roux-en-Y吻合的可行性、安全性、技术特点及优势.方法 自2008年6月至2013年2月期间,对24例胆管囊肿行腹腔镜下病变胆管切除、空肠切断及肠肠吻合、胆总管空肠Roux-en-Y吻合.结果 24例患者均顺利完成手术.手术时间168 ～216 min,平均（168±24） min.术中出血40～ 120 ml,平均（60±33）ml.术后出现胆漏1例,无肠漏、无出血等.结论 腹腔镜下病变胆管切除、肠管切断及肠肠吻合、胆总管空肠Roux-en-Y吻合是安全、可行的,与开腹手术相比,有明显优势.     

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     

Laparoscopic surgery for pheochromocytoma

Because of the excessive production of catecholamines, surgery for pheochromocytoma carries a certain risk that can be reduced by accurate preoperative evaluation and by pretreatment with alpha-blockers. The authors' experience and that of other groups suggests that this inherent risk is not enhanced by the laparoscopic approach, and that, following successful surgery, patients benefit from the minimal invasiveness of this technique. Most surgeons recommend the transperitoneal approach that allows direct access to the adrenal vein, facilitating early ligation. This recommendation does not apply to other pathologies of the adrenal gland. Bilateral adrenal tumors are only seen in patients with familial pheochromocytomas. In this setting, adrenal-sparing surgery should be considered, which can also be performed laparoscopically. Previous adrenal surgery is not a contraindication but will render the procedure more difficult. Laparoscopic excision of paragangliomas is also technically feasible. Laparoscopic adrenal surgery for pheochromocytoma is a difficult and demanding task that must be performed by an experienced surgeon in cooperation with a team of specialists including an internist, endocrinologist, and anesthesiologist.     

Laparoscopic hand-assisted hepatic surgery.

At Ninewells Hospital, we have changed from total to hand-assisted laparoscopic hepatic resections. We report here our initial experience on 10 anatomic hepatic resections with good outcome, and 1 with a significant postoperative complication (fall in the hemoglobin) requiring laparotomy. All resections were undertaken by using the Omniport device (Advanced Surgical Concepts, Dublin, Ireland). The hand-assisted laparoscopic surgery (HALS)-Omniport approach has also been used selectively in 5 patients undergoing in situ ablation for bilateral metastatic disease with lesions not easily accessible to the total laparoscopic approach, ie, situated in the posterior and inferior segments of the right liver. The HALS approach has several advantages; it facilitates and expedites the procedure, reduces the stress factor to the surgeon, greatly improves exposure, and provides an immediate and efficient control of bleeding vessels with the internal hand. The Omniport device, which essentially consists of a handcuff with a spiral inflatable valve, enables withdraw and reinsertion of the hand without loss of pneumoperitoneum during the procedure. The device was effective in maintaining pneumoperitoneum in all cases. All operations were completed with the HALS approach.