Laparoscopic colorectal surgery

Background: A variety of parameters can affect the outcome of laparoscopic colorectal surgery. All consecutive laparoscopic colorectal procedures (LCP) were analyzed in an attempt to define an operative time curve for different categories of procedures. Additionally, impacts of case number and procedure type on length of procedure were assessed. Methods: Our computerized data system was reviewed for all patients who underwent LCP in a 4-year period. Parameters reviewed included age, sex, surgical indications, procedures performed, length of procedure, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and hospital stay. Results: Between August 1991 and December 1995, 175 patients with a mean age of 48.4 (range 15–88) years underwent LCP. Patients were divided chronologically into five consecutive groups. Procedures were classified as either basic or complex. Complex procedures were those in which there was either a fixed tumor, an abscess or fistula, or extensive intraabdominal adhesions from prior surgery. Complex procedures performed each year ranged from 37% to 66%. As well, the percentage of patients with adhesions increased from 17% in 1991 to 29% in 1995. Despite increased difficulty, the intraoperative complication rate fell significantly from 29% in 1991 to 8% in 1995 (p < 0.005). Additionally, the operative length decreased from a mean of 201 min in 1991 to a mean of 141 min in 1995 (p < 0.05). Conclusion: The rapid improvement in these parameters may reflect both ascents in the learning curve and change in type of procedure. Adhesions, due to prior surgery or inflammation making dissection tedious, is the most important technical factor which effects operation time (p < 0.001). However, despite increased complexity, operating time decreased, reflecting improved skills. Thus, the experienced laparoscopic surgeon can increase the spectrum of applications with expectations of shorter operations and lower complication rates. Received: 14 March 1996/Accepted: 31 July 1996     

Indications for laparoscopic colorectal surgery

Background: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. Methods: Our main aim was to define more specifically the indications for laparoscopic colectomy. Results: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. Conclusions: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20–50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting. Received: 1 November 1996/Accepted: 1 July 1997     

Early international results of laparoscopic gastrectomies

Background: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. Methods: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. Results: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. Conclusions: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience. Received: 7 August 1996/Accepted: 28 October 1996     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

A three-trocar technique for limited laparoscopic renal surgery

Laparoscopic renal surgery usually involves the use of five or six trocars. This report concerns the authors' technique for performing such surgery through only three trocars. Semilateral patient positioning, along with additional table rotation, is utilized to facilitate visceral rotation and optimize exposure of the kidney. Four laparoscopic renal procedures were performed: one renal cyst decortication and three upper pole partial nephrectomies with ureterectomies for duplications of the collecting system. Mean operative time was 148 min with no conversions; there were no intra- or postoperative complications. All patients tolerated a liquid diet on postoperative day 1, and the median hospital stay was 2 days. In selected cases laparoscopic renal surgery may be approached safety through three trocars. Received: 29 March 1996/Accepted: 1 July 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     

Duration of postlaparoscopic pneumoperitoneum

Background: Patients who present with abdominal pain after recent laparoscopic surgery present a diagnostic dilemma when pneumoperitoneum is present. Previous studies do not define the duration of postlaparoscopic pneumoperitoneum. In this study, we attempted to define the duration of laparoscopic pneumoperitoneum and to identify factors which affect resolution time. Methods: We followed 57 patients who underwent laparoscopic cholecystectomy (34), inguinal herniorraphy (20), or appendectomy (three). Serial abdominal films were taken until all residual gas was resolved. Results: Thirty patients resolved their pneumoperitoneum within 24 h; 16 patients resolved between 24 h and 3 days; nine patients resolved between 3 and 7 days; two patients resolved between 7 and 9 days. Mean resolution time for all patients was 2.6 ± 2.1 days. There was no apparent difference in resolution time between the three types of procedures; however, the sample size may be insufficient. Duration of the pneumoperitoneum did not correlate with gender, age, weight, initial volume of CO₂ used, length of time for the procedure, or postoperative complications. Sixteen patients had bile spillage during cholecystectomy which significantly reduced the duration of postoperative pneumoperitoneum (p < 0.008), resulting in a mean resolution time of 1.3 ± 0.9 days. While 14 patients reported postoperative shoulder pain, no correlation was found between the presence or duration of shoulder pain and the extent or duration of pneumoperitoneum. Conclusions: We conclude that the residual pneumoperitoneum following laparoscopic surgery resolves within 3 days in 81% of patients and within 7 days in 96% of patients. The resolution time was significantly less in patients sustaining intraoperative bile spillage during cholecystectomy. There was no correlation found between postoperative shoulder pain and the presence or duration of the pneumoperitoneum. Received: 22 March 1996/Accepted: 12 July 1996     

Laparoscopic liver surgery

Background: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the ``four-hands technique' for simultaneous dissection and control of bleeding and bile ducts during resections. Received: 10 May 1996/Accepted: 26 July 1996     

Intracorporeal colorectal anastomosis following laparoscopic left colon resection

Background: The aim of this study was to assess the impact of an intracorporeal double-stapled colorectal anastomosis upon the outcome of laparoscopic left colon resection. Methods: Fifty-four selected patients underwent elective laparoscopic left colon resection for benign disease. Once resection was completed, a 33-mm suprapubic port allowed insertion of the anvil of a circular stapler into the colon, which was closed by a handsewn purse-string suture using the T-needle technique. The circular stapler was passed transanally to perform a double-stapled anastomosis. Specimens were delivered in a plastic bag via the suprapubic port. Results: There were no deaths. Minor intraoperative and postoperative complications occurred in 3.7% and 9.2% of the patients, respectively. Median operating time was 125 min (range 80–210 min). Complete proximal and distal doughnuts were obtained in all patients and anastomoses were all methylene blue tight. Median hospital stay was 4 (range 3–7) days. Conclusions: Fashioning double-stapled colorectal anastomoses intracorporeally is feasable and safe. Received: 26 March 1996/Accepted: 9 September 1996     

Postoperative pain and fatigue after laparoscopic or conventional colorectal resections

Background: Conventional colorectal resections are associated with severe postoperative pain and prolonged fatigue. The laparoscopic approach to colorectal tumors may result in less pain as well as less fatigue, and may improve postoperative recovery after colorectal resections. Methods: Sixty patients were included into a prospective randomized trial to determine the influence of laparoscopic (n= 30) or conventional (n= 30) resection of colorectal tumors on postoperative pain and fatigue. Major endpoints of the study were dose of morphine sulfate during patient-controlled analgesia (PCA), visual analog scale for pain while coughing (VASC), and visual analogue scale for fatigue (VASF). Efficacy of pain medication was assessed by visual analogue score at rest (VASR). Results: Preoperative age, sex, stage, and localization of tumors were comparable in both groups. The PCA dose of morphine given immediately after surgery until postoperative day 4 was higher in the conventional group (median, 1.37 mg/kg; 5–95 percentile 0.71–2.46 mg/kg) than the laparoscopic group (0.78 mg/kg; 0.24–2.38 mg/kg, p < 0.01). Postoperative VASR was comparable between both groups, but VASC was higher from the first to the seventh postoperative day (p < 0.01). Postoperative fatigue was higher after conventional than after laparoscopic surgery from the second to the seventh day (p < 0.05). Conclusions: This study confirms that analgetic requirements are lower and pain is less intense after laparoscopic than after conventional colorectal resection. Patients also experience less fatigue after minimal invasive surgery. Because of these differences, the duration of recovery is shortened, and the postoperative quality of life is improved after laparoscopic colorectal resections. Received: 4 July 1997/Accepted: 16 November 1997     

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     

Results of the routine use of a modified endoprosthesis to drain the common bile duct after laparoscopic choledochotomy

Background: One hundred eighty-one patients were submitted to laparoscopic common bile duct exploration. Methods: A transcystic approach was used in 147 patients, choledochotomy in 14, and both in 20. The indications to perform a choledochotomy included stones larger than 20 mm, stones proximal to the cystic duct entrance, and cases in which the transcystic duct approach proved impossible or unsuccessful. Results: The common bile duct was drained by a T-tube in four patients, by laparoscopic sphincterotomy in one, by laparoscopic choledochoduodenostomy in one, and by a 10 Fr endoprosthesis in 28. The stent placement was technically feasible in all patients but one. The biliary drainage was adequate. Mean hospital stay was 2.1 days. Complication was limited to one umbilical infection and one self-limited biliary leak. Conclusions: The procedure proved to be technically simple, safe, and efficient, and resulted in a low morbidity rate and short hospital stay. Received: 29 March 1996/Accepted: 12 June 1996     

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     

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh

Background: Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques. Methods: A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays. Results: The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05). Conclusions: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay. Received: 22 December 1997/Accepted: 18 August 1998     

Laparoscopic interval appendectomy for periappendicular abscess

Background: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. Methods: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8–10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. Results: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. Conclusion: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay. Received: 13 May 1999/Accepted: 9 December 1999/Online publication: 12 July 2000     

Laparoscopic creation of stomas

Background: Some indications for laparoscopic bowel surgery are still controversial. However, the use of laparoscopic techniques for the treatment of benign disorders is less often challenged. Moreover, the morbidity of nonresectional procedures is less than that encountered with resectional cases. Therefore, stoma creation seems ideally suited to laparoscopy. The aim of our study was to assess the outcome of laparoscopic stoma creation. Methods: All patients who underwent laparoscopic intestinal diversion were evaluated; parameters included age, gender, indication for the procedure, history of previous surgery, operative time, length of hospitalization, recovery of bowel function, and postoperative complications. Results: Between March 1993 and January 1996, 32 patients of a mean age of 42.2 (range 19–72) years (14 males, 18 females) underwent elective laparoscopic fecal diversion (25 loop ileostomy, four loop colostomy, three end colostomy). Indications for fecal diversion were fecal incontinence (n= 11), Crohn's disease (n= 6), unresectable rectal cancer (n= 4), pouch vaginal fistula (n= 3), rectovaginal fistula (n= 2), colonic inertia (n= 2), radiation proctitis (n= 1), anal stenosis (n= 1), Kaposi's sarcoma of the rectum (n= 1), and tuberculous fistula (n= 1). Conversion was required in five patients (15.6%) due to the presence of adhesions (three), enterotomy (one), or colotomy (one). All of these five patients had undergone previous abdominal surgery and were operated on early in our experience. Major postoperative complications occurred in two patients (6%) and in both cases consisted of stoma outlet obstruction after construction of a loop ileostomy. One of the two patients had undergone prior surgery. This patient required reoperation, at which time a rotation of the terminal ileum at the stoma site was found. The other patient had a narrow fascial opening which was successfully managed with 2 weeks of self-intubation of the stoma. The mean operative time was 76 (range 30–210) min; mean length of hospitalization was 6.2 (range 2–13) days; stoma function started after a mean of 3.1 (range 1–6) days. Patients with previous abdominal surgery had a longer mean operative time (14/32; 117 min) compared to patients who had no previous surgery (18/32; 55 min) (p < 0.0002). These longer operative times and hospital stay were attributable to extensive enterolysis, which was required in some cases. Conclusion: In conclusion, laparoscopic creation of intestinal stomas is safe, feasible, and effective. Although the length of the procedure is longer in patients who have had prior surgery, previous surgery is not a contraindication, and even in these cases, a laparotomy can be avoided in the majority of patients. Lastly, care must be taken to ensure adequate fascial opening and correct limb orientation. Received: 25 March 1996/Accepted: 21 May 1996     

A 3-year experience with laparoscopic gastric banding for obesity

Background: The introduction of laparoscopic techniques—especially that of gastric banding—and the fact that conservative management does not provide satisfactory long-term results in patients with morbid obesity has resulted in a marked increase in the demand for bariatric surgery in our department since 1995. In this paper, we present our experience during the first 3 years with this approach. Methods: Data for all patients who had bariatric surgery at our institution were collected prospectively. They were analyzed for the purpose of this study. Results: A total of 150 patients were operated on between December 1995 and December 1998 (37 months). There were 130 women and 20 men, with a mean age of 37.5 years (range, 19–62). The mean initial excess body weight was 102.9% (range, 58–191%), and the mean initial body mass index (BMI) was 44.6 kg/m² (range, 35.1–64.1). A Lapband was used in 101 cases and a SAGB in 47 cases. In two patients in whom conversion was necessary, we performed a vertical banded gastroplasty. Duration of surgery decreased over time from 210 min (first 20 cases) to 73 min (last 20 cases). Six patients (4%) developed major complications, one of whom died. The median duration of postoperative hospital stay was 3 days. The mean follow-up was 17 months. In all, 24 patients (16%) developed late complications, and 22 (14.6%) required reoperation, mainly for band slippage and/or pouch dilatation (14 cases). An incorrect surgical technique used for the first 30 patients (Lapband within the lesser sac) was responsible for more than half of these complications. The mean excess weight loss was 34% at 6 months, 55% at 1 year, and 56% at 2 years. Compared to vertical banded gastroplasty (197 cases between 1981 and 1995), postoperative morbidity was greatly decreased, late morbidity was similar, and weight loss was equivalent. Conclusions: Laparoscopic gastric banding is followed by a weight reduction that is similar to that observed after vertical banded gastroplasty, with a much lower postoperative morbidity, a shorter hospital stay, and an earlier resumption of normal activities. If these results can be confirmed by long-term follow-up, laparoscopic gastric banding will be confirmed as the restrictive procedure of choice for morbid obesity. Received: 20 July 1999/Accepted: 16 December 1999/Online publication: 8 May 2000     

Resolving gastroesophageal reflux with laparoscopic fundoplication

Background: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting. Methods: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures. Results: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases. Conclusions: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications, operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be successfully transferred from academic medical centers to the community hospital setting. Received: 7 October 1996/Accepted: 14 May 1997     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

Laparoscopic colorectal anastomosis: risk of postoperative leakage

Background: We report on a prospective observational multicenter study of more than 1,000 consecutive patients undergoing laparoscopic colorectal procedures. The aim of the current study was to investigate the safety of laparoscopic colorectal surgery as reflected by the anastomotic insufficiency rates in the various sections of the bowel, and to compare these rates with those of open colorectal surgery. Methods: The study was begun on August 1, 1995. Twenty-four centers in Germany, Austria, and Switzerland participated in this prospective multicenter study. All patients undergoing laparoscopic colorectal surgery were included in the study. No selection criteria were applied, which means that every operation begun as a laparoscopic procedure was included. Data on patient demographics, surgical indications, surgical course, and patient outcome were recorded prospectively in a computer database. All data were rendered anonymous. Results: Between August 1995 and February 1998, the 24 participating centers treated 1,143 patients (male/female ratio, 1:1.36; mean age, 60.7 years). In all, 626 operations were performed for benign indications and 517 for cancer. Most procedures involved the sigmoid colon and rectum (80.9%). An anastomosis was performed in 83% of the operations. Most of the anastomoses were laparoscopically assisted using the stapling technique. We observed an overall leakage rate of 4.25% (colon 2.9%; rectum 12.7%), and surgical reintervention was required in 1% of the cases. The rate of conversion to open surgery was 5.6%. Intraoperative complications occurred in 5.9%, and reoperation was necessary in 4.1% of the cases. The overall morbidity rate was 22.3%, and the 30-day mortality rate was 1.57%. Conclusions: The feasibility and safety of the laparoscopic colorectal approach is demonstrated clearly. The current study shows that the laparoscopic or laparoscopically assisted approach to colorectal surgery is not associated with a higher risk of anastomotic leaks. Morbidity and mortality rates with this method approximate those seen with conventional colorectal surgery. Received: 24 August 1998/Accepted: 25 November 1998