Laparoscopic cholecystectomy. A recommendable indication in acute cholecystitis?

While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.     

Laparoscopic radical prostatectomy: The new gold standard?

Radical prostatectomy is the reference treatment for localized prostate cancer. The minimal invasive approach is gaining support in a large number of centers around the world because the laparoscopic approach seems to maintain the oncological control of open surgery with added benefits for the patient. In this paper, the main aspects of the different laparoscopic approaches, their benefits, difficulties, complications, and results are described and compared with the open radical prostatectomy. A critical review of the literature on radical prostatectomy comparing the open and laparoscopic techniques and the differences between each approach was done.     

Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication?

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.     

Laparoscopic cholecystectomy in situs inversus totalis: is it safe?

A 46-year-old woman with known situs inversus totalis and recent mitral valve replacement presented with nausea and vomiting. Ultrasonography demonstrated a left-sided microlithiasic gall-bladder. Laparoscopic cholecystectomy was performed successfully. The postoperative recovery was uneventful. The literature on this subject is reviewed.     

Laparoscopic adrenalectomy: alternative or new standard?

Laparoscopy has become a standard approach for adrenalectomy because of its safety, low invasiveness, and less demanding technical nature and the readily removable size of tumor through trocar incision. Comparative studies between open and laparoscopic adrenalectomy document less blood loss, shorter hospital stay, and lower incidence of complication. These reports also show that the patients have less pain, use fewer narcotics postoperatively, and have quicker resumption of oral intake after surgery with the laparoscopic approach. The techniques for laparoscopic adrenalectomy started with the transperitoneal approach and developed into the retroperitoneal approach. Further technical development and recognition yielded three transperitoneal and two retroperitoneal approaches. Characteristics of each approach are discussed. Due to technical developments and experiences in laparoscopic surgery, application of the laparoscopic approach has been expanded to include excision for adrenal cancer and laparoscopic partial adrenalectomy for bilateral pheochromocytoma in certain cases and in selected institutes.     

Laparoscopic nephrectomy: new standard of care?

OBJECTIVE: The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. METHODS: From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. RESULTS: Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars). CONCLUSION: The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.     

Laparoscopic cholecystectomy as a ‘session’ surgery

Aims: To introduce laparoscopic cholecystectomy to our Day Surgery Unit and assess the implications of a 6 h postoperative stay in unselected patients. Methods: A retrospective analysis of data was performed in which the case notes of a series of 170 consecutive patients undergoing day case laparoscopic cholecystectomy were studied. All patients with symptomatic gallstones were considered for day case laparoscopic cholecystectomy. Patients were excluded if there was major medical co-morbidity but not solely on the basis of age or Body Mass Index (BMI). Surgery was performed in a dedicated Day Surgery Unit and cholangiography was performed selectively. All patients were assessed at 6 h postoperatively for discharge and followed up by telephone at 24, 48 h and 2 weeks postoperatively. Results: Of 170 patients 121 (71.1%) were discharged at 6 h, 116 reported no problems and were satisfied with day case treatment. Two (1.6%) patients required a GP visit at home within 24 h and three (2.5%) patients required readmission. Forty-nine (28.9%) patients required admission, the commonest cause for admission being postoperative pain and nausea (10.6%) in approximately equal proportions. Three were admitted as they had open surgery. One patient required further surgical intervention (laparoscopy). Conclusion: Laparoscopic cholecystectomy as a ‘session’ surgery, with planned discharge 6 h after operation, is successful in the majority of unselected patients even though a significant number of overnight admissions are to be anticipated.     

Laparoscopic cholecystectomy after the learning curve: what should we expect?

Background: The introduction of laparoscopic cholecystectomy (LC) in the late 1980s was accompanied an increase in common bile duct (CBD) injuries. This retrospective analysis of 2,005 cholecystectomies performed at a single institution investigates the factors that have contributed to a record of zero CBD injuries in 1,674 consecutive LC. Methods: The medical records of 1,285 consecutive patients operated on from 7 July 1996 to 6 June 2003 were obtained. We also examined the peer review records of an additional 720 LC performed between 1 January 1990 and 7 July 1996. Results: There were no CBD injuries among 1,674 consecutive LC patients spanning the period since 1990. Of the 954 patients who underwent LC since 1996, six had a cystic duct leak and five had a duct of Luschka leak. Intraoperative cholangiography (IOC) was performed in 20.2% of cases (n = 193/954). Seventy of 157 patients who underwent cholangiography alone demonstrated one or more stones in the CBD (44.6%). In 40 patients (58.0%), endoscopic retrograde cholangio pancreatography (ERCP) was uniformly successful in clearing intraoperatively identified stones. In36.2% of cases, the stones were removed via laparoscopic CBD exploration (CBDE) (n = 25). In 5.8% of positive cases, the stones were removed via open CBDE (n = 4). Among 761 patients who did not undergo IOC, seven patients (0.92%) returned to the hospital for retained stones. Three of these patients had elevated liver function tests (LFT) preoperatively (1.3%) and four had normal LFT (1.1%). Conclusions: Injuries of the CBD can be avoided by performing an extensive dissection of the triangle of Calot and by developing a critical view of the operative field to ensure the patient’s safety during LC. If all LFT are normal and IOC is not performed, the occurrence of clinically significant stones postoperatively is minimal; in this group, only four patients had retained stones. Thus, in the face of normal LFT, routine IOC is unnecessary for a low CBD injury rate, and a return to the hospital for retained bile duct stones is rarely required, regardless of the number of times ductal stones are found on routine cholangiography. This implies that the significance of the stones discovered at IOC is questionable in most cases, thereby providing an argument against routine cholangiography. Most discovered CBD stones can be treated by ERCP, thus obviating the need for the T-tube drainage associated with CBDE. The 21st century finds LC to be a mature and safe surgical procedure.     

Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?

HYPOTHESIS: Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group. METHODS: Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.2%) from 1991 to 2001 at a teaching institution. Of these, 395 patients (6.7%) were older than 65 years. Analysis included patient age, sex, American Society of Anesthesiologists classification, conversion rate, morbidity, mortality, and assessment of results over time. RESULTS: Elderly patients were predominantly male (64%). Septuagenarians had a 40% incidence of complicated gallstone disease, such as acute cholecystitis, choledocholithiasis, or biliary pancreatitis, and octogenarians had a 55% incidence. Overall mortality was 1.4%. The conversion rate was 17% for the first 5 years of the study period and 7% for the second half. The conversion rate was 22% for patients with complicated disease and 2.5% for patients with chronic cholecystitis. Average hospital stay decreased from 10.2 days to 4.6 days during the first and second half of the study period, respectively. CONCLUSIONS: The results of LC in patients aged 65 to 69 years are comparable with those previously reported in younger patients. Patients older than 70 years had a 2-fold increase in complicated biliary tract disease and conversion rates, but a low mortality rate (2%) compared with results of other authors (12%), despite an increase in American Society of Anesthesiologists classification. Increased technical experience with LC favorably affected outcomes over time. Early diagnosis and treatment prior to onset of complications are necessary for further improvement in the outcomes of elderly patients undergoing LC.     

Laparoscopic cholecystectomy after a quarter century: why do we still convert?

Background  

Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon’s decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the “safe” alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.     

Laparoscopic radical prostatectomy. The Créteil experience

OBJECTIVES: In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency. METHODS: 200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogeneous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi-circumferential or a single circumferential running suture. RESULTS: All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night. CONCLUSIONS: Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.     

Laparoscopic repair of colonoscopic perforation: a new standard?

Background  

Scientific evidence demonstrating interest in the laparoscopic approach for surgical repair of colonoscopic perforations is still lacking. The authors retrospectively reviewed the records of 43 patients who suffered from colonic perforations after colonoscopy between 1989 and 2008 in two tertiary centers in order to compare the results of the laparoscopic and the open approaches to repair.     

Laparoscopic cholecystectomy: the anaesthetist’s point of view

Although the surgical advantages of laparoscopic cholecystectomy (LC) have been reported, the anaesthetic problems associated with this new technique have not been well described. For the first 101 patients undergoing laparoscopic cholecystectomy at our institution, we prospectively documented intraoperative critical observations and adverse outcomes in the PACU (Post-Anaesthetic Care Unit). In order to put the magnitude of these problems into perspective, we compared, in an identical manner, the anaesthetic management and outcomes of two more familiar surgical groups, cholecystectomy by laparotomy (C), and laparoscopy for gynaecological examination (LG). For this new procedure LC, intraoperative hypotension (12.9%), and PACU hypothermia (31.4%), nausea and vomiting (12.9%) and desaturation (10.9%) were common but excessive pain (4.0%) was rare. Patients undergoing C, who were older and less healthy, tended to have fewer incidents of OR hypotension (3.4%) but in the PACU experienced more desaturation (25.9%) and excessive pain (12.9%) (P < or = 0.05). The younger and healthier LG group had fewer problems, less OR hypotension (0.4%), and less PACU nausea and vomiting (5.7%) and desaturation (1.3%) (P < or = 0.05). However, the LG group had a similar incidence of excessive pain (4.4%). We have documented considerable postoperative anaesthetic benefits for patients undergoing laparoscopic cholecystectomy compared with conventional cholecystectomy. However, there is still considerable perioperative morbidity compared with gynaecological laparoscopies. Now that specific problems have been identified, they may be amenable to specific anaesthetic interventions.     

Laparoscopic Vertical Sleeve Gastrectomy for Morbid Obesity. The Future Procedure of Choice?

I report the general experience of performing sleeve gastrectomy defined as “a partial gastrectomy that results in removal of most of the stomach,” as a first-stage procedure for morbidly and super-obese people. I also explore its potential as a single procedure evaluating its advantages and disadvantages. This procedure is designed to reduce the size of the stomach and its distention, whereby the patient feels full sooner and their appetite is decreased. Some posit-increased satiety results from the decreased ghrelin, secreted by the fundus, which is resected during this procedure. The advantages of sleeve gastrectomy are as follows: the stomach is reduced without loss of function, pyloric preservation prevents dumping, it requires only 1 day in the hospital, it provides an effective first-stage procedure for super-obese patients, it is useful in patients with disorders such as anemia or Crohn's disease, which preclude intestinal bypass, it can be performed laparoscopically, even in patients who weigh over 500 lbs, no band adjustment is required, it does not result in malabsorption, and it provides a good educational teaching base for doctors lacking experience in the treatment of gastric ulcers. The disadvantages include the risk of stapling complications and its irreversibility.     

Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide contraindicated?

Since it has been suggested that the use of nitrous oxide (N2O) may contribute to bowel distention, we evaluated the effects of N2O on operating conditions during laparoscopic cholecystectomy in 50 healthy patients using a double-blind protocol design. All patients received the same preanesthetic medication (midazolam, 2 mg intravenously) and induction of anesthesia consisted of intravenously administered fentanyl 1.5 micrograms.kg-1, thiopental 4-6 mg.kg-1, and a nondepolarizing muscle relaxant. For maintenance of anesthesia, patients were randomly assigned to one of two treatment groups: group 1 (n = 26) received isoflurane with 70% N2O in oxygen (O2), whereas group 2 (n = 24) received isoflurane in an air/O2 mixture. The surgeon (blinded to the anesthetic technique) estimated the degree of technical difficulty before beginning the operation using a five-point scale. At 15-min intervals throughout the operation, the surgeon was asked to evaluate both "overall operating conditions" and degree of "bowel distension" using independent five-point scales. At the end of the operation, the surgeon was asked whether or not N2O had been used as part of the anesthetic technique. There were no significant intraoperative differences between the two groups with respect to operating conditions or bowel distension. More importantly, there was no time-related change in either variable during the course of the operation. Finally, the incidence of postoperative nausea and vomiting was similar in both treatment groups. The surgeon was able to correctly determine that N2O had been administered only 44% of the time. Thus, N2O had no clinically apparent deleterious effects during laparoscopic cholecystectomy.