Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the ``helping hand.' Received: 27 September 1996/Accepted: 19 November 1996     

Gastrointestinal problems in the immunocompromised host

As the immunocompromised patient population grows, the gastrointestinal surgeon is increasingly called upon to make complex diagnostic and therapeutic decisions. The surgeon should first identify the patient as immunocompromised and then categorize the probable degree of immunocompromise as mild, moderate, or severe. Mildly immunocompromised patients tend to present late and with minimal symptoms, but the disease entities are the same ones seen in the general population. Moderately and severely immunocompromised patients may also develop the usual surgical problems, but the differential diagnosis is expanded to include complications of the immunocompromised state or complications of the underlying problem which caused the immune compromise. The expanded differential diagnosis includes infections with atypical organisms, opportunistic neoplasms, neutropenic enterocolitis, complications of medications, and forms of biliary tract disease not seen in the general population. Advances in oncology, transplantation, and the treatment of AIDS, have extended the life expectancy of these patients and increased the immunocompromised population. Prompt appropriate operative therapy may be lifesaving when surgical complications develop. Received: 11 April 1996/Accepted: 1 May 1996     

Image-guided minimally invasive therapy

From its beginning surgical tomography developed rapidly. The possibility to identify every structure inside the body and to guide instruments with monitoring of tissue changes increase safety. Different therapies have been performed under CT and MRI guidance and evaluated in studies, like biopsies, tumor pain therapy and treatments of tumors as well as treatments of the spine. The results show that surgical tomography is an accurate guiding technique. Especially in combination with micro endoscopy offers a new way of surgery. The complication rate as well as the frequency of side effects is very low. Received: 9 September 1996/Accepted: 15 November 1996     

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis. Case history: A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation. Received: 12 April 1996/Accepted: 26 November 1996     

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

Background: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure. Received: 28 May 1996/Accepted: 25 July 1996     

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

Background: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. Methods: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. Results: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. Conclusions: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer. Received: 10 May 1996/Accepted: 19 November 1996     

Complications of surgical endoscopy

Background: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. Methods: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. Results: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. Conclusions: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications. Received 25 March 1996/Accepted: 24 April 1996     

Video-assisted thoracoscopic repair of an intercostal pulmonary hernia

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS). Received: 12 August 1996/Accepted: 26 November 1996     

Short-term outcome of laparoscopic paraesophageal hernia repair

Background: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). Methods: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. Results: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1.7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. Conclusions: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair. Received: 24 July 1996/Accepted: 20 November 1996     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996     

First trimester of pregnancy laparoscopic procedures

Laparoscopic procedures are being performed during pregnancy with increasing frequency; however, few first-trimester operations have been published. Two first-trimester procedures are here reported, both performed with uneventful recoveries. Received: 25 March 1996/Accepted: 24 January 1997     

Intraoperative ultrasound assessment in management of complex pancreatic pseudocysts

Preoperative imaging studies and operative inspection may provide insufficient information to appropriately manage certain complex pancreatic pseudocysts. Intraoperative ultrasound accurately identifies and localizes peripancreatic fluid collections, cyst wall thickness, parenchymal and ductal anatomy, and relationships to adjacent visceral and vascular structures. Adjunctive use of intraoperative ultrasonography altered the surgical management in the clinical case described herein and is advocated for assessment of problematic pancreatic pseudocysts. Received: 19 June 1996/Accepted: 27 October 1996     

Laparoscopic cholecystectomy in 1994

Background: In 1996, laparoscopic cholecystectomy is the gold standard for symptomatic cholelithiasis. The results of this operation as published so far include data on the learning curve of the method. The aim of this study is to evaluate the results of laparoscopic cholecystectomy when performed by a large number of surgeons during the year 1994, not taking into account the beginning years in which the technique was being used. Methods: This study has been carried out prospectively and anonymously among members of SFCERO. All the patients who underwent a cholecystectomy started laparoscopically during 1994 have been included. Results: Some 4,624 cholecystectomies were performed by 150 surgeons. There were 3,310 females (42.5 ± 19.8 years old) and 1,314 males (56.3 ± 1.61 years old). The conversion rate was 6.9%: 320 operations had to be converted into laparotomy (group II) while 4,261 were performed entirely by laparoscopy (group I). Morbidity was 5% (N= 230)—4.7% in group I (N= 203) and 8.4% in group II (N= 27). Mortality was 0.2% (N= 9)—namely four intraabdominal complications (three cases of peritonitis and one biliary reoperation), two cardiac failures, and one brain infarction. The causes of death were not specified in two patients. Conclusions: These results show that morbidity and mortality have not changed dramatically since the beginnings of this technique, whereas the frequency of common bile duct (CBD) injuries has decreased. However, the conversion rate has increased slightly. These results make it possible to calculate the risk of conversion and postoperative complication according to the age of the patient and the biliary symptoms. Received: 25 January 1996/Accepted: 10 April 1996     

Laparoscopic splenectomy for splenic hamartoma

Advances in imaging techniques have made preoperative diagnosis of splenic tumors possible. A case of successful laparoscopic splenectomy for splenic hamartoma is described here and the indications of this technique are discussed. Received: 12 January 1996/Accepted: 22 March 1996     

A murine model of laparoscopic-assisted intervention

Background: In order to better investigate the effects of laparoscopic surgery, it is necessary to establish reliable, reproducible, and economical animal models of laparoscopic intervention. Here we describe a mouse model of laparoscopic-assisted colon resection. Methods: After successful induction of anesthesia the mouse is placed in Trendelenburg position and the peritoneal cavity is insufflated with carbon dioxide gas through an angiocatheter placed in the right upper quadrant. A 4-mm rigid scope with camera attachment is then inserted through a midline port created just caudal to the xiphoid. A second port is then created in the right lower quadrant to allow introduction of laparoscopic forceps into the peritoneal cavity. The cecum, which extends 1.5 cm beyond the ileocecal valve, is grasped with forceps and exteriorized through the operative port. Extracorporeally, the cecum is ligated and resected before the cecal stump is returned to the peritoneal cavity. The abdominal wall defects are then stapled closed. Results: This simple model can be mastered by individuals with very limited surgical experience. This laparoscopic model has been used successfully in our laboratory in a number of experiments with an intraoperative complication rate of 3.2% (3/94), which was similar to the open surgery group rate of 2.1% (2/95, p= 0.99 by chi square). We observed no postoperative leaks in either group. The only postoperative death occurred in the open resection group due to dehiscence of the laparotomy wound. Conclusions: We propose that this model may be useful for comparing the effects of open to laparoscopic surgery. Received: 19 June 1996/Accepted: 2 November 1996     

The effects of sterile or infected bile and dropped gallstones in abdominal adhesions and abscess formation

Background: The effects of gallstones and sterile or infected bile on postoperative adhesions and abscess formation were investigated in Sprague Dawley rats. Methods: The first three groups were injected intraperitoneally with serum saline, sterile bile, or infected bile, respectively. Laparotomy was adjusted to the next seven groups. Serum saline, sterile bile, and infected bile were injected in the fourth through sixth groups intraperitoneally, respectively. Gallstones were placed intraabdominally to the seventh through ninth groups. The injections of sterile bile in group 7 and of infected bile in group 8 were added to laparotomies. Only laparotomy was carried out in group 10. Results: Abscess formations were seen only in infected-bile-injected groups. Significant adhesion formations were seen in infected-bile groups. Sterile bile and/or gallstones had no significant effect in abscess or adhesion formation. Conclusions: Results suggest that noninfected gallstones and sterile bile, even in combination, do not increase postoperative intraabdominal complications in rats. Received: 29 March 1996/Accepted: 26 August 1996     

Preemptive analgesia in the laparoscopic patient

Background: One hundred consecutive laparoscopic patients were prospectively followed in the Post-anesthesia Recovery Unit (PAR) in a community hospital. Methods: Data was collected regarding (1) intraoperative administration of ketorolac, (2) instillation of local anesthesia into the wound, and (3) requirements for analgesic administration in the PAR. Those patients receiving both forms of preemptive analgesia required less narcotic administration in the PAR. The results were highly significant. Results: Based on these data and the observance of markedly reduced pain in patients during the early postoperative period, an institutional plan of care was developed which has resulted in the virtual elimination of the need to administer narcotics to patients undergoing routine laparoscopic surgical procedures. Conclusions: The resultant plan of care, which includes preemptive analgesia, rapid ambulation, early feeding, and routine timed administration of non-narcotic pain medications, is presented. Data is also presented which demonstrates a more rapid discharge of patients from the hospital. Received: 5 April 1996/Accepted 2 November 1996     

A flower-shaped cannula for three-incision laparoscopic cholecystectomy

A simple flower-shaped cannula, in which up to three laparoscopic instruments can be inserted and manipulated freely, is described. Using this cannula, a three-incision gasless laparoscopic cholecystectomy can be performed easily. Received: 5 July 1996/Accepted: 12 September 1996     

Intraperitoneal adhesions in laparoscopic and standard open herniorrhaphy

Background: Intra-abdominal complications from transabdominal properitoneal (TAP) laparoscopic herniorrhaphy that would not be expected to occur in an open herniorrhaphy are possible. In a previous study, we reported the incidence of significant intra-abdominal adhesions from TAP herniorrhaphies using polypropylene in pigs. Methods: To compare this with an open herniorrhaphy technique, we performed open herniorrhaphies on 31 pigs. Additional animals underwent TAP herniorrhaphy with PTFE. Data were collected on operative and trocar-site adhesions. Graft incorporation was recorded. Results: No intra-abdominal adhesions were found in the 31 animals undergoing open herniorrhaphy. Fifteen adhesions were found in the 31 pigs that underwent TAP herniorrhaphy. These adhesions were graded and there were a total of nine significant adhesions with the TAP procedure. A total of 124 trocar sites resulted in two adhesions. Laparoscopically placed polypropylene was better incorporated than PTFE. The laparoscopically placed PTFE grafts commonly were poorly incorporated. Conclusions: We conclude that there is a risk of intra-abdominal adhesions to either the operative site or the trocar sites in TAP herniorrhaphy that is not present in open techniques. One should, therefore, be circumspect in the choice of TAP herniorrhaphy as a primary repair. Received: 8 April 1996/Accepted: 21 May 1996     

Videothoracoscopic resection of anterior mediastinal teratoma in a child

This report describes a case of anterior mediastinal teratoma in a 10-year-old girl, which was successfully resected thoracoscopically. Received: 4 October 1996/Accepted: 23 January 1997