The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review

Background  Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions. Methods  A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease. Results  The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. Conclusions  The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

The role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. This study aim was a critical examination of the available literature on the role of laparoscopy for the diagnosis and treatment of acute intraabdominal conditions. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. This review examines the role of diagnostic laparoscopy for acute nonspecific abdominal pain, trauma, and the acute abdomen experienced by the critically ill patient. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of diagnostic laparoscopy to determine acute intraabdominal conditions are provided.     

THE CASE FOR LAPAROSCOPIC ADRENALECTOMY

PURPOSE: The current status of laparoscopic adrenal surgery was assessed. MATERIALS AND METHODS: A current MEDLINE search revealed 308 articles pertaining to laparoscopic surgery of the adrenal gland. Based on this literature review laparoscopic surgical anatomy, current indications and contraindications, and laparoscopic techniques were identified. The role of laparoscopic surgery for various adrenal disorders, including aldosteroma, pheochromocytoma, Cushing's syndrome, incidentaloma and adrenal cancer, were evaluated. Studies specifically comparing open versus laparoscopic adrenalectomy and the financial implications of laparoscopy were evaluated. Furthermore, newer advances in the minimally invasive management of surgical adrenal disease were identified. RESULTS: Available data from multiple institutions imply that laparoscopic adrenal surgery is safe and efficacious for aldosteroma, pheochromocytoma, Cushing's disease and incidentaloma. Compared to open surgery laparoscopy provides equally effective treatment, while minimizing patient morbidity. Laparoscopic adrenalectomy is financially superior to open adrenalectomy. For adrenal cancer open surgery currently remains the treatment of choice. CONCLUSIONS: In the majority of patients with surgical adrenal disease except those with adrenal cancer laparoscopy may now be considered an established treatment modality.     

Laparoscopy alone is superior to peritoneal cytology in staging gastric and esophageal carcinoma

Background Laparoscopy identifies metastatic disease in patients with upper gastrointestinal malignancies; however, it has been suggested that cytological examination of peritoneal washings may increase the diagnostic yield. We hypothesize that the addition of cytologic washings to a standardized staging laparoscopy is unnecessary for the identification of intraabdominal metastasis in patients with gastric/esophageal cancer.Methods Forty patients with gastric/esophageal cancer were prospectively evaluated. Patients successfully underwent a diagnostic laparoscopy protocol (with biopsies) during which peritoneal washings were obtained and processed for cytologic analysis. Laparoscopic versus cytologic identification of intraabdominal metastasis were compared.Results Forty patients successfully completed laparoscopy with collection of peritoneal washings. Laparoscopic examination of the peritoneal cavity upstaged 21 (52.5%) patients. Laparoscopic examination consistently identified a statistically significant higher number of positive patients than cytologic examination of peritoneal washings (p = 0.001) and examination of cytologic washings alone failed to identify 45% of patients with positive findings and laparoscopy. The addition of cytologic examination added no additional stage IV patients to the laparoscopy-negative group.Conclusion A standardized laparoscopic examination alone is sufficient for the identification of intraabdominal metastatic disease in patients with gastric and esophageal cancer.Paper presented at the ninth World Congress of Endoscopic Surgery/Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003     

诊断性腹腔镜手术在急腹症诊治中的应用

诊断性腹腔镜手术是用于诊断腹腔内疾病的一种微创方法。（1）可以直接观察腹腔各脏器表面的改变;（2）获取活检标本、抽吸腹腔积液及进行细菌培养;（3）借助腔镜超声行腹腔脏器的进一步探查;（4）必要时可行腹腔镜下治疗。急症情况下诊断性腹腔镜手术主要用于急性非特异性腹痛、外伤以及重症病人的腹痛。     

Laparoscopy and its current role in the management of colorectal disease

Objective To evaluate the current place of laparoscopy in the management of colorectal disease. Method A literature search was undertaken on Medline between the period 1991 and 2002. Results From the literature there is good evidence that the laparoscopic approach is associated with at least some short‐term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long‐term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter‐saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions. Conclusion The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.     

Effect of pneumoperitoneum on renal perfusion and function: A systematic review

Background The precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function. Methods A literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings—renal blood flow, pneumoperitoneum, renal function, and laparoscopy—were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles. Results The literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum. Conclusion There appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.     

The Role of Staging Laparoscopy in Hepatobiliary Malignancy: Prospective Analysis of 401 Cases

Background:Patients with potentially resectable hepatobiliary malignancy are frequently found to have unresectable tumors at laparotomy. We prospectively evaluated staging laparoscopy in patients with resectable disease on preoperative imaging.Methods:Staging laparoscopy was performed on 410 patients with potentially resectable hepatobiliary malignancy. The preoperative likelihood of resectability was recorded. Data on preoperative imaging, operative findings, and hospital course were analyzed.Results:Laparoscopic inspection was complete in 291 (73%) patients. In total, 153 patients (38%) had unresectable disease, 84 of whom were identified laparoscopically, increasing resectability from 62% to 78%. On multivariate analysis, a complete examination, preoperative likelihood of resection, and primary diagnosis were significant predictors of identifying unresectable disease at laparoscopy. The highest yield was for biliary cancers, and the lowest was for metastatic colorectal cancer. In patients with unresectable disease identified at laparoscopy, the mean hospital stay was 3 days, and postoperative morbidity was 9%, compared with 8 days and 27%, respectively, in patients found to have unresectable disease at laparotomy.Conclusions:Laparoscopy spared one in five patients a laparotomy while reducing hospital stay and morbidity. Targeting laparoscopy to patients at high risk for unresectable disease requires consideration of disease-specific factors; however, the surgeons preoperative impression of resectability is also important.     

Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience.

BACKGROUND: Frequently, critically ill patients suffer from intraabdominal pathology, such as sepsis or ischemia, either as a cause of a critical illness or as a complication from another illness requiring an intensive care unit (ICU) admission. These complications are associated with high rates of morbidity and mortality (between 50% to 100%). The diagnosis of these problems can be difficult in these very ill patients because it may require transport of unstable patients to additional departments outside the ICU setting. One option in the diagnosis of these difficult patients is bedside laparoscopy, as it avoids patient transport, is very accurate, and maintains ICU monitoring. METHODS: From 1991 to 2003, 13 patients underwent bedside diagnostic laparoscopy in the ICU to diagnose intraabdominal pathology in critically ill patients. All the procedures were done at the bedside in the ICU with the patient under local anesthesia and intravenous sedation. RESULTS: Mean procedure time was 36 minutes (range, 17 to 55). Mean patient age was 75.5 years (range, 56 to 86). There were 8 males and 5 females. Forty-six percent of the patients were diagnosed with mesenteric necrosis and died within 48 hours with no further testing or procedures. One patient with massive fecal contamination died the same day. Thirty percent of patients had a normal intraabdominal examination; of these, 2 died of unrelated illnesses and 2 survived their nonabdominal illness. Fifteen percent were diagnosed with acute acalculous cholecystitis as a complication of their ICU illness, which resolved satisfactorily. No intraoperative complications occurred with the ICU procedure. CONCLUSION: Bedside diagnostic laparoscopy in the ICU is feasible, safe, and accurate in the assessment of possible intraabdominal problems in properly selected, critically ill patients.     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Background contextThe evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeProvide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsSixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

Fewer adhesions induced by laparoscopic surgery?

Background Laparoscopic surgery has potential theoretical advantages over open surgery in reducing the rate of adhesion formation, but very few comparative studies are available to prove this.Methods A literature search was performed within Medline and Cochrane databases using the key words: adhesion*, adhesiolysis, laparoscop*, laparotomy, open surgery. Further articles were identified from the reference lists of retrieved literature. Both clinical and experimental studies comparing laparoscopy and laparotomy with regard to adhesion formation were retained. In each article, the rates of adhesion formation were identified or deduced for the operative site, access wound site, and distant sites.Results Fifteen studies from 1987 to 2001 were identified. Most studies assessed the operative site. Thus, three clinical studies and six experimental ones found fewer adhesions following laparoscopy than laparotomy, while other five experimental studies found similar adhesion rates for the two surgical methods. There were fewer adhesions to trocar wounds than to the laparotomy wounds in seven studies and equal rates of adhesion in one study. The problem of distant adhesions is poorly represented in literature; three studies favored laparoscopy as being followed by fewer adhesions. Because of the important differences between studies with regard to the design, end points, and statistical calculations, a metaanalysis could not be achieved. The conclusion is based on the prevalence of evidence.Conclusions All clinical studies and most of the experimental studies found a reduction of adhesion formation after laparoscopic surgery compared to open surgery.     

Laparoscopy,computerised tomography and fluorodeoxyglucose positron emission tomography in the management of gastric and gastro-oesophageal junction cancers

Background

The staging laparoscopy has been used in the management of gastrointestinal cancers. The aim of this study was to evaluate the role of staging laparoscopy, in comparison with computed tomography (CT) and fluorodeoxyglucose positron emission tomography (FDG-PET) imaging in staging patients with gastro-oesophageal junction (GOJ) and gastric cancers.

Methods

The data were collected for patients between 1996 and 2013 undergoing investigation and treatment for GOJ and gastric cancers at a single institute. The pre-operative data (staging data), intraoperative details, post-operative course and follow-up were analysed for individual cases.

Results

Staging laparoscopy altered management plan in 64 (17 %) of 387 patients with negative staging CT and FDG-PET scan. Twenty-seven (7 %) patients with GOJ cancer (types I, II and III) were identified with pathological intraperitoneal nodes, 15 (4 %) gastric cancer with metastatic intraperitoneal deposits and liver metastases and 3 % gastric cancers with positive ascitic fluid for cancer cells. Ten (3 %) of patients were downstaged and were offered curative resection. Patients with metastatic disease were referred for palliative chemotherapy. The overall sensitivity of staging laparoscopy in diagnosing intraabdominal pathology was 86 % in comparison with CT (81 %) and FDG-PET (78 %).

Conclusions

The diagnostic laparoscopy is useful for detecting and confirming nodal involvement and distant metastatic disease not evident on the staging CT scan and FDG-PET. This could potentially alter treatment and prognosis in patients with upper gastrointestinal cancer. The diagnostic laparoscopy should be performed as part of investigation and treatment planning for patients suffering from GOJ and gastric cancers. This can help to avoid surgery in patients with advanced disease.

     

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

Background contextThe objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeTo provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.Study designSystematic review and evidence-based clinical guideline.MethodsThis guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsTwenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.ConclusionsThe clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

Laparoscopy for nonpalpable testes

Purpose

Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes.

Methods

Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated.

Results

Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy.

Conclusions

The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration.     

Vacuum-assisted abdominal wall lift for minimal-access surgery: a porcine model study

Carbon dioxide pneumoperitoneum, although used universally in laparoscopy, has several well-documented complications and disadvantages. The authors describe a simple method of creating vacuum between a rigid shell and the abdominal wall in a porcine model to create adequate operative space for minimal-access surgery, which does not requires carbon dioxide, does not raise intraabdominal pressure, and is safe, cost effective, and feasible. The proposed device and method could be useful wherever basic laparoscopic equipment and a vacuum pump are available, including many parts of the developing world. The study was carried out with three groups using individual porcine models for each study. Group 1 was studied for feasibility of abdominal wall lift, adequacy of intraabdominal space, optimal vacuum levels, and safety and efficacy of the procedure. Group 2 was subjected to laparoscopic cholecystectomy and salpingectomy. Group 3 was studied for 2 days and 8 days after the animals were subjected to prolonged, high-level vacuum and monitored every 24 h to establish long-term effects. In all three groups the safety and efficacy of the proposed method were established, as well as the absence of physiological or histological alterations.     

Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria

OBJECTIVE: The literature on unruptured intracranial aneurysms is reviewed, and an attempt is made to stratify it according to the weight of the evidence. Recommendations for surgery are suggested, using evidence-based criteria. METHODS: A MEDLINE search was performed for 1966 to 1999. The focus was restricted to surgical management rather than other types of management, such as endovascular treatments. Each article was classified as Class I, II, or III according to the weight of the evidence. Some articles, such as literature reviews and data analyses, did not fit this classification and were grouped separately. Recommendations are based on the evidence available. RESULTS: Forty-five articles were reviewed. Thirteen articles contained information on the natural history, 19 contained data on the risks of surgery, and 2 contained information on both. In addition, 11 contained analyses of costs and benefits. None met the criteria for Class I evidence. Seven articles on the natural history and 7 on the risks of surgery met the criteria for Class II evidence, and 6 and 12, respectively, met those for Class III evidence. The remainder of the articles were analyses or review articles. CONCLUSION: There is insufficient evidence to recommend a standard of management. As a therapeutic guideline, conservative treatment is recommended for small aneurysms (<10 mm) and asymptomatic nongiant aneurysms in older people, whereas surgery is recommended for larger aneurysms in younger people and symptomatic aneurysms in fit patients. Other recommendations can be justified only as therapeutic options, using evidence-based criteria. Areas for future investigation are discussed.     

Management of gingivobuccal complex cancer

INTRODUCTION

Squamous cell carcinoma of the oral cavity ranks as the 12th most common cancer in the world and the 8th most frequent in males. It accounts for up to one-third of all tobacco-related cancers in India. Cancer of the gingivobuccal complex is especially common in Indians due to their tobacco habits. This review focuses on the management of lower gingivobuccal complex cancers.

PATIENTS AND METHODS

References for this review were identified by search of Medline and other bibliographic information available in the PubMed database. The search terms carcinoma oral cavity, and cancer oral cavity, buccal mucosa, gingiva, gingivobuccal complex, and alveolus cancer/carcinoma were used. References from relevant articles and abstracts from international conferences were also included. Only articles published in the English language were used.

RESULTS

Treatment of gingivobuccal complex cancer is primarily surgical. Radical neck dissection, or its modification, is the standard treatment for the node-positive neck. Supraomohyoid neck dissection is the accepted treatment for the node-negative neck. Radiotherapy is usually not the preferred modality of treatment for early gingivobuccal complex cancer. It is used either as postoperative adjuvant treatment or as definitive treatment for advanced cancer with or witihout chemotherapy. Chemotherapy has been used as neo-adjuvant, adjuvant or palliative treatment. Advanced cancers are common and continue to pose a challenge to the multidisciplinary team.

CONCLUSIONS

Gingivobuccal complex cancer remains a major public health problem despite being highly preventable and easily detectable. Advanced cancers constitute a major proportion of patients presenting for treatment. These patients are difficult to treat and have a poor outcome.     

A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies

Laparoscopy and laparoscopic ultrasound are used widely in cancer staging and are perceived to prevent unnecessary open exploration in many patients. The aim of this study was to analyze the impact of staging laparoscopy in improving resectability in patients with primary and secondary hepatobiliary malignancies. Over a 10-month period (November 1, 1997 to August 31, 1998), 186 patients with primary and secondary hepatobiliary cancers were submitted to operation for potentially curative resection. One hundred four patients staged laparoscopically (LAP) before laparotomy were compared prospectively to 82 patients undergoing exploration without laparoscopy (NO LAP). Assignment to each group was not random but was based on surgeon practice. Demographic data, diagnoses, the extent of preoperative evaluation, and the percentage of patients resected were similar in the two groups. Laparoscopy identified 26 (67%) of 39 patients with unresectable disease. In the NO LAP group, 28 patients (34%) had unresectable disease discovered at laparotomy. In patients with unresectable disease and submitted to biopsy only, the operating times were similar in the two groups (LAP 83 ±22 minutes vs. NO LAP 91 ±33 minutes; P = 0.4). However, laparoscopic staging significantly reduced the length of hospital stay (LAP 2.2 ±2 days vs. NO LAP 8.5 ±8.6 days; P = 0.006). Likewise, total hospital charges, normalized to 100 in the NO LAP patients, were significantly lower in the LAP group (LAP 54 ±42 vs. NO LAP 100 ±84; P = 0.02). Staging laparoscopy identified the majority of patients with unresectable hepatobiliary malignancies, significantly improved resectability, and reduced the number of days in the hospital and the total charges. The yield of laparoscopy was greatest for detecting peritoneal metastases (9 of 10), additional hepatic tumors (10 of 12), and unsuspected advanced cirrhosis (5 of 5) but often failed to identify nonresectability because of lymph node metastases, vascular involvement, or extensive biliary involvement. Eighty-three percent of patients subjected to laparotomy after laparoscopy underwent a potentially curative resection compared to 66% of those who were not staged laparoscopically. Supported in part by grants R01 CA76416 (Dr. Fong) and R01CA/DK80982 (Dr. Fong) from the National Institutes of Health. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.