Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma

Background: Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank. Methods: Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient. Results: Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 ± 1.97 vs 2.43 ± 0.63 (p < 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 ± 17.00 min vs 66.1 ± 6.55 and 47.3 ± 7.50 min, respectively (p < 0.05). The mean length of stay was significantly shorter in the DL group as compared to the NL or CONV groups, 1.43 ± 0.20 vs 4.26 ± 0.31 and 5.0 ± 0.82 (p < 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 ± 175 vs $3,384 ± 102 and $3,774 ± 286, (p < 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 ± 394 vs $7,026 ± 251 and $7,855 ± 750 (p < 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 ± 394 vs $7,028.47 ± 250 (p < 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01, z = 2.550). Conclusion: Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy. Received: 11 March 1996/Accepted: 5 July 1996     

Retracted: Effect of chest ultrasound compared with pericardial window for the diagnosis of occult penetrating cardiac wounds in hemodynamically stable subjects with penetrating thoracic trauma: A meta-analysis

We conducted a meta-analysis to assess the diagnostic performance of chest ultrasound compared with a pericardial window for the detection of occult penetrating cardiac wounds in patients with penetrating thoracic trauma who were hemodynamically stable. A systematic literature search up to December 2022 was performed and 567 related studies were evaluated. The chosen studies comprised 629 penetrating thoracic trauma subjects who participated in the selected studies' baseline. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of different chest ultrasounds on wound infection after penetrating thoracic trauma by the dichotomous methods with a random or fixed effect model. The chest ultrasound resulted in significantly lower occult penetrating cardiac wounds detection (OR, 0.02; 95% CI, 0.01–0.08, P < 0.001), higher false positive (OR, 33.85; 95% CI, 9.21–124.39, P < 0.001), and higher false negative (OR, 27.31; 95% CI, 7.62–97.86, P < 0.001) compared with the pericardial window in penetrating thoracic trauma. The chest ultrasound resulted in significantly lower occult penetrating cardiac wound detection, higher false positives, and higher false negatives compared with the pericardial window in penetrating thoracic trauma. Although care should be taken when dealing with the results because all of the studies had less than 200 subjects as a sample size     

Laparoscopic transabdominal pericardial window

Creation of a transabdominal transdiaphragmatic pericardial window for life-threatening recurrent pericardial effusion has proved to be a safe minimally invasive technique. By inducing adequate pericardial sac decompression while avoiding single-lung ventilation and thoracic drainage in severely ill patients, it provides anatomopathologic diagnosis and can direct further therapeutic measures. The transabdominal approach improves postoperative recovery dramatically by limiting postoperative pain and prevents sometimes invalidating intercostal neuralgia. Transabdominal pericardial sac fenestration should be part of the armamentarium used by every minimally invasive surgeon.     

Misleading symptoms after a minor blunt chest trauma

We present a case of missed diaphragmatic rupture which was treated thoracoscopically. Rupture of the diaphragm is a serious complication of blunt trauma. The diaphragmatic injury can easily be overlooked. This report illustrates the diagnostic dilemma in a patient where the injury was missed at the time of initial presentation. The role of thoracoscopy both for diagnosis and therapy is discussed. Received: 24 January 1997/Accepted: 2 April 1997     

Thoracoscopic partial pericardiectomy in the diagnosis and management of pericardial effusion

Background: An effort was made to present our experience with thoracoscopy in the diagnosis and management of pericardial effusions. Methods: Twenty-two partial pericardiectomies were performed with the thoracoscopic approach in patients with pericardial effusions, the etiology of which was uremic (n= 7), neoplastic (n= 8), idiopathic (n= 5), septicemia (n= 1), and postpericardiotomy (n= 1). All cases had grade III-IV/IV radiological cardiomegaly and ultrasonographic confirmation of the effusion. We found hemodynamic compromise in 17 patients. The operation, requiring the insertion of three trocars, enabled us to remove a large part (approximately 6 × 10 cm) of the left anterolateral side of the pericardium and aspirate the effusion contents for diagnostic and therapeutic purposes. Results: In five cases we found coexisting pleural effusions. The pericardial effusion had a mean volume of 817 ml, which was serous in 11 cases, hematic in six, serohematic in four, and purulent in one. Cytology of the pericardial effusion was positive for neoplasia in four cases (one pulmonary neoplasia, two breast carcinomas, and one lymphoma). We observed conversion to grade I/IV cardiomegaly in 16 cases and a return to normality in the other six, with the absence of ultrasonographic effusion in all cases. There was no recurrence during the mean follow-up period of 20.5 months (range: 2–47). Conclusions: The thoracoscopic management of pericardial effusions is a simple and effective technique that allows us to create a large pericardial window that drains the effusion definitively, determines its etiology, and explores and treats coexisting pleural lesions, all without recurrences. Received: 30 May 1996/Accepted: 27 August 1996     

Pericardio peritoneal window

Transdiaphragmatic approach to the pericarium through the use of the laparoscope is a safe and rapid way to obtain biopsy of the pericardium and create a window. No drainage tubes are needed: pericardial fluid is absorbed by the peritoneum; there is no need for double lumen tubes for one lung ventilation; and the laparoscopy incisions are small and almost painless. Received: 5 December 1997/Accepted: 17 June 1998     

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center

Background

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality.

Methods

A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded.

Results

A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 ± 9.33 (range, 15-54) years. The mean LOS was 10.65 ± 8.30 (range, 5-65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 ± 9.92 days; stab wound, 8.76 ± 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 ± 36.702 mm Hg) compared with those who survived (83.96 ± 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality.

Conclusion

Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.     

Laparoscopy in penetrating abdominal trauma

Summary BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. There is no doubt that persistent hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy. If the patient is hemodynamically stable and has equivocal abdominal examination findings, diagnosis may be obtained by laparoscopy. METHODS: The goal of this article is to evaluate the role of laparoscopy in the management of PAT. RESULTS: Patients with penetrating trauma to the thoracoabdominal and anterior abdominal wall are good candidates for laparoscopic evaluation. The peritoneal cavity and its contents, including the retroperitoneal space, can be thoroughly examined easily and safely. The main benefits of laparoscopy include the reduction of nontherapeutic laparotomies, identification of mostly intra-abdominal injury, and provision of potential therapy for some cases. Diagnostic laparoscopy has a high overall diagnostic accuracy, reduced morbidity, and shortened hospital stay and is also cost-effective. While laparoscopy has some limitations in the diagnosis of hollow viscus injury, it can detect and repair diaphragmatic injuries accurately and exclude the risk of nontherapeutic laparotomy due to a nonbleeding injury of the solid organs. CONCLUSIONS: The use of laparoscopy as a diagnostic or therapeutic method in patients with PAT is reserved only for hemodynamically stable patients and uncertain findings of peritonitis. Laparoscopy is an efficient and effective diagnostic tool when used by a well-trained surgeon. With experience, an increasing number of surgeons are using laparoscopy as an additional diagnostic tool for PAT in stable patients. With more experience and skills, laparoscopy may be used more therapeutically in selected patients. Minimally invasive surgery has already established itself as a useful tool in the management of PAT. The future seems to be promising for this field of surgery by innovative developments in computer technology and robotic systems.     

Emergency laparoscopy for abdominal stab wounds

Background: Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes—hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. Patients and Methods: At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. Results: In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n= 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n= 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. Conclusions: DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW. Received: 24 February 1997/Accepted: 10 August 1997     

Laparoscopic evaluation of patients with suspected acute appendicitis

Background: High error rates are reported in the clinical diagnosis of acute appendicitis. This study was undertaken to discover what additional value laparoscopy has in the diagnosis of suspected acute appendicitis. Methods: From April 1995 to November 1996, a diagnostic laparoscopy, before open appendicectomy, was performed in 100 consecutive patients with suspected acute appendicitis. Appendicectomy was performed only if the appendix showed signs of inflammation at laparoscopy or if the appendix could not be visualized. Results: Twenty-four patients were spared an appendicectomy, and in half of them a new diagnosis was established during laparoscopy. The rate of misdiagnosis was 41% in female patients of reproductive age and 8% in male patients. There were no cases of missed appendicitis in this trial, and all removed appendices showed signs of inflammation at histology. Conclusions: It is safe to rely on the diagnosis made at laparoscopy. Its use for establishing diagnosis before appendicectomy in women of reproductive age is recommended. Received: 13 June 1997/Accepted: 24 October 1997     

Blunt chest trauma

Summary Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early managment of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. Most of the isolated thoracic injuries are adequately treated by conservative means, sufficient analgesia, drainage of intrapleural air or blood, physiotherapy and clearance of bronchial secretions provided; operative intervention is rarely indicated. In multiple injured patients however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase of morbidity and mortality. Hence, patients with this combination of pulmonary injuries, such as lung contusion and associated severe injuries, carry a particular high risk of respiratory failure, ARDS and MOF with a considerable mortality. Therefore, early exact diagnosis of all thoracic injuries is essential and can be achieved by thoracic computed tomography, which becomes more and more popular in this setting. Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.      

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 infrared imaging

A system was developed to determine the potential role of infrared imaging as a tool for localizing anatomic structures and assessing tissue viability during laparoscopic surgical procedures. A camera system sensitive to emitted energy in the midinfrared range (3–5 μm) was incorporated into a two-channel visible laparoscope. Laparoscopic cholecystectomy, dissection of the ureter, and assessment of bowel perfusion were performed in a porcine model with the aid of this infrared imaging system. Inexperienced laparoscopists were asked to localize and differentiate structures before dissection using the visible system and then using the infrared system. Assessment of bowel perfusion was also conducted using each system. Infrared imaging proved to be useful in differentiating between blood vessels and other anatomic structures. Differentiation of the cystic duct and arteries and transperitoneal localization of the ureter were successful in all instances using the infrared system when use of the visible system had failed. This system also permitted assessment of bowel perfusion during laparoscopic occlusion of mesenteric vessels. These initial studies demonstrate that infrared imaging may improve the differentiation and localization of anatomic structures and allow assessment of physiologic parameters such as perfusion not previously attainable with visible laparoscopic techniques. It may thus potentially be a powerful adjunct to laparoscopic surgery. Received: 23 August 1996/Accepted: 14 October 1996     

Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an inaccessible polyp of the colon

Background: The purpose of this report was to describe a simple technique suitable for polyps where circumstances of the bowel anatomy prevent complete access and control of the colonoscopic procedure. Methods: By combining laparoscopic mobilization of the bowel with colonoscopic polypectomy, previously inaccessible polyps could be snared in two patients. Results: Both patients had 3-cm large sessile adenomas in the sigmoid colon safely removed, and they returned home within a day. Conclusions: The described procedure increases the safety of the otherwise difficult polypectomy and also avoids laparotomy with enterotomy or bowel resection as the alternative. Received: 5 May 1996/Accepted: 19 September 1996     

Laparoscopic Heller's cardiomyotomy in achalasia

Background: Inappropriate length of the myotomy incision along the stomach, the most common technical fault during Heller's cardiomyotomy, is related to the difficulty of identifying the gastro-esophageal junction, in particular during laparoscopic surgery. The goal of this study was to evaluate the contribution of endoscopy to gastro-esophageal junction identification during laparoscopic Heller's cardiomyotomy. Methods: In a group of 19 patients with intraoperative endoscopy with laparoscopic Heller's cardiomyotomy, surgical and endoscopic criteria for gastro-esophageal junction identification have been assessed. Then postoperative results of this group were compared with those of another group of 16 patients previously operated on without intraoperative endoscopy. Results: Endoscopic and laparoscopic criteria for gastro-esophageal junction identification were discordant in 11 patients (11/19, 58%). The cardia was in all these cases at a more distal site with endoscopic criteria. Complications ascribable to suboptimal technique were more frequent in the group without intraoperative endoscopy (7/16 patients) than in the other group (2/19 patients). Conclusions: Endoscopy during laparoscopic Heller's cardiomyotomy is of great assistance in identifying the cardia, and thereby could improve surgical outcomes. Received: 20 October 1998/Accepted: 20 January 1999     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Ultrasonography of the ureter after surgical trauma

Background: The purpose of the study was to discover whether ultrasonography can be used in diagnosing ureteral complications during surgery. Methods: The study consisted of an animal experiment with five pigs, that underwent laparotomy. The right ureter was electrocauterized and transsected, and the left ureter was ligated. The type and frequency of peristaltic waves and the diameter of the ureter were recorded by perioperative ultrasonography. Four patients with ureteral trauma during gynecologic surgery were also examined. Results: In the animal study six out of nine ureters dilated after the procedure. In seven ureters the contraction segment became smaller, and the lumen did not close properly during the peristaltic wave. The frequency of peristalsis diminished in all cases after ligation. Human ureters showed similar changes when examined 1.5–48 h after surgical trauma. Conclusions: Perioperative ultrasonography has great diagnostic potential as a method for noninvasive evaluation of ureteral conditions during both laparoscopy and laparotomy. Received: 16 June 1997/Accepted: 4 December 1997     

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 anterior gastroplasty

Background: The treatment of the morbidly obese patient is difficult because compliance with dietary regimens is poor. As a result, most weight reduction programs fail very quickly. Surgical treatment, on the other hand, provides a reliable method for sustained weight reduction. The most frequently performed procedure has been the vertical banded gastroplasty. Adaptation of the standard open procedure to laparoscopic techniques has been technically difficult and imprecise. We have developed, in the laboratory, an anterior wall banded gastroplasty that can be performed precisely and reproducibly using laparoscopic techniques. Methods: Five Yorkshire pigs were used in attempt to laparoscopically perform the standard vertical banded gastroplasty. The procedure was difficult and was associated with a risk of staple line leak and with bleeding along the lesser curvature of the stomach. Furthermore, a reproducible pouch of proper dimension could not be created reliably. Fifteen animals were then used to develop a new technique using a small gastric pouch based on the anterior gastric wall. Results: A reproducible pouch, 4 cm in length, was created over an 18-Fr nasogastric tube. A standard polyproylene band of 5.2 cm in length was utilized at the gastric pouch outlet. Conclusions: This operation can be reproduced accurately and has not demonstrated any leaks on postmortem examination. Received: 14 July 1997/Accepted: 4 February 1998     

Laparoscopic vs conventional bowel resection in the rat

Background: The role of laparoscopic surgery in the treatment of colorectal disease is still controversial. To assess the metabolic consequences of laparoscopic and open bowel surgery, we studied serum levels of insulin-like growth factor 1 (IGF-1), an anabolic and mitogeneic peptide, in rats. Materials and methods: In experiment 1, the serum IGF-1 levels of 10 rats undergoing laparoscopic small bowel resections (group I) and 10 rats undergoing conventional small bowel resections (group II) were determined before surgery and on days 1, 2, and 7. Experiment 2 compared five rats that had CO₂ pneumoperitoneum (group III), five rats that underwent laparotomy (group IV), and five rats that received anesthesia only (group V). Differences in IGF-1 levels were tested with analysis of covariance. Results: In experiment 1, preoperative IGF-1 levels were similar in groups I and II (87.9 ± 6.1 nmol/L versus 90.5 ± 8.1 nmol/L). One day after surgery IGF-1 was 54.6 ± 10.5 in group I versus 41.6 ± 8.3 in group II (p= 0.006). Two days after surgery, IGF-1 was 79.4 ± 9.2 in group I versus 59.0 ± 10.5 in group II (p < 0.001). Seven days after both types of surgery, IGF-1 levels had returned to almost normal levels. In experiment 2, no significant differences were found between the rats with CO₂ pneumoperitoneum (group III) and those with laparotomy only (group IV). Rats that had anaesthesia only showed a significant decrease in IGF-1 levels between days 0 and 1 (p < 0.018). Conclusion: Our study indicates that laparoscopic bowel surgery is associated with a better postoperative anabolic state (i.e., less catabolism) than conventional surgery. This finding reflects a potential benefit of laparoscopy in bowel surgery. Received: 22 May 1996/Accepted: 10 July 1997