Laparoscopic gastric banding for morbid obesity

Background: Morbid obesity occurs in 2–5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients. Materials and methods: A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications. Results: All patients have needed band adjustments of 1–4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss. Conclusions: Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience. Received: 12 May 1998/Accepted: 12 February 1999     

Laparoscopic Collis gastroplasty and Nissen fundoplication

Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach. Received: 8 September 1997/Accepted: 17 December 1997     

Endoscopy in patients undergoing gastroplasty for morbid obesity

Summary Fifty patients underwent gastroplasty for morbid obesity. The follow-up regimen included both nutritional and weight assessment and gastroscopy. Weight loss was satisfactory in patients with gastric stomas less than 9 mm in diameter. Stomal obstruction was endoscopically diagnosed in 5 patients. Endoscopic dilatation was successful in 4 patients. Gastroscopy should thus be a routine postoperative procedure in patients undergoing gastric partitioning for morbid obesity.     

Left side thoracoscopically assisted gastroplasty

Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay. Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000     

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     

A 3-year experience with laparoscopic gastric banding for obesity

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

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 repositioning of an adjustable silicone gastric band for pouch dilatation and stoma obstruction

Pouch dilatation with stoma obstruction is a well-known late complication after adjustable gastric banding operations for morbid obesity. Surgical treatment of this problem usually results in removal of the band, with or without replacement by another, or in repositioning of the band via laparotomy. We present the case of a patient with late pouch dilatation and stoma obstruction after placement of a Laparoscopic Adjustable Gastric Banding system (LAGB—Bioenterics) and in whom the adjustable band was laparoscopically opened, disconnected from the access port, and repositioned more proximally on the stomach. The postoperative course was uneventful. A postoperative radiographic contrast examination showed a correct repositioning of the band. The case demonstrates that the LAGB can be successfully opened and repositioned by a minimal invasive procedure. This is the first time to our knowledge that such a procedure has been reported. Received: 25 May 1996/Accepted: 26 November 1996     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Laparoscopic repair of a colonoscopic perforation

We report a case of laparoscopic repair of a diagnostic colonoscopic perforation. No other such reports were noted in the literature. The management of colonoscopic perforations has become controversial. Operative vs nonoperative treatment is continually debated. The morbidity of operative management is significant. Colostomy is often performed. Laparoscopy should allow early evaluation of operative patients and primary repair of those with minimal contamination and no residual pathology. The benefits of minimally invasive surgery, such as shortened hospitalization and rapid return to full activities, including work, were realized in our patient. Laparoscopy should be considered in the selective management of colonoscopic perforations. Received: 15 September 1995/Accepted: 16 January 1996     

Laparoscopic treatment of ventral hernia

Laparoscopic repair of abdominal wall hernias has been introduced recently to treat both spontaneous and incisional hernias with reported good results. In the Mafraq and Al Jaziera Hospitals in the United Arab Emirates, 18 patients have been treated using the laparoscopic technique. These cases included 11 incisional hernias, 5 spontaneous paraumbilical hernias, and 2 combined incisional and paraumbilical hernias. A bilayer repair was performed in all cases using a layer of polyester mesh to bridge the defect and a sheet of Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) to prevent adhesions between first layer and the bowel. Seroma at the hernia site was the most frequent postoperative complication. Hospital stay ranged from 2 to 7 days (mean, 3.2 days). Recurrent hernia developed in one patient after a mean follow up of 22.3 months. This technique is in its evolution. Long follow-up evaluation is required before the effect on recurrence is known, and further development regarding the composition of prosthetic biomaterials and the methods of its fixation is expected. Received: 4 February 2000/Accepted: 11 May 2000/Online publication: 28 September 2000     

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     

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目的 评估腹腔镜垂直捆绑胃成形术（LVBG）的减肥效果并探讨肥胖手术治疗的适应证。方法 利用该手术治疗25例病态肥胖病人，平均年龄27．56岁（12－47岁），体重指数（BMI）为41（26－56）。结果 平均手术时间120min(50-240min)，未出现手术死亡和并发症。术后随访23例病人，第1个月减重均在12kg以上，6个月后平均减重24.3kg，平均BMI降至35。一年平均减重约42kg，平均BMI降至31。无营养不良。结论 LVBG是一种治疗病态肥胖症的安全、有效手术方法。     

Laparoscopic management of tubo-ovarian abscesses

Background

The laparoscopic management of tubo-ovarian abscesses (TOA) was evaluated. The study sought to answer the following question: Does operative laparoscopy with only incision of the abscess cavity and lavage (organpreserving treatment) improve intraoperative and postoperative safety and long-term prospects of fertility as compared with laparoscopic salpingectomy or salpingo-oophorectomy (ablative treatment)?

Methods

A retrospective chart review of 60 patients with TOA undergoing laparoscopic treatment in combination with broad-spectrum antibiotics from 1994 to 1998 was performed. Patients not wishing to have children underwent salpingectomy or salpingo-oophorectomy, whereas patients wishing to remain fertile were treated by means of an organpreserving procedure. To investigate the operative and reproductive outcome, patients were interviewed by telephone.

Results

Of 60 women with TOA, 25 were treated laparoscopically, preserving the internal genital organs, and 35 underwent ablative treatment. Apart from one postoperative readmission because of lower pelvic pain in the organpreserving group, there were no operative complications or serious systemic sequelae. In contrast, there was a significantly higher incidence of intraoperative and postoperative complications when ablative treatment was performed: one intestinal perforation requiring subsequent laparotomy, four serosal lesions, two lesions of the greater omentum, two lacerated collaterals of the internal iliac artery, one postoperative fever higher than 38°C for 2 days, two bowel obstructions, one thrombosis of the upper leg, and one thrombosis of the lower leg. There were no significant differences between the two patient groups in body mass index, duration of pelvic pain, laboratory findings at admission, ultrasonic assessment of abscess size, and the extent of the abscess at laparoscopy.

Conclusions

When laparoscopic treatment of TOA is performed, organ-preserving treatment should be chosen irrespective of the patient’s age or desire to have children because of the risk of complications.     

Laparoscopic management of acute small-bowel obstruction

Background: A retrospective review is given of the authors' experience with a consecutive series of acute small-bowel obstruction unresponsive to medical management. Methods: There were 33 exploratory laparoscopies. The etiology was accurately diagnosed in 100% of the cases. Twenty-five (76%) were secondary to postoperative adhesions, of which 18 (72%) were successfully treated by laparoscopic lysis of adhesions. Minilaparotomy was needed to treat iatrogenic perforation (two), gangrenous bowel (one), and Meckel's diverticulectomy (one). Formal laparotomy was utilized for small-bowel resection (two), malignant adhesions (two), and intolerance of pneumoperitoneum (one). Four cases of incarcerated hernias were treated by conventional herniorrhaphy. Results: Overall, 67% of our cases were spared formal laparotomy. Conclusion: We conclude that laparoscopy is an excellent diagnostic modality in acute small-bowel obstruction, the majority of which can be simultaneously managed laparoscopically. Laparotomy should be reserved for malignant adhesions, surgical misadventure, or when the pathology dictates. Received: 4 March 1996/Accepted: 13 May 1996     

Laparoscopic gastric bypass after failed open horizontal stapled gastroplasty

The number of people in the population who have undergone an operative procedure for morbid obesity is likely to rise steadily as the awareness and popularity of bariatric surgery continues to develop. As this number increases, the number of patients with long-term failures and complications from these procedures will also rise. Although previous operations, particularly open procedures, normally deter surgeons from choosing a laparoscopic approach, the evolving technical skill of laparoscopic surgeons should allow for the reconsideration of these inhibitions. In this case, we present of laparoscopic Roux-en-Y gastric bypass on a 48-year-old woman who had undergone horizontal gastric stapling 20 years prior to presentation.     

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 resection of posterior gastric leiomyoma

Laparoscopic gastric surgery is gaining momentum, especially in the treatment of benign disease. Simultaneous endoscopy and laparoscopy allow precise localization of lesions. Because of the stomach's size, mobility, and distensibility, relatively large lesions can be safely excised. Wedge resection for anterior lesions and a transgastric or intragastric approach for posterior lesions are feasible laparoscopically. Two cases of posterior gastric leiomyomas successfully resected laparoscopically are presented. The use of stapling devices greatly facilitates this procedure. Received: 17 February 1995/Accepted: 7 September 1995     

Laparoscopic transabdominal lumboperitoneal shunt

Communicating hydrocephalus can be handled either by the ventriculoperitoneal or, occasionally, the ventriculoatrial shunt. The lumboperitoneal shunt is another option. It does not require a transcranial approach; therefore, it is safer for the patient. We describe a technique that can be performed easily by a skilled laparoscopic surgeon through an anterior approach transabdominally. The lumboperitoneal (LP) shunt is placed laparoscopically under direct videoscopic vision, with the catheter inserted transabdominally through the L3 disc space into the thecal sac. In our patient, the lumboperitoneal shunt was placed at the L3 disc space for communicating hydrocephalus. There were no intraoperative or postoperative complications. The LP shunt can be easily placed by a skilled laparoscopic surgeon. The incidence of infection and complications is lower, and the patency rate is higher. This should be the initial choice for communicating hydrocephalus.     

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