Laparoscopic repair of rectal prolapse

Background: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. Methods: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. Results: Median operation time was 255 min (range, 180–360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3–15) and median time off work was 14 days (range, 12–21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12–60 months). Conclusions: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated. Received: 30 April 1999/Accepted: 8 July 1999/Online publication: 22 May 2000     

Laparoscopic resection of extraperitoneal rectal cancer: a comparative analysis with open resection

Purpose  The aim of this study was to compare the outcomes of laparoscopic surgery with those of open resection in patients with extraperitoneal rectal cancer. Methods  Five hundred forty-four patients with extraperitoneal rectal cancer who underwent curative resection between 1996 and 2007 were included. Patients were divided into a laparoscopic surgery group (LAP, n = 170) and an open surgery group (OPEN, n = 374). Results  Morbidity requiring surgical correction was 5.8% in the LAP group and 4.8% in the OPEN group (p = 0.75). The anastomotic leakage rate was similar in both groups (5.7% in both; p = 0.98). Differences were found in preoperative carcinoembryonic antigen (CEA) (LAP group 4.6 ng/ml, OPEN group 7.7 ng/ml, p = 0.001), sphincter preservation (LAP group 82.9%, OPEN group 69.8%, p = 0.001), and mean distance from anal verge (LAP group 4.6 cm, OPEN group 5.2 cm, p = 0.002). Local recurrence and metastasis were similar by stage. Conclusions  The results of this study show that laparoscopic resection of extraperitoneal rectal cancer was safe and effective.     

Laparoscopic vs conventional Nissen fundoplication

Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Received: 15 May 1996/Accepted: 10 September 1996     

Laparoscopic rectopexy for complete rectal prolapse

Background: The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations. Methods: Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography. Results: No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p=0.005) and the rectoanal inhibitory reflex improved in seven patients (p=0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p=0.02). Conclusions: Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Laparoscopic rectopexy according to Wells

Background: The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy. Methods: A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure. Results: Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively. Received: 22 January/Accepted: 7 May 1998     

Pneumoperitoneum with carbon dioxide enhances liver metastases of cancer cells implanted into the portal vein in rabbits

Background: Little is known about the role of the CO₂ pneumoperitoneum on tumor cells that spread from the portal system into the liver during laparoscopic surgery for gastrointestinal malignancies. Therefore, we designed a study to investigate the effect of CO₂ pneumoperitoneum on cancer cells implanted in the portal vein in a rabbit model. Methods: Immediately after intraportal inoculation of 2.5 × 10⁵ cells of VX₂ cancer, the rabbits received either CO₂ pneumoperitoneum at a pressure of 10 mmHg for 30 min (pneumoperitoneum group, n= 14) or laparotomy alone for 30 min (laparotomy group, n= 14). Results: The number (p < 0.01) and area of cancer nodules (p= 0.045) on the liver surface on day 17 were greater in the pneumoperitoneum group than in the laparotomy group. The frequency of cancer nodules >3.0 mm in diameter was higher in the pneumoperitoneum group than in the laparotomy group (p < 0.001). Conclusions: Compared with laparotomy, CO₂ pneumoperitoneum enhanced the development of liver metastases in this experimental model. Received: 9 December 1998/Accepted: 3 April 1999     

Laparoscopic surgery for diverticulitis

Background: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. Methods: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p= NS). Results: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). Conclusion: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment. Received: 25 March 1996/Accepted: 17 July 1996     

Effects of laparotomy vs pneumoperitoneum on the hepatic catabolic stress response in ambulatory and stationary settings in pigs

Background: We recently demonstrated that laparoscopic cholecystectomy is followed by a much smaller hepatic catabolic stress response than conventional cholecystectomy. It is not known what is responsible for this difference. Methods: Thirty pigs were randomly allocated to the following five treatment groups: (1) laparotomy, (2) pneumoperitoneum, (3) pneumoperitoneum with insertion of four trocars, (4) laparotomy, (5) pneumoperitoneum. Groups 1–3 were operated on in an ambulatory setting, whereas groups 4 and 5 were operated on in a stationary setting. Urea synthesis, as quantified by functional hepatic nitrogen clearance, and the response of stress hormones and cytokines were assessed. Results: Laparotomy increased the functional hepatic nitrogen clearance by 195% (p < 0.001); pneumoperitoneum and trocars increased it by 145% (p < 0.001); and pneumoperitoneum alone increased it by 113% (p < 0.001). The difference between laparotomy and both pneumoperitoneum groups was significant. If the stress factor of ambulatory surgery was eliminated, the increase in functional hepatic nitrogen clearance was reduced to 87% (p < 0.01) after laparotomy and 38% (NS) for animals subject to pneumoperitoneum. There were significant differences in concentrations of stress hormones, tumor necrosis factor α, and interleukin 8 among groups intra- and postoperatively. Conclusions: The magnitude of the postoperative hepatic stress response after laparotomy compared to pneumoperitoneum with and without insertion of trocars seems to be caused by the greater trauma to the abdominal wall. Furthermore, an ambulatory setting seems to be an important postoperative stress factor in itself. Received: 28 April 1998/Accepted: 18 August 1998     

Adrenocortical response and regional T-lymphocyte activation patterns following minimally invasive surgery in a rat model

Background: Laparoscopic surgery is associated with less tissue trauma and postoperative pain as well as a more rapid recovery than open surgery. We hypothesized that these factors may result in less immune impairment following laparoscopic surgery. Methods: We measured mitogen-induced surface interleukin-2 receptor (IL2R) expression and lymphocyte proliferation in CD4⁺ and CD8⁺ T-lymphocytes as well as serum corticosterone levels in rats 24 h following open (OP) and laparoscopic (LAP) fundoplication. Results: Serum corticosterone levels were lower in LAP vs OP rats (p= 0.02). CD4⁺ IL2R expression was higher in the blood, but not in the spleen, in LAP vs OP animals (p= 0.02). CD8⁺ IL2R expression was similar in both groups. Mitogen-induced lymphocyte proliferation was no different in the blood but decreased in the spleen in LAP vs OP rats (p= 0.03). Conclusions: Compared to open surgery, laparoscopic fundoplication in the rat results in lower adrenocortical hormone levels and better-preserved T-helper-cell activation in the blood. Lymphocyte proliferation is suppressed in the spleen 24 h after laparoscopic surgery. Minimally invasive surgery may better preserve cell-mediated immunity in the early postoperative period. Received: 2 April 1997/Accepted: 15 July 1997     

Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation

Objective Abdominal rectopexy is ideal for otherwise healthy patients with rectal prolapse because of low recurrence, yet after posterior rectopexy, half of the patients complain of severe constipation. Resection mitigates this dysfunction but risks a pelvic anastomosis. The novel nerve‐sparing ventral rectopexy appears to avoid postero‐lateral rectal dissection denervation and thus postoperative constipation. We aimed to evaluate our functional results with laparoscopic ventral rectopexy. Method Consecutive rectal prolapse patients undergoing laparoscopic ventral rectopexy were prospectively assessed (Wexner Constipation and Faecal Incontinence Severity Index scores) pre‐, 3 months postoperatively, and late (> 12 months). Results Sixty‐five consecutive patients with external rectal prolapse (median age 72 years, 34% > 80 years, median follow up 19 months) underwent laparoscopic ventral rectopexy. There was one recurrence (2%) and one conversion. Morbidity (17%) and mortality (0%) were low. Median operating time was 140 min and median length of stay 2 days. At 3 months, constipation was improved in 72% and  mildly induced in 2% (median pre‐and postoperative Wexner scores 9 vs 4, P < 0.0001). Continence was improved in 83% and mild incontinence was induced or  worsened in 5% (median pre‐ and postoperative incontinence score 40 vs 4, P < 0.0001). Significant improvement in both constipation and incontinence (P < 0.0001) remained at median 24 months late follow‐up. Conclusion Ventral rectopexy has a recurrent prolapse rate of < 5%, similar to that of posterior rectopexy. Its correction of preoperative constipation and avoidance of de novo constipation appear superior to historical functional results of posterior rectopexy. A laparoscopic approach allows low morbidity and short hospital stay, even in those patients over 80 years of age in whom a perineal approach is usually preferred for safety.     

Immediately recognizable benefits and drawbacks after laparoscopic colon resection for benign disease

Background: A prospective assessment of the impact of laparoscopic colon resection (LCR) was carried out in order to quantify immediately recognizable benefits and limitations of this approach. Methods: Elective LCR was attempted in 95 selected patients (mean age 64 years, range 39–81 years) presenting with benign disease of the colon. A completely intracorporeal approach was adopted. Results were compared with a control group of 90 patients who had previously undergone open colectomy (OC) by the same surgeons at the same institution. Results: There were no perioperative deaths. Intraoperative complications included difficult extraction of accidentally detached anvil (n= 1), air leak at colonoscopy (n= 2), and conversion to OC (n= 1). Operating time was significantly longer after LCR compared with OC (180 ± 10.3 vs 116 ± 97, p < 0.001). Passage of flatus (3.5 ± 1.2 days vs 4.4 ± 1.4, p < 0.5) and morbidity (4 vs 3, p= 0.48) were not significantly different in the two groups. Hospital stay was significantly shorter after LCR (5.2 ± 1.3 days vs 12.2 ± 1.9 days, p < 0.001). Theater and ward costs were, respectively, significantly increased ($ 2,829.6 ± 340 vs $ 1,422 ± 318, p < 0.001) and decreased ($ 2,600 ± 366 vs $ 6,022 ± 916, p < 0.001) in LCR patients compared with the OC group. There was no significant difference in total hospital costs ($ 10,929 ± 369 vs $ 9,944 ± 1,014). Conclusions: LCR does not appear to offer any immediately recognizable advantages. Received: 15 October 1996/Accepted: 13 December 1996     

Effect of surgical stress on endogenous morphine and cytokine levels in the plasma after laparoscopoic or open cholecystectomy

Background: Endogenous morphine in the brain leads to various biological responses after surgery. The aim of this study was to determine whether morphine levels in the plasma would be enhanced by open laparotomy rather than by laparoscopic procedures. Methods: We compared 19 patients who underwent laparoscopic cholecystectomy with five patients who underwent resection of the gallbladder by open laparotomy. Morphine levels in the plasma were measured by an electrochemical detection system. Results: Postoperative endogenous morphine levels were higher with open laparotomy than with the laparoscopic technique (three h after surgery: open, 200 ± 52.6 fmol/ml vs laparoscopy, 17.6 ± 3.7, p < 0.01). This morphine elevation accounted for higher levels of cytokine, greater pain scores, and longer duration of fasting in open laparotomized patients than in laparoscopic cholecystectomy patients. Stress hormone levels in the plasma were also higher with open laparotomy than with laparoscopy. Conclusion: Morphine synthesis was enhanced by open laparotomy, resulting in greater biological response postoperatively than that seen with laparoscopic cholecystectomy. Received: 21 October 1998/Accepted: 3 April 1999     

Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach

Background and objectives

The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes.

Methods

Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach.

Results

Overall, 294 patients were analyzed—116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1–20) LAP, 6 days (range 3–13) CONVERTED, and 8 days (range 1–35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)—complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43).

Conclusions

LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.     

Does laparoscopy increase bacteremia and endotoxemia in a peritonitis model?

Background: Laparoscopy is increasingly used in patients with intraabdominal bacterial infection although pneumoperitoneum may increase bacteremia by elevated intraabdominal pressure. Methods: The influence of laparotomy and laparoscopy on bacteremia, endotoxemia, and postoperative abscess formation was investigated in a rat model. Rats received intraperitoneally a standardized fecal inoculum and underwent laparotomy (n= 20), or laparoscopy (n= 20), or no further manipulation in the control group (n= 20). Results: Bacteremia and endotoxemia were higher after laparotomy and laparoscopy compared to the control group (p= 0.01) 1 h after intervention. One hour after intervention, aerobic and anaerobic bacterial species were detected in the laparotomy group while only anaerobic bacteria were found in the other two groups. Although bacteremia and endotoxemia did not differ among the three groups after 1 week, the mean number of intraperitoneal abscesses was significantly higher (p < 0.05) after laparotomy (n= 10) compared with laparoscopy (n= 6) and control group (n= 5). Conclusion: Laparoscopy does not increase bacteremia and intraperitoneal abscess formation compared to laparotomy in an animal model of peritonitis. Received: 28 May 1996/Accepted: 25 July 1996     

Increased tumor establishment and growth after open vs laparoscopic bowel resection in mice

Background: Surgery can suppress immune function and facilitate tumor growth. Several studies have demonstrated better preservation of immune function following laparoscopic procedures. Our laboratory has also shown that tumors are more easily established and grow larger after sham laparotomy than after pneumoperitoneum in mice. The purpose of this study was to determine if the previously reported differences in tumor establishment and growth would persist in the setting of an intraabdominal manipulation. Methods: Syngeneic mice received intradermal injections of tumor cells and underwent either an open or laparoscopic cecal resection. In study 1, the incidence of tumor development was observed after a low dose inoculum; whereas in study 2, tumor mass was compared on postoperative day 12 after a high-dose inoculum. Results: In study 1, tumors were established in 5% of control mice, 30% of laparoscopy mice, and 83% of open surgery mice (p < 0.01 for all comparisons). In study 2, open surgery group tumors were 1.5 times as large as laparoscopy group tumors (p < 0.01), which were 1.5 times as large as control group tumors (p < 0.02). Conclusion: We conclude that tumors are more easily established and grow larger after open laparoscopic bowel resection in mice. Received: 27 October 1997/Accepted: 19 January 1998     

Postoperative pain and fatigue after laparoscopic or conventional colorectal resections

Background: Conventional colorectal resections are associated with severe postoperative pain and prolonged fatigue. The laparoscopic approach to colorectal tumors may result in less pain as well as less fatigue, and may improve postoperative recovery after colorectal resections. Methods: Sixty patients were included into a prospective randomized trial to determine the influence of laparoscopic (n= 30) or conventional (n= 30) resection of colorectal tumors on postoperative pain and fatigue. Major endpoints of the study were dose of morphine sulfate during patient-controlled analgesia (PCA), visual analog scale for pain while coughing (VASC), and visual analogue scale for fatigue (VASF). Efficacy of pain medication was assessed by visual analogue score at rest (VASR). Results: Preoperative age, sex, stage, and localization of tumors were comparable in both groups. The PCA dose of morphine given immediately after surgery until postoperative day 4 was higher in the conventional group (median, 1.37 mg/kg; 5–95 percentile 0.71–2.46 mg/kg) than the laparoscopic group (0.78 mg/kg; 0.24–2.38 mg/kg, p < 0.01). Postoperative VASR was comparable between both groups, but VASC was higher from the first to the seventh postoperative day (p < 0.01). Postoperative fatigue was higher after conventional than after laparoscopic surgery from the second to the seventh day (p < 0.05). Conclusions: This study confirms that analgetic requirements are lower and pain is less intense after laparoscopic than after conventional colorectal resection. Patients also experience less fatigue after minimal invasive surgery. Because of these differences, the duration of recovery is shortened, and the postoperative quality of life is improved after laparoscopic colorectal resections. Received: 4 July 1997/Accepted: 16 November 1997     

A simplified simulator for the training and evaluation of laparoscopic skills

Background: Laparoscopic skills can be measured objectively in a video-laparoscopic cart simulator system. These scores have been shown to be sufficiently sensitive to distinguish differences in performance between residents at different levels of training. The purpose of this study was to compare a simplified mirrored-box simulator to the video-laparoscopic cart system. Methods: A total of 22 surgical residents performed seven structured tasks in both simulators in random order. Scores reflected precision and speed. The tasks were transferring, cutting, clip + divide, looping, mesh placement + fixation, and suturing with intracorporeal and extracorporeal knots. Results: There were no significant differences in mean raw scores between the simulators for six of the seven tasks. Resident total scores correlated well between simulators (r= 0.68, p= 0.001). Resident ranking also correlated well (r= 0.69, p < 0.001). Conclusions: A mirrored-box simulator was shown to provide a reasonable reflection of relative performance of laparoscopic skills. Practical, effective laparoscopic skills training and evaluation can be accomplished without the need for cumbersome equipment. Received: 26 April 1999/Accepted: 2 July 1999     

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse—Influence on Clinical Symptoms and Quality of Life

Background

Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients’ symptoms and quality of life.

Methods

The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life.

Results

Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life.

Conclusion

Our study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

     

Effects of laparoscopic vs laparotomy treatment of E. coli peritonitis on hemodynamic responses in a porcine model

Background: Laparoscopic surgery is being used now for increasingly diverse clinical applications, including diagnosis and treatment of appendicitis and bacterial peritonitis. However, some concerns and controversies exist regarding the effectiveness of laparoscopic irrigation of the abdominal cavity compared with that achieved during laparotomy. Of no less importance is concern that establishing a CO₂ pneumoperitoneum in patients with cardiopulmonary insufficiency or endotoxemic shock may compromise hemodynamic function. The objective of this randomized, controlled study was to determine the effects of laparoscopic versus laparotomy intervention on hemodynamic and outcome measurements using a porcine model of Escherichia coli peritonitis. Methods: For this study, 24 specific pathogen-free Hanford pigs underwent surgical placement of carotid, Swan-Ganz, and peritoneal catheters. After a 24-h recovery period, one subset of pigs (n= 12) received a bolus infusion of 9 × 10⁸ CFU/kg E. coli intraperitoneally (septic) and intravenous fluid resuscitation. The remaining 12 pigs were not challenged with E. coli (control). Twenty-four hours later, all 24 pigs underwent either laparoscopic or open peritoneal irrigation with saline, then were reevaluated 48 h after surgical intervention. Standard cardiopulmonary, hematologic, and bacteriologic assessments were obtained both perioperatively and 48 h after surgical intervention. Results: Pigs given E. coli exhibited significantly elevated heart rates and core temperatures and decreased O₂ saturation during the initial 6 h. Within 24 h, these pigs exhibited respiratory alkalosis, altered blood leukocyte profiles, and E. coli–infected peritoneal fluid. Random blood samples from the septic pigs tested negative for E. coli. Mean pulmonary artery and capillary wedge pressures were lower (p < 0.05) in septic than in control pigs before and after surgical intervention. Septic pigs that underwent laparoscopy had significantly lower (p < 0.05) arterial pH and higher arterial pCO₂ levels than septic pigs after laparotomy. Other cardiopulmonary responses were similar irrespective of the surgical modality used. One of six septic pigs from each surgical group still had E. coli growth in its peritoneal fluid 48 h after surgical intervention. Conclusion: Laparoscopic intervention demonstrated effectiveness equal to that of laparotomy for treating acute E. coli peritonitis in pigs without septic shock. Received: 26 June 1998/Accepted: 12 January 1999     

Laparoscopic vs open inguinal hernia repair

Background: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. Methods: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. Results: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p= 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p= 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5–14) days vs 14 (8–19) days (p= 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17–60) days vs 35 (20–56) days (p= 0.25). The return to work was not significantly different, median 14 (8–25) days after laparoscopic repair and 15 (11–21) days after open repair (p= 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. Conclusions. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly. Received: 23 May 1997/Accepted: 1 August 1997