Laparoscopic cholecystectomy in a community hospital setting.

Recently, laparoscopic cholecystectomy has become the preferred surgical procedure for removal of the gallbladder. However, many surgeons believe that the safety and efficacy have yet to be proved in the community hospital setting. To address this concern, a retrospective chart review of the initial 271 instances of inpatient laparoscopic cholecystectomy within a community hospital was undertaken. All procedures were performed by 15 general surgeons in private practice and residents in general surgery. Of the 271 patients, 11 were converted to open cholecystectomy. Surgical complications occurred in six of the 260 instances of laparoscopic cholecystectomy (2.3 percent), with only one injury to the common bile duct. Major postoperative complications occurred in 23 patients, including severe postoperative pain (nine patients), prolonged ileus (seven patients), bile leakage (three patients), retained common duct stones (two patients), respiratory failure (one patient) and postoperative myocardial infarction (one patient). The period of hospitalization ranged from one to 64 nights with a median of one night. The operative mortality rate was zero percent. Multivariate analysis identified two factors associated with an increased risk of postoperative complications. Patients 70 years of age or older and patients whose operating times were greater than one hour and 45 minutes were at increased risk for postoperative complications. We believe that these data represent the general outcomes of the laparoscopic procedure in a community hospital setting and lend support to the argument that the procedure can be performed safely and effectively in this setting.     

Laparoscopic cholecystectomy during pregnancy. Case report and literature review

The outors report of two cases of sucsessfully done laparoscopic cholecystectomy in pregnant women with cholelithiasis. The first patient was pregnant with 6 lunar months and suffering of acute cholecystitis, and the second woman is pregnant in 4-th lunar month whith cholelithiasis. During both postoperative periods--no complications. The pregnancies in both cases ended in therm and healthy mature children was born. We make a brief literature review and present whith the opinion that with strong indications and good prepared and experienced surgents, laparoscopic cholecystectomy is a method of choice.     

Laparoscopic presacral neurectomy. Results of the first 25 cases

Since the 1960s, medical therapy utilizing nonsteroidal antiinflammatory drugs and oral contraceptives with the addition of danazol and gonadotropin releasing hormone have become the treatment of choice for chronic pelvic pain and dysmenorrhea. The surgical approach to this problem, incorporating interruption of the superior hypogastric nerve plexus (presacral neurectomy), therefore, has become less popular. Investigations, however, have demonstrated that 20-25% of patients treated medically for this problem fail to show an improvement. As a result, attention has turned once again toward surgical treatment for those who have failed to respond to medical management. Laparoscopic uterosacral nerve ablation, or laparoscopic uterine nerve ablation, appears to offer hope in this regard and represents a return to a surgical approach for conservative management of severe, disabling dysmenorrhea and pelvic pain in women who have failed medical treatment. Since there has been such an emphasis on outpatient treatment and surgery, a laparoscopic approach to the classic presacral neurectomy was devised and implemented.     

Laparoscopic pelvic and paraaortic lymph node dissection: analysis of the first 100 cases

OBJECTIVE: The aim of this study was to analyze the first 100 cases of planned laparoscopic pelvic and paraaortic lymph node dissection (LND) done for staging of gynecologic cancers. The goal of the study was to assess prognostic factors for conversion to laparotomy and document complications. METHODS: A retrospective review of patients who had planned laparoscopic bilateral pelvic and bilateral paraaortic LND for staging of their gynecologic cancer was performed. Patients were identified by our institutional database and data were collected by review of their medical records. Data were obtained regarding demographics, stage, histology, length of stay, and procedural information including completion rates, operating room time, estimated blood loss, assistant, lymph node count, and complications. Associations between variables were analyzed using Student t tests, analysis of variance, and chi(2) testing (Excel v7.0). RESULTS: A total of 103 patients were identified from 12/15/95 to 8/28/00. Demographics included mean age of 66.2 (25-92) and mean Quetelet index (QI) of 30.8 (15.9-56.1). A total of 34/103 (33.0%) had > or =1 previous laparotomy. Ninety-five patients had endometrial cancer and 8 had ovarian cancer. Eighty-six of 103 (83.5%) were stage I or II. The length of stay was shorter for those who had laparoscopy than for those who needed conversion to laparotomy (2.8 vs 5.6 days, P < 0.0001). Laparoscopy was completed in 73/103 (70.9%) of the cases. Completion rates were 62/76 (81.6%) with QI < 35 vs 11/27 (40.7%) with QI > or = 35, P < 0.001. Significantly more patients had their laparoscopy completed when an attending gynecologic oncologist was the first assistant compared to a fellow or a community obstetrician/gynecologist (92.9%, 69.0%, 64.5%, P < 0.0001). The top three reasons for conversion to laparotomy were obesity, 12/30 (29.1%), adhesions, 5/30 (16.7%), and intraperitoneal disease, 5/30 (16.7%). Pelvic, common iliac, and paraaortic lymph node counts did not differ when compared to those of patients who had conversion to laparotomy (18.1, 5.1, 6.8 vs 17.3, 5.7, 6.8, P = ns). Complications included 2 urinary tract injuries, 2 pulmonary embolisms, and 6 wound infections (all in the laparotomy group). Two deaths occurred, 1 due to a vascular injury on initial trocar insertion and 1 due to a pulmonary embolism after a laparotomy for bowel herniation through a trocar incision. CONCLUSION: Laparoscopic bilateral pelvic and paraaortic LND can be completed successfully in 70.9% of patients. Age, obesity, previous surgery, and the need to perform this procedure in the community were not contraindications. Advantages include a shorter hospital stay, similar nodal counts, and acceptable complications.     

Laparoscopic surgery in gynecologic practice]

Paper concerns 293 laparoscopic operations. The most frequent types of laparoscopic operations in presented material were: adhesion lysis in minor pelvis (33.8% cases), cystectomy and cyst-ovariectomy (27.6%) and electrocoagulation of ovarian capsule. Operative laparoscopy because of small injury is useful method in the treatment some gynecological disease.     

Loss of the urethra: a report on 50 patients

A series of 50 patients presented with total urinary incontinence secondary to traumatic loss of much or all of the urethral floor and bladder neck. Previously, the 50 patients had been subjected to 94 unsuccessful operations; this serves to indicate the challenging nature of the problem. Surgical reconstruction was accomplished by creating a small-caliber neourethra from the contractile tissue that remained in the urethral roof. In addition, 22 of the 50 patients (44 per cent) required a supplemental myocutaneous labial skin flap (12 patients) or a bulbocavemosus muscle flap of the Martius type (10 patients). A "second-stage" retropubic urethrovesical suspension was required in 20 patients. After a follow-up period of five to 15 years, 37 of the 50 patients (74 per cent) were cured and an additional four patients (8 per cent) were greatly improved.     

Kinematic navigation in total knee replacement--experience from the first 50 cases.

BACKGROUND/PURPOSE: Proper alignment of the prosthesis is critical in total knee replacement (TKR) to minimize long-term wear, risk of osteolysis, and loosening of the prosthesis. This study examined the accuracy of lower limb alignment obtained using a kinematic navigation system for TKR, and the extra time needed to adopt this system. METHODS: From August 2002 to April 2003, 71 patients with knee osteoarthritis underwent 79 primary TKR operations by the same surgical team. Fifty of these operations were performed with the aid of the CT-free kinematic navigation system, and the remaining 29 were performed with conventional manual methods. Results, including operation time, radiographic alignment of the prosthesis and complications, for the two groups were compared. RESULTS: Patients in the kinematic navigation group achieved better accuracy in the coronal plane than the conventional group in terms of postoperative mechanical axis (1.89 +/- 0.63 degrees vs. 3.38 +/- 1.07 degrees ). Less variation was noted in the navigation group (femur: SD 1.88 degrees vs. 7.12 degrees ; tibia: SD 1.54 degrees vs. 2.99 degrees ), although the difference in the mean values was not significant (p = 0.475 and 0.55, respectively). The operation time (from skin to skin) in the navigation group (100.6 +/- 4.3 minutes) was longer than that in the conventional group (92.7 +/- 5.1 minutes; p = 0.027). Two perioperative fractures occurred in the navigation group, both of which were attributed to patient factors as opposed to operation procedures. No major complications such as infection or pulmonary embolism occurred during this study. CONCLUSION: Use of a kinematic navigation system in TKR provides better accuracy than conventional manual methods. The technique is easy to use, has a short learning curve, and requires an additional operation time of less than 10 minutes. Precise alignment can be achieved with the aid of navigation in most cases.     

Laparoscopic lymphadenectomy for gynecologic malignancies using ultrasonically activated shears: analysis of first 100 cases

OBJECTIVE: To evaluate the feasibility, safety and utility of the ultrasonic shears for laparoscopic pelvic and para-aortic lymph node retrieval in the treatment of gynecologic cancers. METHODS: Data on laparoscopic lymphadenectomy performed for gynecologic malignancies using ultrasonic shears over a 5-year period were collected and analyzed prospectively. RESULTS: Laparoscopic lymphadenectomy using ultrasonic shears was performed on 100 patients with a median age of 58 (17-87) years. The types of malignancies included cervical (n = 29), endometrial (n = 48), ovarian (n = 15), fallopian tube (n = 2), malignant mixed mesodermal tumor (n = 2), vaginal (n = 2) and synchronous ovarian and endometrial cancers (n = 2). Sites of lymphadenectomy included pelvic (n = 49), para-aortic (n = 30) or both pelvic and para-aortic (n = 21). The median nodal yield was 22 (0-87). 66/100 were complete lymphadenectomies with a median nodal yield of 28 (2-71). The median length of hospital stay was 2 (1-13) days and the average blood loss was 148 (0-500) ml. Overall complication rate was 13%. There were 3 intra-operative complications, which were all managed laparoscopically. There were no unplanned conversions to laparotomy. There were 10 post-operative complications including port-site metastasis in a patient with positive nodes (n = 1), trocar-site hernia requiring a second laparoscopy (n = 1), deep leg vein thrombosis (n = 1), and a small bowel obstruction (n = 1). CONCLUSIONS: This is the largest series to date demonstrating the safety and efficacy of ultrasonic shears in laparoscopic lymphadenectomy for gynecologic malignancies. In addition to the potential for lowering the risk for tissue damage, ultrasonic shears offer multifunctionality which allows for a simpler technique with the use of fewer instruments.     

Laparoscopic appendectomy in patients with endometriosis

STUDY OBJECTIVE: To report the frequency and spectrum of histologically proved diseases of the appendix in patients undergoing laparoscopic surgery for chronic pelvic pain in conjunction with endometriosis in a tertiary referral center. DESIGN: Patient database with retrospective chart review (Canadian Task Force classification II-3). SETTING: University ambulatory endoscopic surgery center-tertiary referral center. PATIENTS: Two hundred thirty-one women. INTERVENTIONS: Appendectomy during laparoscopic surgery for endometriosis. MEASUREMENTS AND MAIN RESULTS: We reviewed the medical records of 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis performed from January 1994 through July 2004. Of the 231 patients with pelvic endometriosis, concomitant appendiceal pathology was present in 115. CONCLUSION: The appendix may be involved and may contribute to pelvic pain in patients with endometriosis.     

The first 50 live births after autologous oocyte vitrification in France

PurposeThe study aims to describe the newborn health parameters of the 50 first children conceived after autologous oocyte vitrification in France.MethodsThe 50 children born after autologous oocyte vitrification/warming cycle (VAO children) have been retrospectively compared with 364 children conceived by micromanipulation using freshly recovered non-vitrified oocytes (ICSI children). Children included in the study were born between 2011 and 2015. Maternal characteristics (age, body mass index, smoking habits), obstetric outcomes (diabetes, hypertension, placenta previa, parity, mode of delivery), and perinatal outcome (twinning, sex, birth weight, macrosomia, birth defects) were analyzed. The generalized estimating equation for correlated data was performed to evaluate perinatal outcomes and caesarean section.ResultsNo statistically significant difference was found between VAO children and ICSI children, even after adjusting confounding factors (low birth weigh odds ratio (OR) 0.8, 95 % confident interval (CI) 0.3–2.2, adjusted (AOR) 0.5, 95 % CI 0.2–1.7; large for gestational age OR 1.5, 95 % CI 0.3–7.0, AOR 1.6, 95 % CI 0.3–7.5; birth defects OR 0.4, 95 % CI 0.1–3.2, AOR 0.5, 95 % CI 0.1–3.7; caesarean section OR 1.8, 95 % CI 0.9–3.4, AOR 1.8, 95 % CI 0.9–3.7).ConclusionsAccording to our results, newborn health parameters of children conceived in our center by micromanipulation using vitrified/warmed autologous oocytes seem not to be different from children born after micromanipulation on freshly recovered oocytes.     

Laparoscopic sacral colpopexy: short-term results and complications in 83 patients

We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with two strips of synthetic mesh. Five patients had previously undergone hysterectomy and 4 others had experienced failure of surgery for prolapse of the uterus. Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All other 77 patients underwent laparoscopic sacropexy using anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was associated in 60 cases, laparoscopic Burch colposuspension in 74 and levator myorraphy using the vaginal approach in 55. Operative time decreased from 292 to 180 minutes as the surgeon gained experience. The main operative complications were one rectal and two bladder injuries. Three patients required reoperations for haematoma or hemorrhage. One patient complained of chronic inflammation of the cervix and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow up was 343 days. Three other patients required reoperation: one for a 3(rd) degree cystocele and two for recurrent stress incontinence. The conclusion of this study is that laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long term assessment is required to confirm the results of this procedure.