Aseptic laparoscopic colon resection with intraabdominal anastomosis

Background: We evaluated a new aseptic method for laparoscopic left colon resection in terms of technical feasibility and outcome. Methods: Ten pigs were operated on under general anesthesia. Pre- and postoperative body weight, stools, behavior, and need for analgesics were recorded. Fourteen days later, the animals were killed. At autopsy, the degree of intraabdominal adhesions was noted. The anastomoses were sent for histological examination. The entire procedure was performed intracorporeally, and no antibiotics were given. After division of the mesocolon, the segment to be resected was invaginated down through the colon. This was facilitated by a custom-made instrument that was introduced into the bowel via the anus; it consisted of a pull-out device and a modified diathermy wire. The anastomosis was completed at the invagination fold by a row of hernia staples that were covered by an interrupted suture. Then the invaginated bowel was transected by the diathermy wire and delivered through the anus. Results: One animal was killed before completion of the operation because of a colonic perforation. The remaining nine animals had an uneventful and rapid recovery. They ate from the 1st postoperative day and gained weight rapidly. Stools were normal after 2 days (median), and normal behaviour was noted in all animals from the 1st postoperative day. At the postmortem examination, intraabdominal adhesions were observed in two animals. In one case, the adhesions extended from a hematoma in the mesentery to the abdominal wall. There were no adhesions to the anastomosis or the colon. In the other case, the anastomosis adhered to the right uterine tube and a loop of small intestines. Conclusions: The method is technically feasible, but a modification is suggested for cases where the invagination is impossible. Recovery after the operation is rapid. Received: 3 December 1997/Accepted: 21 January 1998     

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     

Is laparoscopic resection of colorectal polyps beneficial?

Background: We set out to compare the results of laparoscopic and open resections of colorectal polyps. Methods: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n= 23); and group II, open procedures for colonic polyps (n= 22). Results: No significant differences were seen between the groups relative to age [71.7 ± 10.7 versus 70.6 ± 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 ± 1.7 cm versus 2.7 ± 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 ± 5 versus 6.6 ± 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost ($22,840 versus $18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 ± 1.0 days versus 5.5 ± 1.8 days), postoperative pain (2.3 ± 1.4 versus 3.7 ± 1.9 on postoperative day 1 [patient pain rating scale 1–10]), length of hospital stay (6.5 ± 2.0 days versus 9.4 ± 2.7 days), and return to normal activity (5.2 ± 4.2 weeks versus 9.3 ± 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 ± 6.4 cm versus 29.1 ± 22.7 cm) and a shorter mean operative time (177.6 ± 52.7 min versus 143 ± 51.4 min) than patients in group I. Conclusions: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen. Received: 27 January 1997/Accepted: 2 February 1998     

Indications for laparoscopic colorectal surgery

Background: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. Methods: Our main aim was to define more specifically the indications for laparoscopic colectomy. Results: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. Conclusions: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20–50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting. Received: 1 November 1996/Accepted: 1 July 1997     

Intracorporeal vs laparoscopic-assisted resection for uncomplicated diverticulitis of the sigmoid

Background: Minimally invasive surgery for uncomplicated diverticulitis of the sigmoid (UDS) may be performed either as an intracorporeal procedure (LICR) or as laparoscopically assisted colon resection (LACR). Methods: Prospectively collected data of 40 selected patients who had undergone LICR for UDS between 1992 and 1994 were compared retrospectively with those of 34 diagnosis-matched LACR controls operated on at the same hospital between 1995 and 1996 to assess the short-term outcome. Results: There were no mortalities. LICR and LACR patients were well matched for age, gender, weight, American Society of Anesthesiologists (ASA) grade, duration of symptoms, and number of previous admissions. There were no significant differences in conversions (one vs three), mobilization of splenic flexure (11:29 vs 9:25), anastomotic distance from anal verge (12 vs 13 cm), estimated blood loss (270 vs 285 ml), passage of flatus (3.1 vs 3.8 days), operating room (OR) costs ($3,040 vs $2,820), and total hospital costs ($9,250 vs $10,050) in LICR and LACR patients, respectively. Suprapubic skin-incision length (36 vs 60 mm, p << 0.01), size of circular stapler 28:31 mm (1:39 vs 6:28, p= 0.03), specimen length (21 vs 11 cm, p << 0.01), complication rates (6 vs 5, p= 0.02), OR time (180 vs 244 min, p < 0.001), resumption of oral solid food intake (3.2 vs 5.8 days, p < 0.001), hospital stay (4.6 vs 9.9 days, p < 0.001), and ward costs ($2,360 vs $4,950, p < 0.001) were significantly different in LICR and LACR patients, respectively. Conclusion: The immediately recognizable advantages of LICR over LACR surmised from this study need further evaluation in a prospective randomized setting. LICR remains a procedure of considerable technical complexity requiring high surgical skills. Received: 20 May 1999/Accepted: 23 November 1999/Online publication: 17 April 2000     

Laparoscopic resection of high rectovaginal fistula with intracorporeal colorectal anastomosis and omentoplasty

A 46-year-old Caucasian female underwent vaginal hysterectomy for myoma in another hospital and developed a high rectovaginal fistula 6 weeks later. A diverting-loop colostomy of the sigmoid colon was performed 2 months later. The patient was admitted to our service with persistent high rectovaginal fistula 6 months later. We resected the sigmoid colon and two-thirds of the rectum including the fistula tract using laparoscopic techniques. An intracorporeal anastomosis was accomplished using a double-stapling technique. An omental flap was mobilized and placed between the colorectal anastomosis and the vagina. Except for a subcutaneous wound infection at the former colostomy site, the postoperative course was uneventful. The patient was discharged at the 7th postoperative day and remained free of symptoms. We conclude that laparoscopic resection of high rectovaginal fistula with primary intracorporeal anastomosis is feasible and should be considered in selected cases as an alternative ``minimal-invasive' approach to this disease. Received: 4 December 1995/Accepted: 23 March 1996     

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer?

Background: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery. Methods: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification. Results: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone. Conclusions: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy. Received: 2 May 1997/Accepted: 11 February 1998     

Conversion of laparoscopic colon resection does not affect survival in colon cancer

Background  Laparoscopic and open resections of colon cancer are considered oncologically equivalent treatment methods. Conversion of laparoscopic procedures, however, was associated with decreased survival in colon cancer patients in the only prior study examining this question. We conducted this study to evaluate the effect of conversion on survival. Methods  A series of consecutive patients treated with laparoscopic resection of colorectal cancer (n = 174) in the period 1998–2003 was evaluated retrospectively. Median follow-up was 51 months with a minimum of 3 years. Results  There was no statistically significant difference in all-cause mortality between laparoscopically completed and converted groups (22/143, 15.4% versus 8/31, 25.8%; OR 1.9, p = 0.164). Kaplan–Meier survival analysis did not show any survival difference between the two groups (p = 0.266). Conclusions  The results of our study suggest there is no survival difference in patients requiring conversion of laparoscopic resection indicated for colorectal cancer. Further examination of this question is warranted to determine whether laparoscopic resection of colorectal cancer should be offered to all patients, including those at high risk for conversion. Partial data were presented at the Society of Surgical Oncology Annual Meeting, March 15–18, 2007, Washington, DC.     

Safety of adrenal vein ligation during endoscopic adrenalectomy

Endoscopic adrenalectomy has been recommended for the treatment of several benign adrenal diseases. The safety of this procedure largely depends on a careful surgical dissection and appropriate hemostatic technique. An established slipknotting technique was employed to control the main adrenal vein in a consecutive series of 14 patients undergoing endoscopic adrenalectomy. The operative steps to ligate the adrenal pedicle are described. A Medline search also was conducted to identify all reported bleeding episodes associated with this procedure. All attempted ligatures of the main adrenal vein were completed successfully by the described technique, and none of our patients required perioperative blood transfusion. Twenty-eight episodes of bleeding collected from the literature were analyzed. Hemorrhagic accidents related to dislodgement of clips were documented at least in three patients. The cause of bleeding was unspecified in 10 patients. Extracorporeal ligation of the main adrenal vein is feasible, safe, and advisable to prevent the occurrence of hemorrhage during endoscopic adrenalectomy. Received: 16 February 1998/Accepted: 28 May 1998     

完全腹腔镜右半结肠癌扩大根治术

在全麻下行完全腹腔镜右半结肠癌扩大根治术:先行腹腔探查,沿肠系膜上动脉左侧打开右结肠系膜,清扫回结肠血管根部淋巴结,进入toldt间隙,显露胰头。分别裸化离断右结肠动静脉、结肠中动静脉的右支,显露肠系膜上静脉的Henle干,裸化离断胃网膜右动静脉。然后血管弓内打开胃结肠韧带,用腔镜切割闭合器离断横结肠;游离回盲部,距回盲部20 cm离断回肠。最后腔镜下将回肠与横结肠行overlap吻合,用倒刺线关闭共同开口及系膜裂孔。手术顺利,历时160 min,术中出血约5 ml。患者术后恢复良好,未出现术后并发症,术后第7天出院。术后病理分期示:T4a N0M0。     

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     

腹腔镜结肠癌根治术的临床疗效评估

目的评价腹腔镜结肠癌根治术的临床疗效。方法对2000年1月到2004年1月间于浙江大学医学院附属邵逸夫医院进行腹腔镜与传统开腹结肠癌根治术病例共102例,作同期非随机对照研究。其中,腹腔镜结肠癌根治术(腹腔镜组)47例,常规开腹结肠癌根治术(开腹组)55例。比较两组病例术中和术后情况、病理分期及随访结果。结果2组病例在年龄、性别和手术方式方面差异均无统计学意义。腹腔镜组平均手术时间长于开腹组[分别为(182±62)min和(141±37)min],而其术后住院时间明显缩短[分别为(5.3±1.9)d和(8.2±1.2)d]。两组切缘均为阴性,淋巴结清扫数和Dukes分期差异无统计学意义。随访12～48个月(平均21个月),两组均未发现切口转移,两组局部复发和远处转移差异也无统计学意义。结论腹腔镜结肠癌根治术具有切口小、创伤轻、恢复快的优点;而在根治彻底性、复发率与生存率方面与传统开腹手术无明显差异。     

A simple laparoscopic method to provide access to the gastroesophageal junction in obese patients

By now, the feasibility of laparoscopic surgery in obese patients is well established; a conversion rate of 1.4–4.3% has been reported [1, 2]. The main reason for conversion in these cases is the difficulty encountered in exposing the gastroesophageal junction due to a huge fatty liver that covers the entire upper abdomen (``the invisible stomach' [1]). We report here a simple method that allows easy access to the upper stomach in such cases. This technique involves the exposure of the gastroesophageal junction using a laparoscopic suprahepatic route. Received: 30 April 1999/Accepted: 5 October 1999/Online publication: 24 March 2000     

Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis

Background: The management of rectal cancer has been changing to include more sphincter-sparing procedures. We report our initial experience with a new technique incorporating laparoscopy and a transsacral approach for low or midlevel rectal cancer. Here, we tried to determine whether this sphincter-sparing method could produce acceptable morbidity and recurrence rates. Methods: Patients with rectal cancer 4 to 8 cm from the dentate line underwent laparoscopically-assisted transsacral resection (LTR) with primary anastomosis. With this technique, the rectosigmoid is mobilized via laparoscopy while the patient is in the supine position. Next, the patient is placed in the prone jackknife position, and a segment of rectum is resected by a transsacral approach. Age, estimated blood loss, length of time in the operating room, length of stay, and postoperative complications were noted. Aspects of the tumor pathology regarding stage, lymph nodes, tumor size, and presence of tumor at resection margins also were recorded. Results: A total of 13 patients, ages 26 to 70 years (mean, 52.5 years), underwent the procedure. No perioperative deaths occurred. The mean hospital stay was 9.6 days. The average size of the rectal lesion was 4.3 cm in the largest dimension. The average specimen contained 11.5 total, and 2.0 metastatic lymph nodes. Postoperative complications included two anastomotic breakdowns and two other wound complications. Late follow-up evaluation ranged from 10 to 30 months, with 11 of 13 patients alive (85% survival). Two local recurrences and three distant recurrences were noted at long-term follow-up assessment. Conclusions: In selected patients with low or midlevel rectal cancer, LTR may be a viable option. Further experience is necessary to define its oncologic efficacy and whether routine temporary diverting colostomy is indicated. Received: 16 June 1999/Accepted: 1 November 1999/Online publication: 12 July 2000     

Short-stay laparoscopic adrenalectomy

Background: We performed a consecutive series of unilateral laparoscopic adrenalectomies (LA) with the expectation of short (less than 24 h) hospital stay. Results were compared with those from laparoscopic cholecystectomy (LC) and unilateral open adrenalectomy (OA). Methods: A combination of chart review and patient questionnaires was used to compare LA (n= 19) to LC (n= 20) regarding length of stay (LOS), narcotic requirements, and time to full recovery. Chart reviews also were used to compare LA to OA (n= 48) regarding operating room time (OR time), LOS, and surgical morbidity. Results: All of the LC patients as compared with 47% of the LA patients were discharged within 24 h. The reason for additional hospitalization in the LA group was pain control. After discharge, the narcotic requirement lasted 6.6 days in the LA group as compared with 3.4 days in the LC group (p < 0.01), but the times until full recovery were not significantly different (12.2 vs 11.3 days respectively). Operating room times did not differ significantly between the LA and OA groups (3.3 and 3.8 h, respectively), but there were fewer postoperative complications and much shorter LOS in the LA group (1.5 vs 6.3 days; p < 0.001), a difference that remained significant even when cases from the same time period were compared. Conclusions: Increased pain in LA as compared with LC patients may result in a slightly longer LOS and higher narcotic requirement during the early postoperative period, but time to full recovery between the two groups is the same. As compared with its open counterpart, LA offers a significant reduction in LOS and morbidity with no increase in OR time. Received: 12 February 1999/Accepted: 24 October 1999/Online publication: 28 April 2000     

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis. Case history: A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation. Received: 12 April 1996/Accepted: 26 November 1996     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

A new technique for laparoscopic resection of a submucosal tumor on the posterior wall of the gastric fundus

Several reports have been published which describe the technique of using an Endo GIA to resect submucosal tumors on the anterior wall of the stomach. Lesions on the posterior wall, however, especially near the esophagocardiac junction (ECJ), are difficult to resect using these reported techniques. This is because the surgeon must divide the omentum and enter the omental bursa in order to use a similar extraluminal technique. Furthermore, special care must be taken to ensure that resections do not involve the ECJ and narrow the esophagus. In order to overcome these difficulties, we have proposed a new technique for the laparoscopic excision of a submucosal tumor located on the posterior wall of the gastric fundus. The principle of this procedure involves the intraluminal resection of the submucosal tumor, including the surrounding stomach wall, using the Endo GIA. This technique is safe, simple, and effective. We believe that we are the first to address the excision of a submucosal lesion by resecting the full thickness of the posterior gastric wall lesion intraluminally. Received: 11 November 1996/Accepted: 2 April 1997     

Anaesthetic experience with laparoscopic cryotherapy

Background: Laparoscopic cryotherapy is a new technique for treating hepatic tumors that obviates the need for a laparotomy and may reduce the amount of surgical trauma and heat loss associated with the open technique. Liquid nitrogen is applied to the tumor via a cryoneedle probe introduced through a laparoscopic port. The aim of this study was to assess the effect on body temperature and the hematological and biochemical changes associated with this technique. Methods: Five patients who underwent this procedure were studied prospectively under a standardized general anaesthetic. Core and peripheral temperature were measured during the procedure, and blood samples were taken for hematological and biochemical analysis. Results: Freezing time ranged 19–57 min and measured blood loss 0–1000 ml. In one case, bleeding resulted from hepatic surface cracking. Three patients required a blood transfusion. The mean fall in both nasopharyngeal and right atrial temperature was 0.4°C. Postoperatively, all patients showed a large rise in alanine aminotransferase (ALT) and a fall in platelet count. A systemic inflammatory response syndrome was seen in some cases, but all patients survived to hospital discharge. Conclusions: Laparoscopic hepatic cryotherapy can be performed without significant temperature changes, but it entails significant morbidity. Received: 3 March 1997/Accepted: 28 April 1997