An easy and effective method of cholangiography in laparoscopic cholecystectomy: laparoscopic cholecystocholangiography

BACKGROUND: There is ample evidence that the incidence of operative cholangiography has declined since the introduction of laparoscopic cholecystectomy. It has been suggested that one of the reasons for this decline is the technical difficulty of cystic duct catheterization. A method of cholangiography which does not require such catheterization has been developed by others. This paper examines the ease and effectiveness of operative cholangiography performed by direct puncture of the gall-bladder. METHODS: A retrospective study was made of the records of 380 consecutive patients who underwent attempted laparoscopic cholecystectomy. After exclusion of patients in whom laparoscopic cholecystectomy was abandoned in favour of open cholecystectomy and those patients in whom operative cholangiography was not attempted, the records of 325 patients were available to the study. The operation notes of each patient were studied to determine whether, in the operator's opinion, a successful cholangiogram had been obtained. RESULTS: There were 290 patients in whom cholangiography was attempted using direct gall-bladder puncture (cholecystocholangiography (CCC)). There were 35 patients in whom cholangiography was attempted via cystic duct cannulation (CDC). Cholecystocholangiography was successful in 86% of those cases in which it was attempted. Cystic duct cannulation was successful in 83% of those cases in which it was attempted. CONCLUSION: Cholecystocholangiography is a valid alternative to cystic duct catheterization in its ability to achieve intra-operative cholangiography in the setting of laparoscopic cholecystectomy.     

后腹腔镜输尿管切开取石术中防止结石移位的改良方法

目的探讨应用一个血管夹防止后腹腔镜输尿管切开取石术术中结石移位的临床应用价值。方法 2006年3月至2009年6月共收治输尿管上段结石患者58例,随机分组后所有患者均行后腹腔镜输尿管切开取石术。26例术中采用无损伤血管夹钳夹结石上方输尿管再行输尿管切开取石,32例术中直接切开输尿管取石,两组术中均留置双J管,比较两组的总手术时间、取石时间、术中出血量及术后随访手术疗效。结果 58例手术全部成功,无一例中转开放手术,术中均无输血。两组在手术时间、术中出血量及住院时间上差异均无统计学意义。血管夹组较直接切开取石组取石时间短。两组术后复查均未见结石残留,无并发症发生。结论术中应用血管夹可防止结石向输尿管上方移位,降低取石难度,缩短术中取石时间,有临床应用价值。     

Minimizing ports to improve laparoscopic cholecystectomy

BACKGROUND: Minimizing the number and scope of ports used to perform laparoscopic cholecystectomy attempts to build on the improvements in postoperative pain control, rapid return to activity and work, patient satisfaction, and cosmetic result achieved by the laparoscopic method. METHODS: We studied 141 patients in two sequential studies: the first a prospective randomized trial with 41 patients, and the second an examination of the more minimal procedure in 100 patients. In the randomized trial, patients underwent laparoscopic cholecystectomy with three ports: three 5-mm ports or two 10-mm ports and one 5-mm port. The 100 patients underwent the three 5-mm port procedure. RESULTS: In the randomized trial, differences were not statistically significant. However, on the average, the group with three 5-mm ports required less medication over less time, had less postoperative pain, and took less time to return to activity than the second group with larger ports. A statistically significant difference was found in incisional pain between the smaller group (21 patients) with two 10-mm ports and one 5-mm port and the larger group (100 patients) with three 5-mm ports, whether the measure was overall incisional pain (p = 0.014) or a comparison based on specific ports (p = 0.001). The percentage of cases requiring port enlargement to remove the gallbladder was not significantly different between the groups. There were no conversions to an open procedure, no fourth trocars added, and no complications. No patient required overnight hospitalization. CONCLUSIONS: Reducing the number and size of ports in laparoscopic cholecystectomy sustains or enhances the improvements initiated by performing laparoscopic rather than open cholecystectomy. In a comparison of microlaparoscopic procedures, patients undergoing the procedure with the shorter incisions experienced significantly less pain.     

A new method to prevent port dislodgement during laparoscopic surgery

We report a quick, reliable, and inexpensive method of ensuring laparoscopic port position when used in conjunction with a port anchoring device.     

An easy method for diagnosis of lymphedema

Lymphoscintigraphy has been very useful in determination of lymphatic abnormalities. However, the radioactive isotopes used have been investigational and difficult to obtain. The purpose of this study was to examine patients with extremity edema by lymphoscintigraphy using a radioactive colloid readily available in our nuclear pharmacy, Technetium 99m sulfur minicolloid. Forty limbs in 20 patients were evaluated using Technetium 99m sulfur minicolloid lymphoscintigraphy. All patients had lower extremity edema initially attributed to a venous or lymphatic etiology. There were 12 patients with normal bilateral studies. Seven patients exhibited unilateral obstruction to lymphatic flow, and one had unilateral enhanced flow of lymph. Those with normal studies included five patients with nonspecific edema, four with varicosities, and one patient each with acute deep vein thrombosis, chylous ascites, and excision of the greater saphenous vein for arterial bypass grafting. Five patients with obstructed patterns had previous arterial bypass procedures, one had trauma to the extremity, and one had lymphedema tarda. The one enhanced lymphoscintigraphic pattern was seen in a patient with acute cellulitis. All patients had Doppler venous examinations and other studies included strain gauge phlethysmography, venograms, computed tomography, magnetic resonance imaging, and ultrasound. As with other scintigraphic imaging agents used to study lymphatic flow, Technetium 99m provides clinically useful information in evaluating the swollen extremity noninvasively.Presented at the Annual Meeting of the Peripheral Vascular Surgery Society, New York, New York, June 17, 1989.The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense.     

The suprahepatic approach. An easy laparoscopic access to the hiatus in obese patients

The conventional laparoscopic access to the gastroesophageal junction involves the retraction the left hepatic lobe upward. This approach could be particularly difficult in obese patients because of a huge fatty liver. The technique described here aims to overcome this difficulty be using a suprahepatic route by displacing the left lobe downward after dividing the left triangular ligament. This approach allows a good exposure of the gastroesophageal junction to perform a fundoplication or a gastric banding.     

An easy method for laparoscopic-assisted percutaneous anterior gastropexy

Laparoscopic antireflux surgery is becoming a standard procedure in pediatric surgery. Anterior gastropexy is often performed in antireflux procedures, as well as in children with recurrent and intermittent volvulus of the stomach. We present a simple and secure technique for anterior laparoscopic-assisted gastropexy.     

An easy method for preparation of postage stamp autografts

A modified technique of postage stamp autografting is studied. By using quick cutting plates, chessboard tray, skiing technique and petrolatum gauze, skin islands can be uniformly located and correctly oriented on the gauze. Moving the skin squares on the stainless steel tray is relatively easy, and the expansion ratio can be predicted by means of the chessboard diagram. The skin island grafts adhere to the petrolatum gauze when the gauze is applied to the tray. Then, as in the modified Meek technique, the “autografting carrier” can be used to cover the burn wound. In comparison with the modified Meek technique, this method does not require expensive equipment. The quick cutting plates can take over the function of the modified Meek–Wall dermatome. The stainless steel trays and the petrolatum gauze are easily available. The advantages of this method include: (1) the expansion ratio can reach up to 1:9, (2) the preparation procedures are not time consuming, (3) regular distribution of these skin islands shortens the healing time, and (4) the cost of this method is relative low. The results of this technique are comparable to that of the modified Meek technique. This preliminary study reveals that this technique is an easy and economic alternative for the treatment of extensive burn patients.     

An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery

Laparoscopic appendectomy, cholecystectomy, or anti-reflux procedures are conventionally performed with the use of one and often two 10/12-mm ports. While needlescopic or micropuncture laparoscopic procedures reduce postoperative pain, they invariably involve the use of one 10/12-mm port and the instruments applied have their ergo-dynamic shortcomings. Between September 2002 and March 2003, we have attempted an "all 5-mm ports" approach in 49 laparoscopic procedures, which included 18 of 59 laparoscopic cholecystectomies (31%), 26 diagnostic laparoscopies for suspected appendicitis (of which we proceeded to a laparoscopic appendectomy in 17 patients), and in the last 5 of 9 laparoscopic Nissen fundoplications. Conversion of one of the 5-mm ports to a 10-mm port was required in 5 of the 18 (28%) laparoscopic cholecystectomies and in 6 of the 17 (35%) laparoscopic appendectomies to facilitate organ retrieval in patients with large gallstones (>5 mm in diameter) and in obese patients with fatty mesoappendix. There were no conversions to open surgery. No significant differences in the operating time between the laparoscopic procedures performed by the all 5-mm ports approach or the conventional approach were observed. No intraoperative or postoperative complications occurred in this series. The "all 5-mm ports" approach to laparoscopic cholecystectomy and appendectomy in selected patients and to laparoscopic fundoplication appears feasible and safe. A randomised comparison between this approach and the conventional laparoscopic approach to elective cholecystectomy and fundoplication in which two of the ports employed are of the 10-mm diameter is warranted.     

An easy method of deflating a blocked Foley balloon

Blocked Foley balloons are occasionally encountered by many urological surgeons. A number of methods of removing a blocked balloon catheter have been advocated. They are usually invasive, time and resource consuming and often ineffective. A non-invasive, reliable and safe technique of deflating a blocked catheter balloon by inserting a Glidewire through the balloon channel is reported in the present paper.     

An improved method of laparoscopic diagnosis

The construction of a modified tube of laparoscope is described which allows to perform reiterated examinations without a repeated puncture of the abdomen. No complications were noted after dynamic (repeated) laparoscopies in 125 patients.     

预防腹腔镜脾切除术出血的外科技术要点

目的:探讨预防腹腔镜下脾切除术术中出血的技术。方法:完全腹腔镜手术治疗肝硬化脾肿大6例,特发性血小板减少性紫癜(idiopathic thrombocytopenic purpura,ITP)5例,脾恶性淋巴瘤3例,脾血管瘤2例,外伤性脾破裂1例。手术步骤包括解剖结扎脾动脉,切断脾周韧带,解剖结扎脾门血管并离断。结果:全部病例均用腹腔镜完成手术。患者均行脾门血管逐条解剖后结扎离断。手术时间50～240min,平均(110±35)min。出血20～1500ml,平均(160±87)ml。结论:完全腹腔镜脾切除术可行,术中早期脾动脉结扎、脾门血管逐条解剖结扎后离断是控制术中出血的关键,紧贴脾实质处理脾蒂可防止胰腺损伤。     

An easy method for passing fine silicone nasogastric tubes

The ready insertion of soft, fine silicone tubes using a spring guide which is used routinely in angiography is described. This has greatly simplified the passage of nasogastric tubes for the delivery of defined liquid diets.