Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe

Laparoscopic ultrasonography is a novel technique which may be useful in screening for choledocholithiasis during laparoscopic cholecystectomy. Following concerns regarding the learning curve and accuracy associated with the adoption of this user-dependent technology, we have prospectively evaluated a commercially available 90° sector scanning laparoscopic ultrasound probe during elective laparoscopic cholecystectomy. Laparoscopic ultrasonography was performed in 60 patients and identified common duct stones in nine patients (one false positive and one false negative), and previously unsuspected duct stones were defined in three out of four patients. The gallbladder and portal vein were constantly defined anatomical landmarks throughout the study, whereas the suprapancreatic bile duct, intrapancreatic bile duct, and pancreatic duct were identified in 100%, 80%, and 85% of patients in the third consecutive group of 20 patients examined. Laparoscopic ultrasonography has the potential to accurately identify common duct stones during laparoscopic cholecystectomy and thereby implement a policy of superselective operative cholangiography. However, adequate training for surgeons unfamiliar with this technology is recommended.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Usefulness of both operative cholangiography and conversion to decrease major bile duct injuries during laparoscopic cholecystectomy

Background/Purpose We evaluated the role of operative cholangiography and of conversion to decrease major bile duct injuries.Methods We report 1074 patients who underwent laparoscopic cholecystectomy, out of a total of 1195 patients who underwent laparoscopy, over an 8-year period. The planned laparoscopic operative procedure in all the patients was the standard four-port technique with the operator on the left side of the patient. Operative cholangiography was performed with Olsens pliers.Results We performed 993 (83%) operative cholangiographies; 121 (10.1%) patients were converted from laparoscopic to open cholecystectomy. Despite a prolonged time of dissection, 54 (4.5%) patients were converted because of unclear anatomy of Calots triangle. One hundred and ninety patients suffered acute cholecystitis and, of those, 52 (27.3% of 190 patients) were converted. Fifteen patients showed intraoperative biliary duct stones and they were converted. Seven (0.58%) bile duct injuries (one stricture and six fistulas) are reported.Conclusions The low number of major bile duct injuries reported in our study showed the value of operative cholangiography during laparoscopic cholecystectomy. Moreover, another important factor found to reduce major bile duct injuries was conversion when, despite accurate dissection, the anatomy of Calots triangle remained unclear.Presented at the poster session of the 103rd Congress of The Japan Surgical Society, Sapporo, Hokkaido, Japan, June 2003, and published in abstract form in the Journal of the Japan Surgical Society (2003) 104: 1072–1073 (data-related years 1993–2000).     

Calibration of papillotomy in the surgical treatment of papillary stenosis: the “little train”

Although laparoscopic and endoscopic surgery have brought about an indisputable revolution in biliary surgery, many surgeons still prefer open surgery for lithiasis of the common bile duct, and if it is associated with a papillary pathology, they perform a papillotomy. However, great controversy regarding the site, modalities, and extension of the papillary section has now developed among surgeons. Our technique is not original; however, we do propose a calibration of the papillotomy, carried out by constructing a little train made up of several consecutive Nélatons of increasing caliber to identify the sphincter fibers and to obtain sections proportionate to the size of the bile duct. Of the 115 patients in this series who were treated by open papillotomy, only 1 developed acute pancreatitis; 2 demonstrated bleeding, 1 of whom required surgical exploration.     

Bile leak from the liver bed following laparoscopic cholecystectomy

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the ducts of Luschka. Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.     

Complications after laparoscopic cholecystectomy

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed.From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n=15), associated in six cases also with percutaneous cholangiography (PTC). Minimally invasive treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by minimally invasive techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n=4), ductal stricture by endoloop (n=1), iliac artery injury (n=1), and phlegmon of gallbladder bed (n=1).It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be managed by a multidisciplinary approach wherein the radiologist and the endoscopist strictly cooperate with the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patient's problem. Using this approach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.     

The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

Background The routine use of laparoscopic common bile duct exploration (LCBDE) for common bile duct (CBD) stones discovered during cholecystectomy would be further supported if the long-term outcomes were similar to those for endoscopic retrograde cholangiopancreatography with endoscopic papillotomy (ERCP/EP).Methods A retrospective review was completed of 151 patients who had a positive intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). A positive IOC was defined as a filling defect or lack of contrast flow into the duodenum. A successful CBDE was defined as a negative IOC after completion of CBDE. Long-term follow-up was obtained using a standardized questionnaire to determine the incidence of recurrent biliary pain or need for subsequent ERCP/EP.Results CBD exploration was attempted in 142 patients (transcystic LCBDE 126 and open CBDE 16) and was successful in 107 of 142 (75%). Transcystic LCBDE was successful in 90 of 126 (71%). ERCP/EP was used in 41 patients; 35 of these cases were for failed LCBDE. Pancreatitis was not observed in any patient after CBDE but was observed in 3 of 41 patients (7.3%) after ERCP/EP. Long-term follow-up of the LCBDE versus ERCP/EP patients revealed no difference in the incidence of recurrent biliary pain or need for subsequent ERCP (mean follow-up time of 61 months).Conclusion LCBDE is safe and effective in the majority of cases when an attempt at transcystic LCBDE was made. In addition, after long-term follow-up of >5 years, the outcomes were similar if the stones were removed by intraoperative laparoscopic methods versus postoperative ERCP. LCBDE seems worthy of pursuing when an intraoperative CBD stone is discovered.Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 2003     

Immunohistochemical study of characteristics of bile duct dysplasia evaluated on the basis of expression of metastasis/invasion-related factors and p53

Background/Purpose Bile duct carcinoma still continues to have an unfavorable prognosis, despite an improved rate of curative resection and the development of surgical techniques. We evaluated the expression of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and intercellular adhesive factors (E-cadherin, -catenin, -catenin) in cancer, dysplastic lesions, and normal (nonatypical) epithelia (glandulous ducts) in patients with bile duct carcinoma. Positivity rates for these factors were compared among the three histological types to examine the characteristics of bile duct dysplasia.Methods Among 89 patients with bile duct carcinoma resected at our hospital during the past 10 years, we studied 18 patients who concurrently had a cancerous lesion, dysplastic lesion, and normal (nonatypical) epithelia adjoining each other in excised specimens. The immunohistochemical expressions of MMPs, TIMPs, E-cadherin, -catenin, and -catenin were investigated.Results Positivity rates for MMP-9, TIMP-1, TIMP-2, membrane type (MT) 1-MMP, MT2-MMP, and E-cadherin were significantly higher in cancerous than in normal epithelium. Only the positivity rate for MT1-MMP was significantly higher in dysplasia than in normal epithelium. Positivity for MMP-related factors correlated with the degree of atypia of the bile duct epithelium. Differences between cancer and dysplasia were slightly greater than those between dysplasia and normal epithelium. Likelihood ratios between cancer and dysplasia, cancer and normal epithelium, and dysplasia and normal epithelium were higher than 5 for all metastasis-related factors and higher than 10 for most factors. This finding suggests that a normal-dysplasia-carcinoma sequence underlies the development of bile duct cancer accompanied by dysplasia.Conclusions The phenotypic characteristics of dysplasia are closer to those of normal epithelium than to those of cancerous epithelium. A normal-dysplasia-carcinoma sequence is apparently involved in the development of bile duct cancer accompanied by dysplastic cells.     

Fundus-first laparoscopic cholecystectomy

Removal of the gallbladder with commencement of dissection at the fundus is well recognized as a safe technique during difficult open cholecystectomy because it minimizes the risks of damage to the structures in or around Calot's triangle. We report here the routine employment of liver retractors and fundus-first dissection during laparoscopic cholecystectomy (LC) as an alternative to techniques previously described.Retraction of the liver and fundus-first dissection was used in 53 patients who underwent laparoscopic cholecytectomy. There were 16 male and 37 female patients. Seven were operations performed during an acute admission and 20 had moderate or severe adhesions involving the gallbladder. Thirteen patients had a preexisting abdominal incision.The procedure was successful in 52 patients (98%), but in one patient it was converted to open operation because of dense adhesions. Median duration of operation was 90 min (range 35–240 min). There was no mortality and two complications (persistent right upper quadrant pain for 2 weeks after operation and bile leakage from the gallbladder bed).The facility to retract the liver and carry out a fundus-first dissection extends techniques developed for open surgery into the laparoscopic arena. It offers the surgeon the safety and versatility during laparoscopic cholecystectomy that it confers during conventional open surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Confirmation of a ``safety zone' by intraoperative cholangiography during laparoscopic cholecystectomy

Background: Creating a safety zone during laparoscopic cholecystectomy is defined as dissection of the cystic duct as close as possible to the gallbladder. Methods: In 29 out of 802 cases in which laparoscopic cholecystectomy was difficult to perform due to uncertainty about the orientation of Calot's triangle, intraoperative cholangiography was performed, using a titanium clip as a marker that designated the safety zone. The distance between the clip and the common hepatic duct or the common bile duct could be determined by evaluation of two intraoperative cholangiograms taken in different orientation. Results: If the clip was located in the safety zone, and was distant from the common hepatic duct or common bile duct, the safety of preparation around the clip was ensured. No complication was encountered in these cases with this method. Eventually, no biliary tract injury was experienced, and the overall conversion rate to open cholecystectomy was only 0.4% (3 of 802 consecutive cases). Conclusions: This method of confirming the safety zone by intraoperative cholangiography is a useful procedure for avoiding inadvertent injury to the biliary tract.     

Importance of surgical technique in prevention of retained and recurrent bile duct stones

Approximately 10% of the 500,000 patients who undergo cholecystectomy for gallstones each year in the U.S.A. have associated choledocholithiasis. Of the patients who have a choledocholithotomy, 10–13% are found to have retained bile duct stones in the immediate postoperative period, and an unknown additional number are found to have biliary calculi subsequently. Residual bile duct calculi come from 3 sources, namely, retained stones that were overlooked during the initial operation, retained stones that were recognized but could not be removed at the initial operation, and recurrent stones that re-form in the bile ducts in association with highly lithogenic bile. Most retained stones can be prevented by knowing when and how to perform common bile duct exploration. Absolute indications, which have a high yield of calculi, are: (a) palpable stones, (b) obstructive jaundice with cholangitis, (c) demonstration of stones by cholangiography, and (d) dilatation of the common duct beyond a diameter of 12 mm. Relative indications, use of which requires judgment because of a generally low yield of calculi, are: (a) jaundice without cholangitis, (b) biliary-enteric fistula, (c) small stones in the gallbladder, (d) a single-faceted gallbladder stone, and (e) pancreatitis. Technical aspects of common duct exploration that are important for prevention of retained bile duct calculi include: (a) routine use of a Kocher maneuver, (b) routine preexploratory operative cholangiography, (c) use of the balloon-tipped catheter, (d) routine completion cholangiography through a T tube, and (e) operative biliary endoscopy. A large number of retained stones results from inadequate operative cholangiography due to poor radiographic equipment, inattention to details of technique, and insufficient collaboration between radiologist and surgeon. Since approximately 25% of reoperations for residual stones are followed by subsequent recurrence of choledocholithiasis, sphincteroplasty and choledochoduodenostomy play an important role in prevention of recurrent calculi. Use of these adjunctive biliary drainage procedures is indicated: (a) when it is impossible to surgically extract bile duct stones or for impacted ampullary stones, (b) when the biliary tree is packed with many stones, (c) when reoperation is required for primary bile duct stones, (d) in third operations for bile duct calculi of any type, and (e) rarely, when bile duct stones are associated with stenosis of the papilla of Vater.

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Résumé Quelques 10% des 500,000 malades qui sont cholécystectomisés pour lithiase vésiculaire chaque année aux U.S.A. ont une lithiase cholédocienne. Après exploration de la voie biliaire principale, on trouve dans la période postopératoire précoce des calculs résiduels du cholédoque chez 10–13% des opérés; de plus, chez un certain nombre de malades, dont le pourcentage est inconnu, des calculs résiduels sont découverts ultérieurement. Ces calculs cholédociens peuvent avoir 3 causes: calculs résiduels oubliés à l'exploration initiale, calculs résiduels découverts à l'opération mais que l'on n'a pu extraire, calculs récidivants qui se reforment dans la voie biliaire en association avec une bile à pouvoir lithogène élevé. Pour éviter les calculs résiduels, il faut savoir quand et comment explorer un cholédoque. Les indications absolues, celles qui découvrent très fréquemment des calculs sont: (a) calculs palpables, (b) ictère obstructif avec angiocholite, (c) calculs démontrés par la cholangiographie, (d) cholédoque dilaté à diamètre supérieur à 12 mm. Les indications relatives, qui demandent un meilleur jugement parce que leur rendement est plus faible, sont: (a) ictère sans angiocholite, (b) fistule bilio-digestive, (c) calculs de petite taille dans la vésicule, (d) un seul calcul polyédrique dans la vésicule, (e) pancréatite.Les aspects techniques importants pour éviter l'oubli de calculs sont: (a) utilisation de routine de la manoeuvre de Kocher, (b) cholangiographie peropératoire systématique avant l'exploration cholédocienne, (c) utilisation d'un cathéter à ballonnet, (d) cholangiographie systématique après mise en place du drain de Kehr, (e) endoscopie biliaire peropératoire. Dans un bon nombre de cas, le calcul oublié est dû à une cholangiographie peropératoire inadéquate, par mauvais équipement, technique imparfaite ou insuffisance de collaboration entre le radiologue et le chirurgien.Comme quelques 25% des réinterventions pour calculs résiduels sont suivies de récidive de lithiase cholédocienne, la sphinctéroplastie et la cholédocoduodénostomie ont un rôle préventif important. Les indications de ces opérations de drainage sont: (a) l'impossibilité d'extraire les calculs et les calculs enclavés dans l'ampoule de Vater, (b) les calculs très nombreux avec empierrement cholédocien, (c) les rénterventions pour calculs primaires du cholédoque, (d) toute troisième opération, quel que soit le type de calcul, (e) plus rarement, l'association d'une lithiase biliaire avec une sténose de la papille.

     

Experience with laparoscopic double gallbladder removal

Double gallbladder is a rare congenital anomaly and an encounter with it while performing cholecystectomy laparoscopically is a challenge to the laparoscopic surgeon. A 28-year-old man complaining of epigastric pain was evaluated at Teikyo University Hospital, Mizonokuchi, Japan. There were no abnormal laboratory findings. Ultrasonography revealed an acoustic shadow in each compartment without any inflammatory changes in the gallbladder. No lesions were endoscopically noted in the stomach. CT scan could not demonstrate the anomaly. ERCP revealed a duplication of the gallbladder shadow with a stone in each vesicle and also the confluence of two cystic ducts from both the gallbladders draining into the common bile duct (CBD). Laparoscopic cholecystectomy was performed successfully in this case. This paper presents this particular case because of double gallbladder's rarity in the literature and to emphasize the importance of preoperative cholangiographic evaluation for double gallbladder. The laparoscopic surgeon is given an idea of the meticulous dissection at the hepatocystic triangle due to the various other vascular and other congenital anomalies associated with it. An account of the classification of this congenital abnormality and its various types is also discussed here.     

Changing trends in the management of gallstone disease

Background: Day case cholecystectomy is increasingly becoming a management option for elective cases while same admission cholecystectomy is now considered a favorable option in the treatment of acute cholecystitis. To assess the advent of these changes in our surgical practice, a retrospective analysis of our experience is presented. Methods: All patients undergoing cholecystectomy between January 2000 and January 2001 were analyzed according to admission status, operation type, conversion rate, complications, and nonsurgical intervention. Results: 156 patients underwent cholecystectomy and 152 charts were retrieved. Laparoscopic cholecystectomy was performed on 95% of patients with a conversion rate of 9%. Morbidity for the series was 12.5%, including one common bile duct injury (0.6%). Day case and acute cholecystectomy comprised 67% of our cholecystectomy practice. Conclusions: Our findings suggest that there is an increasing trend toward shortening the hospital stay of patients undergoing laparoscopic cholecystectomy. This does not appear to have had a deleterious effect on outcome.     

Suppression of proliferative cholangitis in a rat model by local delivery of paclitaxel

Background. Proliferative cholangitis (PC) leads to biliary stricture, which is the main cause of hepatolithiasis, recurrent cholangitis, and biliary cirrhosis. The aim of this study was to determine whether local delivery of paclitaxel, which inhibits cell proliferation by overstabilization of microtubules, prevents PC in a rat model.Methods. PC was induced by introducing a fine nylon thread into the bile duct in a rat. Paclitaxel (100µl of 10, 100, and 1000µmol/l) or solvent vehicle was administered into the bile duct for 15min. One week after treatment, histopathologic examination and 5-bromodeoxyuridine (BrdU) labeling of the bile duct were performed.Results. In comparison with the control, the mean thickness of the bile duct was reduced by 29% in the 1000µmol/l paclitaxel-treated group (2.61 ± 0.31µm vs 3.67 ± 0.25µm, P 0.05). The luminal area increased (P 0.0001) and the grade of epithelial–glandular proliferation was decreased (P 0.01) as the dose of paclitaxel increased. Ductal fibrosis and inflammatory cell infiltration were similar in both groups. The BrdU labeling index was significantly lower in the paclitaxel-treated group (P 0.05).Conclusions. Local delivery of paclitaxel suppressed PC in a rat model by the inhibition of epithelial–glandular proliferation and may offer an effective therapeutic option for biliary stricture.     

Injury to the diaphragm and its repair during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has now become the gold standard for the treatment of gallstone disease. Parallel with the conversion from the open to the laparoscopic technique, some complications peculiar to the laparoscopic approach have been experienced. Such a technique-related complication, resulting in an injury to the diaphragm and its repair during laparoscopic cholecystectomy is presented.     

Which X-ray views are required in juvenile ankle trauma?

Summary Although ankle sprains are probably the most common injury in adolescent sports people, epiphyseal injuries are missed on the presumption of a ligamentous tear. The risk of damaged ligaments has been over-emphasized while the potentially dangerous epiphyseolysis has been understressed. An oblique X-ray of the ankle joint is indicated prior to stress pictures.     

Demonstration of the 5-flap technique

Summary Demonstration of the 5-flap technique which is double opposed Z-plasty and Y – V advancement is presented. A 4×4 gauze serves to demonstrate this technique.The authors dedicate this paper to the dear memory of their teacher, the late Prof. Zvi Neuman, who passed away untimely on March 22, 1977     

PTSD among vietnam veterans: An early look at treatment outcome using direct therapeutic exposure

Vietnam combat veteran inpatients were evaluated after being treated in a PTSD special treatment unit. Selected pretreatment measures that included mental and physical problems, combat variables, PTSD symptoms, and the standard MMPI scales found no clinically meaningful differences between a group that was found to be successes and another group found to be failures, based on predetermined cutoff scores on the VETS scale, a reliable outcome measure for veteran patients. At 3 months post-therapy, a significantly greater number of subjects treated with Direct Therapeutic Exposure (DTE) (flooding therapy) as compared to another group treated with a more conventional individual therapy, were identified as successes as opposed to failures, based on the VETs scale. Also, the number of failures was greater for those treated with the more conventional therapy and the number of successess was greater for those treated with DTE, when compared to all other subjects in the sample. These preliminary results were interpreted as indicating that DTE, when offered as part of an inpatient milieu, shows promise as an effective treatment for chronic/severe combat veteran PTSD sufferers.     

The intercollegiate Basic Surgical Skills Course

Objective: This study was undertaken to establish residents progress in minimal access surgery (MAS) after attending the Intercollegiate Basic Surgical Skills Course (BSSC) by means of the Xitact LS500 laparoscopy simulator assessment program. Methods: Twenty-five surgical residents attended the BSSC in Leiden and Eindhoven, The Netherlands. Before and after the course, participants performed three runs on the Xitact LS500, featuring a standardized laparoscopic cholecystectomy clip-and-cut task. A control group of 25 interns not attending the course also performed two sessions of three runs. Parameters of interest were score and time for completion of task. Results: No significant differences were found within the resident group for the parameters time and score when comparing outcomes pre- and post-BSSC. No significant differences were found comparing time and score between residents and interns on each of the six runs, except for time in run 2. Over six runs, both residents and interns became significantly faster. Conclusions: The Xitact LS500 cholecystectomy simulator did not detect significant improvement in MAS performance among a group of surgical residents attending the BSSC.     

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

Summary A triangular flap repair for unilateral cleft lip is stated to have the potential problem of creating a lip that is too long. Although preoperative measurements were performed with calipers, the gap created in the medial segment was directly measured during the procedure, in order to determine the size of the flap more precisely. Ninety patients with complete unilateral cleft lips underwent a triangular flap repair using this method. The symmetry of the Cupid's bow was evaluated at a follow-up period averaging between six years and three months. Sixty-two lips obtained symmetry and the remaining 28 cases showed a lip which was too long; none of the lips were too short. The comparison between 27 primary palate clefts (UCLA) and 63 primary and secondary palate clefts (UCLP) showed no significant difference in the surgical result. The preoperative shortness of the lip on the cleft side was significantly greater in the too long group (5.01 ± 0.95 mm) than in the symmetry group (4.40 ± 0.87 mm). The width of the flap used was significantly larger in the too long group (3.76 ± 0.79 mm) than in the symmetry group (3.42 ± 0.69 mm). The triangular flap repair with intraoperative measurements is considered to be beneficial, although preoperative measurements provide an optimal design in most cases. It is suggested that the use of a wider triangular flap results in a lip which tends to be too long in spite of the preoperative shortness on the cleft side.     

Laparoscopy and major retroperitoneal vascular injuries (MRVI)

Injury to major retroperitoneal vessels is a potential serious complication of laparoscopy occurring when the Veress needle or trocar is inserted. This report is a review of major retropertioneal vascular injuries (MRVI) occurring during laparoscopy, as these injuries have not been well documented in the literature. A retrospective, observational review of general surgical laparoscopy cases was conducted over a 3.5-year period in three community, university-affiliated hospitals. We identified 4 MRVI in 3591 laparoscopic procedures. These cases were critically analyzed and compared. The incidence of MRVI was 0.1%. All cases occurred with the closed (blind) insertion technique of Veress needle and primary trocar insertion technique with disposable safety shield trocars. All patients sustaining MRVI had acute hypotension introperatively and significant blood loss necessitating postoperative transfusions. Recognition and rapid conversion to laparotomy are keys to enhancing outcome. There is significant potential for morbidity and mortality with laparoscopic MRVI, although each patient in this series was discharged without obvious short-term problems. The advantages of an open approach for primary trocar insertion are numerous and should alleviate the risk of MRVI associated with general laparoscopic surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995; and the Third European Congress of the European Association for Endoscopic Surgery, Luxembourg, 13–17 June 1995