Laparoscopic nephrectomy in childrenrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopic nephrectomy in the adult population is reported with increased frequency. We present our initial experience with laparoscopic nephrectomy in children. Methods: Over a 2-year period, 11 nephrectomies were performed in nine children aged 16 months to 16 years (mean, 6.5 years). All patients were referred due to complications of a nonfunctioning kidney. Seven patients had recurrent urinary tract infections, and two had refractory hypertension. Two patients underwent bilateral laparoscopic nephrectomy. The operation was performed using four access ports measuring 3.5 to 10 mm. Results: All kidneys were removed successfully using a laparoscopic technique. The average length of the operation was 163 min per kidney (range, 90–420). The estimated blood loss was <10–150 ml (mean, 45). No patient required transfusion. Seven patients were discharged home by postoperative day 2. The two patients with the longest operating times were discharged home on postoperative days 4 and 5 due to delay in return of bowel function. Narcotic use was minimal, and all patients enjoyed a rapid return to full activity. Conclusion: Laparoscopic nephrectomy is a viable alternative to open nephrectomy in children. Further experience with this technique is required to establish its efficacy and reduce the operating time Received: 29 April 1999/Accepted: 29 August 1999/Online publication: 17 April 2000     

Laparoscopic bilateral adrenalectomy following failed hypophysectomy

Background: Laparoscopic adrenalectomy has recently been shown to be a safe and effective means of treating adrenal pathology with much lower morbidity than the traditional approach. The majority of reports in the literature involve removal of adrenal tumors. Although open bilateral adrenalectomy has been utilized for persistent Cushing's syndrome following attempted hypophysectomy, there is little data available describing the application of laparoscopic adrenal surgery to this problem. Methods: Four patients with persistent Cushing's syndrome after attempted treatment with hypophysectomy underwent laparoscopic bilateral adrenalectomy at our institution. One procedure was done transabdominally in the supine position. Three procedures were done transabdominally using sequential lateral decubitus positions. Results: All procedures were completed laparoscopically. The mean operative time was 4.6 h (range 3.9–5.25). Repositioning and reprepping the patients resulted in a slight increase in operative time, but visualization was improved using the lateral decubitus position. Average blood loss: 156 cc (range 50–300). One patient required early reoperation for bleeding from the left adrenal bed, which was controlled laparoscopically. Three patients were eating the following day and were discharged on postoperative days 1, 2, and 5. The fourth patient remained hospitalized for 18 days due to problems unrelated to surgery. After a mean follow-up of 10 months, all patients have done well and have no clinical or biochemical evidence of recurrent disease. Conclusion: Our clinical experience indicates that laparoscopic bilateral adrenalectomy is a viable treatment option for Cushing's syndrome following failed hypophysectomy. Received: 29 March 1996/Accepted: 12 June 1996     

Coagulation activation after laparoscopic cholecystectomy in spite of thromboembolism prophylaxis

Background: The aim of this study was to determine whether laparoscopic cholecystectomy (LC), in spite of its minimally invasive nature, causes coagulation activation. Methods: Sixty-four patients undergoing LC were included prospectively. All received either dextran or low-molecular-weight heparin (LMWH). Blood samples taken the morning of the operation and the following morning were analyzed for TAT, FM, fragment 1+2, tPA, PAI-1, vWf, D-dimer, Hb, hematocrit, and APC resistance. Results: Significant increases in TAT, FM, fragment 1+2, and D-dimer were seen, whereas APC resistance, Hb, and hematocrit decreased significantly. Dextran led to a decrease in vWf and no change in tPA, whereas LMWH led to an increase in both these parameters. Conclusions: Laparoscopic cholecystectomy causes coagulation activation. There are differences in the response between patients receiving dextran and LMWH as thromboembolism prophylaxis. Since most patients are discharged the day after the operation, there could be practical as well as theoretical advantages to using dextran. Received: 29 November 1999/Accepted: 17 January 2000/Online publication: 12 July 2000     

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain

Background: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. Methods: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). Results: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p= 0.49) or morbidity (DL = 11%, ILA = 5%, p= 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. Conclusions: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option. Received 3 April 1997/Accepted: 3 July 1997     

The laparoscopic management of post-transplant lymphocele

Background: The management of lymphocele in patients following kidney (KT) and kidney pancreas (KPT) transplants is evolving. Open surgery has been the traditional treatment, but some authors have advocated laparoscopic drainage in selected patients. Methods: We retrospectively reviewed our results in lymphocele treatment since developing a laparoscopic program at our institution. Results: Between May 1994 and June 1995, 186 KTs and 48 KPTs were performed, and 1,354 patients are currently being followed. Eight patients developed symptomatic lymphoceles an average of 26 months (range 4–59) following 6 KTs and 2 KPTs. All patients diagnosed were successfully drained laparoscopically, with no conversions to open surgery. Laparoscopic ultrasound was used to help with localization of the fluid collection. Operative time averaged 59 min, median hospital stay was 1 day (range 1–4), and there were no perioperative complications. Follow-up imaging was obtained on six patients, 3–16 months following their procedures, and no recurrences were noted. A review of the literature demonstrates a 5.3% rate of major complications and a 7% incidence of lymphocele recurrence. Conclusions: Intraoperative laparoscopic ultrasound can help localize fluid collections and prevent organ injuries. Laparoscopic drainage of lymphocele following transplantation results in minimal disability and an acceptable complication rate, although it is higher than with open drainage. Therefore, laparoscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphocele. Received: 15 March 1996/Accepted: 3 July 1996     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

Background: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. Methods: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p= ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. Conclusions: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis. Received: 3 April 1997/Accepted: 19 August 1997     

Role of laparoscopic ultrasonography in intraoperative localization of pancreatic insulinoma

Background: A combination of digital palpation and ultrasonography plays an important role in locating insulinomas intraoperatively. Laparoscopic resection of insulinomas has been described recently, but experience in locating insulinomas during laparoscopy is lacking. Methods: From January 1998 to January 1999, three patients with pancreatic insulinomas underwent laparoscopy and laparoscopic ultrasonography aimed at intraoperative localization and potential resection. The role of laparoscopy and laparoscopic ultrasonography in locating insulinomas is evaluated. Results: Preoperative localization studies were routinely performed, and two patients had an occult tumor before laparoscopy. None of the tumors was detected by laparoscopic examination, but laparoscopic ultrasonography identified solitary tumors located at the body and tail of the pancreas. Conversion to laparotomy was performed in one patient as a planned procedure. One patient underwent laparoscopic enucleation, whereas the other had a laparoscopic distal pancreatectomy. Conclusions: Laparoscopic ultrasonography seems to be sensitive in locating insulinomas at the body and tail of the pancreas. It optimizes and facilitates resection of insulinomas through a minimally invasive approach. Received: 8 March 1999/Accepted: 10 August 1999/Online publication: 7 September 2000     

Macroscopic assessment of the appendix at diagnostic laparoscopyis reliable

Background: Healthy-looking appendixes are often removed at laparoscopy for suspected appendicitis. This practice may have adverse secondary effects. Methods: We reviewed the literature for the years 1978 to 1998 to analyze the negative appendectomy rates, complication rates, the accuracy of laparoscopic appendix assessment, and the incidence of false negative diagnosis of appendicitis at surgical and gynecological laparoscopy. Results: The respective negative appendectomy rates were 22% and 15% in studies that compared laparoscopic with open appendectomy. The appendix was left in situ in 37% of 4,281 surgical diagnostic laparoscopies. There were instances of missed appendicitis among the 3,367 gynecological diagnostic laparoscopies performed on women for lower abdominal pain, and there were 188 appendectomies in this group. Studies comparing the macroscopic appearance of the appendix at operation with microscopic findings from the excised specimen had a false negative error rate of 3%. Conclusions: Contrary to general opinion, there is no substantial evidence to support the assumption that the macroscopic diagnosis of appendicitis is unreliable. High rates of conflicting diagnoses of excision specimens suggest that endoappendicitis has little clinical significance. At present, negative appendectomy rates are considerably higher for laparoscopic appendectomy than for the open approach. The role of diagnostic laparoscopy in suspected appendicitis should be reconsidered. It may be useful in particular subgroups of patients, but it is no substitute for good clinical judgment. Furthermore, it is not always necessary to perform an incidental appendectomy. Received: 7 September 1999/Accepted: 21 October 1999/Online publication: 30 May 2000     

A simple scoring system to reduce intraabdominal septic complications after laparoscopic appendectomy

Background: The development of intraabdominal abscess (IAA) following laparoscopic appendectomy (LA) is associated with significant morbidity. The aim of the present study was to validate an IAA risk score constructed from a previous review of 156 consecutive LA. Methods: The score was tested in 250 subsequent consecutive LA and in patients with a positive risk score. Broad-spectrum antibiotics were administered in order to avoid IAA. Results: Factors related to IAA included clinically complicated appendicitis, leucocytosis >15,000/μl, a difference of >1°C between axillary and rectal temperature, intraoperative findings such as (gangrenes and perforation), and intraoperative perforation of the appendix. In this series, broad-spectrum antibiotic therapy in patients with a positive IAA risk score reduced the incidence of IAA from 7.05% to 1.60%. Conclusion: This policy of identifying high-risk patient via the scoring system and instituting subsequent antibiotic therapy in patients at risk reduces the incidence of IAA following LA. Received: 20 October 1999/Accepted: 7 March 2000/Online publication: 7 September 2000     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Laparoscopically assisted bowel surgery for inflammatory bowel disease

Background: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n= 4), end colostomy (n= 1), ileocecal resection (n= 26) and (procto)colectomy (n= 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. Results: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. Conclusions: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained. Received: 12 August 1998/Accepted: 13 January 1999     

Initial results of a prospective trial of outpatient laparoscopic cholecystectomy

Background: Whether or not laparoscopic cholecystectomy may be performed safely as an outpatient procedure is controversial. In 1993, a protocol for outpatient laparoscopic cholecystectomy was instituted to determine the benefits and safety of discharging patients within several hours of surgery. Methods: The initial 60 outpatient laparoscopic cholecystectomies performed by one surgeon in a hospital-based outpatient teaching facility between February 1993 to June 1996 were prospectively studied. Results: Fifty-eight (97%) patients were discharged successfully after an average stay in the recovery room of 3 h. There were no deaths. Two patients required overnight observation and three patients required readmission. Two patients (3%) had cystic duct leak. The average hospital stay for all patients undergoing laparoscopic cholecystectomy at the institution (inpatient and outpatient) decreased from 3.2 to 1.5 days and the average hospital cost decreased from $7,800 to $4,600 during this period. Conclusion: Laparoscopic cholecystectomy in an outpatient setting is safe and cost-effective in healthy patients. Received: 3 April 1997/Accepted: 10 June 1997     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Spilled gallstones after laparoscopic cholecystectomy

Background: Spilled gallstones after laparoscopic cholecystectomy may cause abscess formation, but the exact extent of this problem remains unclear. Method: The data (collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery) on 10,174 patients undergoing laparoscopic cholecystectomy at 82 surgical institutions in Switzerland between January 1992 and April 1995 were retrospectively analyzed with special interest in spilled gallstones and their complications. Results: In 581 cases (5.7%) spillage of gallstones occurred; 34 of these cases were primarily converted to an open procedure for stone retrieval. Of the remaining 547 cases only eight patients (0.08%) developed postoperatively abscess formation requiring reoperation. Conclusions: Spillage of gallstones after laparoscopic cholecystectomy is fairly common and occurs in about 6% of patients. However, abscess formation with subsequent surgical therapy remains a minor problem. Removal of spilled gallstones is therefore not recommended for all patients, but an attempt at removal should be performed whenever possible. Received: 4 April 1997/Accepted: 9 July 1997     

Videoscopic surgery under local and regional anesthesia with helium abdominal insufflation

Background: High-risk patients may not be good candidates for laparoscopic surgery due to the metabolic consequences of transperitoneal absorption of insufflated CO₂ gas and the necessity of general anesthesia because CO₂ insufflation produces pain. Helium gas is metabolically inert and does not produce pain. Thus it permits an alternative approach to performing laparoscopic surgery in high-risk patients. Methods: Laparoscopic cholecystectomy, appendectomy, hernia repair, and peritoneal dialysis catheter procedures were performed under local or regional anesthesia in high-risk patients utilizing helium gas as the insufflation agent. Results: Twenty-one patients underwent laparoscopic procedures under local or regional anesthesia. None of the procedures initiated under local-regional anesthesia required abandonment of the laparoscopic approach or conversion to general anesthesia. There were no operative or perioperative mortalities. Two incidences of pneumothorax occurred with extraperitoneal hernia repair; one required a tube thoracostomy. Conclusions: Helium gas should be considered the agent of choice for intraperitoneal insufflation in high-risk patients not only because helium avoids the metabolic consequences of CO₂ insufflation but also because it permits selected procedures to be performed under local-regional anesthesia. Helium may be contraindicated for laparoscopic procedures involving extraperitoneal insufflation due to the increased risk for pneumothoraces. Received: 15 April 1998/Accepted: 25 August 1998     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Perforating appendicitis

Background: This pilot study was performed to reassess the widespread postulate that laparoscopic surgery is contraindicated in cases of perforating appendicitis. Methods: A total of 75 children (appendiceal perforation: n= 67; perityphlic abscesses and peritonitis: n= 8) were analyzed in a prospective nonrandomized trial. Ten of them were treated by laparoscopic appendectomy. Results: In the laparoscopy group, both pain and hospitalization were less time-consuming (i.e., by 50% and 19%, respectively). Antibiotics use was down from 2.6 over 6 days to 2.2. over 5.5 days, while the duration of surgery was up by 52%. Wound healing disturbances occurred in 10% (n= 1) and postoperative fever in 50% (n= 5) of patients, compared to 14% (n= 9) and 15% (n= 10) in the group treated by open surgery. All severe complications requiring reintervention (10%; massive subcutaneous abscess, n= 3; retrocolic abscess, n= 2; adhesion-related ileus, n= 3; appendicular stump, n= 1) were associated with open surgery. Conclusions: There was not a single major complication in the laparoscopy group. These unexpected results are in contrast to previous reports and have prompted us to initiate a prospective randomized trial. Received: 27 August 1998/Accepted: 20 January 1999     

Follow-up of 161 unselected consecutive patients treated laparoscopically for common bile duct stones

Background: Aim was to study the incidence of recurrent ductal stones and of biliary strictures at follow-up after laparoscopic treatment of gallstones and common bile duct stones and to update the short-term results. Methods: Ductal stones were proven in 161 patients of 1,975 (8.1%) undergoing laparoscopic cholecystectomy. Laparoscopic transcystic CBD exploration was the method of choice. If this was unsuccessful, laparoscopic choledochotomy was performed. After treatment, all patients were enrolled in a continued, ongoing follow-up study. Results: Laparoscopic CBD exploration was completed in 157 cases (transcystic 107, choledochotomy 50). Retained stones occurred in eight patients (5%) and major complications (cystic duct leakage, hemoperitoneum) in six (3.8%); mortality occurred in one high-risk patient (0.6%). Follow-up available in 154 patients (two unrelated deaths) for a period of up to 62 months showed the occurrence of recurrent ductal stones in five cases (3.2%) and no signs of bile stasis, suggestive of ductal stricture, on the basis of clinical and laboratory findings. Conclusions: This prospective, ongoing follow-up study demonstrates that laparoscopic treatment of gallstones and common bile duct stones in unselected patients is feasible and safe. Received: 21 May 1996/Accepted: 10 March 1997     

Micropuncture laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. Methods: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. Results: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45–180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. Conclusions: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure. Received: 28 January 1998/Accepted: 7 May 1998