Laparoscopic surgery in the elderly

Summary

Patients over the age of 65, undergoing either laparoscopic cholecystectomy or laparoscopic groin hernia repair in two centres, were retrospectively reviewed. 114 patients (median age 73) case-notes were reviewed. 94 patients had undergone laparoscopic cholecystectomy and 20 laparoscopic hernia repair. 81 % were American society of Anaesthesiologists (ASA) Grade I or II, with 17% Grade III and 2% Grade IV. 8% of the laparoscopic cholecystectomy patients had unsuspected common bile duct stones detected on cholangiography. There was a 5% conversion to open procedure in the cholecystectomy group and 0% in the hernia group. Median hospital stay was 2 days. Mortality was 0% in both groups. Major post-operative morbidity occurred in 4% of the laparoscopic cholecystectomy patients, delaying their discharge. We conclude that laparoscopic surgery is a safe procedure in the elderly patient when accompanied by good patient selection and anaesthetic care.     

腹腔镜经腹腔腹膜前网片疝修补术和开放疝修补术的随机对照研究

目的 通过一项随机临床试验对腹腔镜经腹腔腹膜前网片疝修补术（TAPP）和开放式疝修补术进行比较.方法 将101例腹股沟疝病人随机分成腹腔镜组（n=51）及开放手术组（n=50）,分别行TAPP和开放无张力疝修补术（Lichtenstein修补）,术后对病人进行随访,比较2组病人的相关参数.结果 腹腔镜组病人的手术时间比开放组长（P＜0.05）.2组术中并发症率无差异.术后1周的腹腔镜组的并发症率较开放组高（P＜0.05）.腹腔镜组病人的住院时间、恢复工作的时间比开放组短（P＜0.05）.术后1年,腹腔镜组病人发生慢性疼痛的比率与开放组相比差异无显著性（P＞0.05）.结论 TAPP治疗腹股沟疝是可行的、安全的,且在术后恢复方面较开放无张力修补更有优势.     

Post-operative rehabilitation following laparoscopic inguinal hernia repair

Summary

In a pilot study, 100 patients undergoing laparoscopic inguinal hernia repair and 20 patients undergoing open inguinal hernia repair have been compared. The time taken to regain full mobility following laparoscopic repair was 2.3 ± 0.1 d (mean ± SE) compared with 7.2 ± 0.9 d after open repair (P < 0.003). Following laparoscopic repair patients returned to work after 7.6 ± 0.6d compared with 21.2 ± 1.5d after open repair (P < 0.0001). Hospital stay was shorter following laparoscopic hernia repair. Operating time was longer in the laparoscopic group (64 ± 3.0 min, [mean ± SE]) compared with the open group (24 ± 1.2 min, P > 0.0001) but diminished with increasing experience. Studies of the patients' subjective experience of pain failed to show a significant difference post-operatively, both groups of patients claiming low pain scores.     

Laparoscopic management of adhesive acute postoperative small bowel obstruction

Laparoscopic management of postoperative acute adhesive small bowel obstruction (SBO) may often have clinical advantages. This prospective study included patients with postoperative acute SBO in whom sufficient intestinal decompression was achieved using a nasoenteric ileus tube preoperatively, but pass disorder was not improved. This study describes our experience with the laparoscopic procedure for patients with adhesive acute SBO. The laparoscopic approach was undertaken in 24 of 51 patients admitted for acute postoperative SBO from July 1994 through June 2000; it was performed successfully in 20 patients (83%), and four cases were converted to open surgery (17%) because of strong adhesions. In four patients with gallstones and inguinal hernia, laparoscopic surgery (cholecystectomy, hernioplasty) was performed simultaneously. There was no mortality and low morbidity (4.1%). The group of patients treated laparoscopically had a shorter hospital stay than the conventional open group (12 versus 21 days; p < 0.05). At the median follow-up of 84 months, 21 of the 22 patients who had received laparoscopic procedure remained asymptomatic. Laparoscopic treatment was effective, involved a shorter hospital stay and has shown good long-term results for most patients with adhesive acute SBO.     

运用腹腔镜修补腹壁切口疝的术式选择

目的 探讨腹腔镜腹壁切口疝修补术的可行性、安全性及优点。方法对18例腹壁切口疝患者施行两种方式腹腔镜切口疝修补术（完全悬吊法12例及部分悬吊法6例）,对其临床资料进行回顾性分析。结果所有18例腹腔镜腹壁切口疝修补术均顺利完成,无中转开腹。手术时间：完全悬吊法100-180min,部分悬吊法80-120min;出血10-30ml;术后6h进食,并下床活动,术后4-6d出院。患者随访3-57个月,平均（28.26±10.45）月．未见复发。结论腹腔镜切口疝修补术符合疝修补的生物力学原理,应是切口疝修补的理想术式。完全悬吊法虽固定确切,但手术费时;部分悬吊法补片固定牢固,操作简便,易于推广。     

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.     

开放手术与腹腔镜下手术治疗新生儿嵌顿性腹股沟斜疝的临床疗效比较

目的比较开放与腹腔镜下腹股沟斜疝疝囊高位结扎术治疗新生儿嵌顿性腹股沟斜疝的临床疗效。方法 2014年3月-2018年9月该院共收治28例腹股沟斜疝嵌顿新生儿,其中13例行开放手术(开放组),15例行腹腔镜手术(腹腔镜组)。对两组患儿的手术时间、切口长度、术中出血量、术后住院时间、总住院费用及术后并发症进行对比分析。结果腹腔镜组术中发现对侧隐匿性疝6例,3例行对侧鞘状突高位结扎术,腹腔镜组手术时间(16.00±4.68)min,开放组(34.54±5.30)min,两组比较,差异有统计学意义(t=15.14,P 0.05);腹腔镜组切口长度、术中出血量、术后住院时间、总住院费用优于开放组,差异均有统计学意义(P 0.05)。在手术并发症方面,开放组出现1例伤口感染(7.69%),5例阴囊红肿(38.46%),3例阴囊血肿(23.08%),1例隐睾(7.69%)。腹腔镜组出现1例阴囊红肿(6.67%),两组并发症总发生率比较,差异有统计学意义(P 0.05)。随访2～56个月,两组均无复发及异时疝发生。结论腹腔镜手术治疗新生儿腹股沟斜疝嵌顿,操作简便、疗效确切,与开放性手术相比,具有创伤小、手术时间短、切口美观、术后阴囊肿胀发生率低、住院时间短和总住院费用低等优点,术后恢复快,是安全、有效、可行的方法,值得临床推广应用。随着儿童的生长发育,鞘状突开口比较小或者鞘状突有腹膜遮挡的隐匿性疝有自愈的可能,这部分患者可以考虑观察。     

Post-laparoscopic mesh in post-menopausal umbilical hernia repair: A case series

Abstract

We evaluated the efficacy and safety of the use of a composite PTFE/polypropylene patch, Ventralex (Davol Inc., C.R. Bard, Inc., RI, USA), to repair, concurrent with laparoscopy, umbilical hernia in 51 postmenopausal women. After laparoscopy, patients were submitted to the hernia repair by a patch intraperitoneally placed behind the hernia. Primary outcomes included complication rates, while hernia recurrence was the secondary outcome. Patient age range was 58 ± 4.3 years, the size of patches was small in 17.6% of women, medium in 68.7% and large in 13.7%. Seventy-six percent of patients had an ASA I–II score, the mean operating time for hernia repair was 7 ± 2 minutes with 15 cc of related blood loss, with 1.8 days of hospital stay. The visual analogue scale was 0–3 for 62.7%, 4–6 for 27.5% and 7–10 for 9.8% of women. All laparoscopic and umbilical hernia repair terminated without any further intra or postoperative complications, with 36 months of follow-up; none of the patients showed recurrences. Combining laparoscopy and intraperitoneal mesh repair appears to be indicated for umbilical hernia treatment in post-menopausal patients undergoing laparoscopy, resulting in a safe and easy procedure, with short hospital stay and fast dismissal, with no major morbidity or recurrence.     

An audit of open and laparoscopic inguinal hernia repair

A retrospective case review to describe current practices and outcomes of patients undergoing inguinal hernia repair was undertaken in a principal referral hospital (John Hunter Hospital, Newcastle, New South Wales). The participants were patients who had elective laparoscopic or open inguinal hernia repair between 1 June 1997 and 31 May 1998. The main outcome measures were duration of surgery, type of anaesthesia, use of antibiotics, length of stay, postoperative complications, analgesic administration, and costs. Laparoscopic repair was advantageous in terms of length of stay and use of analgesia, but at a higher in theatre financial cost. Low rates of day stay surgery and use of local anaesthesia, and a high rate of antibiotic administration were apparent. It was concluded that local surgical practice has adopted some but not all advances described in the literature. Performance of a more expensive hernia repair in some patients may mitigate against performance of any repair in others.     

Endoscopic repair of groin hernia--what ist evidence-based

The endoscopic techniques of groin hernia repair have developed tremendously over the past 10 years. There are numerous prospective randomized clinical trials comparing conventional techniques of groin hernia repair with endoscopic methods. However, it is difficult to establish a proper meta-analysis of the currently available data due to widely differing study designs. We assessed the currently available prospective randomized clinical trials comparing conventional versus laparoscopic hernia repair. We conclude that based on present data there is a clear advantage for the endoscopic techniques regarding length of hospital stay, postoperative recovery and return to normal activity. The conventional techniques are superior regarding duration of operation and direct cost. Rate of recurrence are comparable in both, endoscopic and conventional approach using mesh prosthesis. Endoscopic techniques are far superior to conventional operation without the use of mesh prosthesis. In patients with recurrent hernia endoscopy offers a major advantage regarding postoperative pain, lenght of hospital stay, return to normal activity and rate of recurrence. We demonstrate these suggestions discussing our own results. Therefore we recomend endoscopic hernia repair in patients with bilateral or recurrent hernia.     

An endoscopic view of the surgical anatomy of the inguinal region

Laparoscopic techniques in general are being increasingly exploited in surgery. One recently introduced procedure is laparoscopic hernia repair, which potentially offers a shorter recovery time, a return to normal activity and a significant reduction in groin discomfort for patients. Unlike other laparoscopic procedures such as laparoscopic cholecystectomy and appendicectomy where the anatomy encountered by the surgeon through the laparoscope is essentially the same as that seen at open surgery, laparoscopic repair of an inguinal hernia requires a different anatomical approach and the development of a different technique for repair. The anatomy of the inguinal region as seen laparoscopically is unfamiliar to most surgeons. Consequently, so that the procedure is completed successfully without causing damage to anatomical structures or the potential for post-operative recurrence, a detailed anatomical knowledge is essential. In this paper, the intra-abdominal anatomy of the inguinal region is revisited with the aid of diagrams and photographs, to aid the surgeon in understanding the laparoscopic anatomy of the region. In addition the critical elements of successful repair are discussed with respect to anatomical landmarks.     

加速康复措施对腹腔镜子宫内膜癌根治术患者术后康复的影响

目的:探讨加速康复外科(enhanced recovery after surgery, ERAS)措施对腹腔镜子宫内膜癌根治术患者术后康复的影响。方法:收集行腹腔镜分期手术的子宫内膜癌患者92例,分为2组:ERAS组(n=46)和对照组(n=46)。对照组患者实施常规妇科手术围手术期处理,ERAS组患者采用加速康复外科措施进行围术期干预,比较两组患者术后康复相关指标。结果:ERAS组患者术后下床活动时间、肛门排气、排便时间、平均住院日、平均住院费用均少于对照组,差异有统计学意义(P0.05)。ERAS组围术期并发症发生率低于对照组,差异有统计学意义(P0.05)。结论:加速康复可促进腹腔镜子宫内膜癌根治术患者术后恢复,缩短平均住院日及降低住院费用,降低患者术后并发症的发生。     

生物补片修补食管裂孔疝的效果:1年随访

背景:尽管腹腔镜食管裂孔疝修补已取得良好的治疗效果,但对术中是否应该使用生物补片仍存在争议。目的:分析生物补片修补腹腔镜食管裂孔疝的效果。方法:回顾性分析2006-11/2009-06在复旦大学附属华山医院实施手术的57例食管裂孔疝患者临床资料,其中单纯膈肌脚缝合+Nissen胃底折叠24例(对照组),单纯膈肌脚缝合+Nissen胃底折叠同时行补片加强33例(实验组)。对比分析使用补片和未使用补片的治疗结果。结果与结论:术后随访1年,实验组与对照组术后复发率、患者满意度、症状控制情况差异均无显著性意义(P>0.05)。与对照组比较,实验组术中、术后并发症并未增加,同时手术时间及住院时间也未明显延长(P>0.05)。短期随访结果说明补片加强修补食管裂孔疝是安全、有效的,但应严格掌握适应证。     

Short‐term outcome of single‐incision laparoscopic totally extra‐peritoneal inguinal hernia repair

We performed single‐incision laparoscopic surgery for totally extra‐peritoneal (SILS‐TEP) repair using a lightweight mesh fixed by absorbable tacks and without balloon dilation. Thirty‐four patients (mean age, 66.5 years) underwent SILS‐TEP repair in our hospital between September 2011 and April 2012; 30 patients had unilateral hernia and 4 had bilateral hernias. Mean operative time was 85.6 min for unilateral hernia and 137.7 min for bilateral hernias. All patients underwent successful SILS‐TEP repair. Mean hospital stay was 3.4 days. Mean duration of follow‐up was 7.1 months. Four seromas were observed, but no recurrences or major complications occurred. SILS‐TEP is an economical and useful method for decreasing postoperative complications, such as neuralgia and recurrence, and it could be an attractive approach for inguinal hernia.     

肾上腺嗜铬细胞瘤腹腔镜手术的安全性评价

目的:评价后腹腔镜行肾上腺嗜铬细胞瘤切除术的安全性。方法:对肾上腺嗜铬细胞瘤后腹腔镜切除术9例(A组),腹膜后开放手术15例(B组)的临床资料进行回顾分析,对手术时间、术中出血量、术中输血率、术后肠道恢复时间、术后住院时间、术中、术后并发症以及手中各时点的血压、心率情况和术中血流动力学不稳定事件的发生率进行对比并做统计学分析。结果:A组手术时间长于B组,差异有统计学意义(P<0·05)。两组间出血量、输血率、术后肠道恢复时间、总并发症率、术中及术后并发症率差异没有统计学意义(P>0·05)。A组术后住院时间短于B组,差异有统计学意义(P<0·05)。两组收缩压、舒张压、心率在术中各时间点的差异均没有统计学意义(P>0·05)。两组间在心动过速、低血压及血流动力学不稳定事件发生率方面的组间差异均也没有统计学意义(P>0·05)。结论:后腹腔镜肾上腺切除可缩短术后住院时间,不增加并发症发生率,并且术中对患者的血流动力学影响与开放手术相当。手术适应症选择适当,后腹腔镜肾上腺嗜铬细胞瘤切除术与开放手术具有同样的安全性。     

Laparoscopic intraperitoneal mesh repair of Spigelian hernia: A case report

Spigelian hernia is a rare congenital defect of the anterior abdominal wall located along the semilunar line through the aponeurosis fascia of the transversus abdominis muscle. It represents 1%–2% of all abdominal wall hernias. Few cases of laparoscopic treatment for Spigelian hernia have been reported, especially in Japan. However, several reports of laparoscopic surgery to repair Spigelian hernias have been published, and some have shown that the laparoscopic approach repair is feasible because it is associated with less morbidity and a shorter hospital stay than open surgery. We herein describe a 63‐year‐old Japanese woman who presented with painful bulging in the right lower abdominal quadrant. A preoperative diagnosis of Spigelian hernia was made, and we performed laparoscopic intraperitoneal repair. The patient was discharged 6 days after laparoscopic surgery with no perioperative complications. This report describes the first successful laparoscopic intraperitoneal mesh repair of Spigelian hernia in Japan.     

102例腹腔镜下完全腹膜外疝修补术的临床分析

目的探讨腹腔镜下完全腹膜外疝修补术（TEP）的经验。方法回顾分析2007年9月～2012年3月102例TEP术,观察手术时间、术后舒适性、并发症和复发率。结果102例手术均顺利完成,住院时间3～13d,平均5d,随访6个月～2年,3例复发。结论TEP是一个微创的、无张力的腹股沟疝修补术,手术安全可靠,术后疼痛轻,住院时间短,恢复快,复发率及并发症低。     

生物补片修补食管裂孔疝的效果：1年随访

背景：尽管腹腔镜食管裂孔疝修补已取得良好的治疗效果,但对术中是否应该使用生物补片仍存在争议。目的：分析生物补片修补腹腔镜食管裂孔疝的效果。方法：回顾性分析2006-11/2009-06在复旦大学附属华山医院实施手术的57例食管裂孔疝患者临床资料,其中单纯膈肌脚缝合＋Nissen胃底折叠24例（对照组）,单纯膈肌脚缝合＋Nissen胃底折叠同时行补片加强33例（实验组）。对比分析使用补片和未使用补片的治疗结果。结果与结论：术后随访1年,实验组与对照组术后复发率、患者满意度、症状控制情况差异均无显著性意义（P〉0.05）。与对照组比较,实验组术中、术后并发症并未增加,同时手术时间及住院时间也未明显延长（P〉0.05）。短期随访结果说明补片加强修补食管裂孔疝是安全、有效的,但应严格掌握适应证。     

Multifactor study of efficacy and recurrence in laparoscopic surgery for inguinal hernia

BACKGROUNDInguinal hernia is a common clinical manifestation in children with a low self-healing rate. AIMTo determine the effect of laparoscopic surgery on indirect inguinal hernia and the risk factors for postoperative recurrence and to provide a reference for the clinical treatment and prevention of recurrence.METHODSWe selected 360 children who underwent laparoscopic high ligation in our hospital as the laparoscopic group and 120 patients treated for inguinal hernia with conventional surgery as the control group. The operation time, blood loss, incision length, hospitalization time, total hospitalization cost and surgical complications were compared between the two groups. According to telephone follow-up or return visits, the children who had recurrence within 2 years after the operation in the laparoscopic group were analyzed, and the laparoscopic high ligation hernia sac level was analyzed by the logistic multifactor method. Ligation was used to treat recurrence in children with inguinal hernia.RESULTSThe operation time, blood loss, length of incision, and length of hospital stay in the laparoscopic group were lower than those in the control group (P < 0.05). The total hospitalization cost in the laparoscopic group was higher than that in the control group (P < 0.05). The operative complication rate was 1.67% lower than that in the control group (12.50%) (P < 0.05). In 360 children with laparoscopic high ligation of the hernia sac, 14 patients had recurrence within 2 years after surgery. After analysis, 14 cases in the recurrence group did not recur. The preoperative incarceration rate, inner ring diameter, ligature use and age difference were statistically significant (P < 0.05). According to logistic regression multivariate analysis, an inner ring diameter ≥ 1.0 cm, the use of an absorbable ligature line and age > 3 years increased the risk of postoperative recurrence in children with inguinal hernia after laparoscopic high ligation of the hernia sac (P < 0.05). CONCLUSIONLaparoscopic surgery for indirect inguinal hernia in children has the advantages of low trauma and a rapid postoperative recovery. An inner ring diameter ≥ 1.0 cm, the use of absorbable ligature, and age > 3 years may increase the risk of recurrence after laparoscopic high ligation of the hernia sac.     

开放手术与腹腔镜手术治疗小儿腹股沟斜疝的疗效比较

目的：比较开放手术与腹腔镜手术治疗小儿腹股沟斜疝的疗效。方法：121例腹股沟斜疝患儿,行开放疝囊高位结扎术73例（A组）,采用18G套管针经二孔腹腔镜辅助腹膜外疝囊高位环扎术48例（B组）,比较两组疗效及并发症发生情况。结果：A组并发症发生率3．9％,B组无并发症发生。B组术中发现对侧存在开放鞘状突18例（38％）,同时行对侧开放鞘状突高位结扎。单侧手术时间、术后24h内出院率两组比较差异均无统计学意义（P〉0．05）。双侧手术时间两组比较差异有统计学意义（P〈0．05）。术后随访两组均无复发、睾丸萎缩、肠黏连等。结论：小儿腹股沟斜疝采用腹腔镜手术安全有效,较开放手术在对侧开放鞘状突处理方面更具优势。