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1.
D. Collet 《Surgical endoscopy》1997,11(1):56-63
Background: In 1996, laparoscopic cholecystectomy is the gold standard for symptomatic cholelithiasis. The results of this operation
as published so far include data on the learning curve of the method. The aim of this study is to evaluate the results of
laparoscopic cholecystectomy when performed by a large number of surgeons during the year 1994, not taking into account the
beginning years in which the technique was being used.
Methods: This study has been carried out prospectively and anonymously among members of SFCERO. All the patients who underwent a cholecystectomy
started laparoscopically during 1994 have been included.
Results: Some 4,624 cholecystectomies were performed by 150 surgeons. There were 3,310 females (42.5 ± 19.8 years old) and 1,314 males
(56.3 ± 1.61 years old). The conversion rate was 6.9%: 320 operations had to be converted into laparotomy (group II) while
4,261 were performed entirely by laparoscopy (group I). Morbidity was 5% (N= 230)—4.7% in group I (N= 203) and 8.4% in group II (N= 27). Mortality was 0.2% (N= 9)—namely four intraabdominal complications (three cases of peritonitis and one biliary reoperation), two cardiac failures,
and one brain infarction. The causes of death were not specified in two patients.
Conclusions: These results show that morbidity and mortality have not changed dramatically since the beginnings of this technique, whereas
the frequency of common bile duct (CBD) injuries has decreased. However, the conversion rate has increased slightly. These
results make it possible to calculate the risk of conversion and postoperative complication according to the age of the patient
and the biliary symptoms.
Received: 25 January 1996/Accepted: 10 April 1996 相似文献
2.
Laparoscopic cholecystectomy and gallbladder cancer 总被引:2,自引:0,他引:2
Background: This study was designed to assess the treatment of patients in whom gallbladder cancer was diagnosed in the course of histological
examination of their gallbladders, which were removed during laparoscopic cholecystectomy.
Methods: Six (0.29%) cancers were found among 2,017 patients who underwent laparoscopic cholecystectomy. Four of these cancers (0.22%)
were in 1,831 gallbladders with normal walls, two (1.0%) were in 186 with thicker walls, and two (1.8%) were in 109 patients
in whom conversion was necessary because of extensive inflammation and thickening of gallbladder wall.
Results: In two cases, the cancer did not cross the muscular layer. In one of them, no further treatment was undertaken. In the second
case, liver resection and lymphadenectomy was performed. In the other four cases, dissemination was diagnosed during laparotomy,
precluding radical treatment.
Conclusions: Thickened and infiltrated gallbladder walls in patients without preoperative symptoms of cholecystitis should raise a suspicion
of cancer. The surgeon should be prepared to perform a conversion, an intraoperative histological examination, and an appropriate
radical operation, if necessary.
Received: 16 June 1998/Accepted: 17 November 1998 相似文献
3.
The clinical impact of warmed insufflation carbon dioxide gas for laparoscopic cholecystectomy 总被引:2,自引:0,他引:2
Background: Reports suggest that the insufflation of cold gas to produce a pneumoperitoneum for laparoscopic surgery can lead to an intraoperative
decrease in core body temperature and increased postoperative pain.
Methods: In a randomized controlled trial with 20 patients undergoing laparoscopic cholecystectomy, the effect of insufflation using
carbon dioxide gas warmed to 37°C (group W) was compared with insufflation using room-temperature cold (21°C) gas (group C).
Intraoperative body core and intra-abdominal temperatures were determined at the beginning and end of surgery. Postoperative
pain intensity was evaluated using a visual analog scale and recording the consumption of analgesics.
Results: There were no significant group-specific differences during the operation, neither in body temperature (group W: 36.1 ± 0.4°C
vs group C: 35.7 ± 0.6°C) nor in intra-abdominal temperature (group W: 35.9 ± 0.3°C vs group C: 35.6 ± 0.6°C). Postoperatively,
the two groups did not differ in pain susceptibility and need of analgesics.
Conclusion: The use of carbon dioxide gas warmed to body temperature to produce a pneumoperitoneum during short-term laparoscopic surgery
has no clinically important effect.
Received: 13 August 1999/Accepted: 24 September 1999/Online publication: 9 August 2000 相似文献
4.
The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy 总被引:11,自引:0,他引:11
Background: The increased intra-abdominal pressure during pneumoperitoneum, together with the head-up tilt used in upper abdominal laparoscopies,
would be expected to decrease venous return to the heart. The goal of our study was to determine whether laparoscopy impairs
cardiac performance when preventive measures to improve venous return are taken, and to analyze the effects of positioning,
anesthesia, and increased intra-abdominal pressure.
Methods: Using invasive monitoring, hemodynamic changes were investigated in 15 ASA class I or II patients under isoflurane–fentanyl
anesthesia during laparoscopic cholecystectomy. Before laparoscopy, the patients received an intravenous (IV) infusion of
colloid solution if cardiac filling pressures were low, and their legs were wrapped from toes to groin with elastic bandages.
Measurements were taken while the patients were awake in the supine (baseline) and head-up tilt (15–20°) positions, and after
the induction of anesthesia in the same positions. Measurements were repeated at regular intervals during laparoscopy (intra-abdominal
pressure at 13–16 mmHg), after deflation of the gas, and in the recovery room.
Results: With the passive head-up tilt in awake and anesthetized patients, the cardiac index (CI), stroke index (SI), central venous
pressure (CVP), and pulmonary capillary wedge pressure (PCWP) decreased, and systemic vascular resistance increased. With
the patient under anesthesia, SI decreased, but CI did not change significantly as a result of the compensatory increase in
heart rate. Carbon dioxide (CO2) insufflation at the start of laparoscopy produced increases in CVP and PCWP as well as mean systemic and mean pulmonary
arterial pressures without changes in CI or SI. Toward the end of the laparoscopy, CI decreased by 15%. The hemodynamic values
returned to nearly prelaparoscopic levels after deflation of the gas, and CI was elevated during the recovery period, whereas
systemic vascular resistance was decreased in comparison with the baseline.
Conclusions: By correcting relative dehydration and preventing the pooling of blood, CI decreased less than 20% during pneumoperitoneum
as compared with the baseline awake level. The head-up positioning accounts for many of the adverse effects in hemodynamics
during laparoscopic cholecystectomy.
Received: 6 November 1998/Accepted: 8 July 1999 相似文献
5.
Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy 总被引:6,自引:3,他引:3
Sungler P Heinerman PM Steiner H Waclawiczek HW Holzinger J Mayer F Heuberger A Boeckl O 《Surgical endoscopy》2000,14(3):267-271
Background: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy.
Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore
require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high
recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality.
Methods: During a 4-year period, all pregnant patients (n= 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria.
Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these
underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe
pain or cholecystitis; all were in their 13th–32nd gestational week. Access was established by Veress needle in all cases.
Insufflation pressure was 8–10 mmHg, and mean operative time was 62 min.
Results: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients
enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice.
Conclusions: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment
of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment
to be employed.
Received: 7 September 1998/Accepted: 2 June 1999 相似文献
6.
Summary Laparoscopic cholecystectomy is a viable and safe alternative for the treatment of symptomatic gallstones and biliary colic. As surgeons gain more experience with this procedure, contraindications become fewer and indications increase. Well-documented advantages of this approach include less patient discomfort, less surgical scarring, and earlier return to employment. Not previously discussed in the literature, however, are the additional advantages that this procedure holds for a specific subset of patients—namely, those patients that have undergone successful organ transplantation and are receiving immunosuppressive drugs. We report a case of a laparoscopic cholecystectomy in such a patient. 相似文献
7.
Background: The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected choledocholethiasis
remains a controversial subject. There have been few studies exploring the role of intraoperative ERCP. Therefore, we set
out to perform a retrospective review of 29 patients who underwent combined laparoscopic cholecystectomy (LC) and intreoperative
ERCP (LC/ERCP). Our objective was to assess the feasibility of a one-stage approach using intraoperative ERCP.
Methods: We identified 29 patients in whom LC/ERCP was attempted between January 1996 and November 1998 at a university-affiliated
hospital with a large private faculty. Parameters reviewed included preoperative diagnosis, liver function tests (LFT), finding
on transcystic cholangiogram (TCC), ERCP, stone retrieval, failure of ERCP, length of stay, morbidity, and mortality.
Results: Twenty-eight of 29 patients (97%) underwent successful combined LC/ERCP. Successful TCC followed by ERCP was performed in
21 of 26 patients (81%). Five TCC were technically unsuccessful; in these patients, ERCP was performed on the basis of preoperative
criteria. In three patients, TCC was not attempted. Stones were successfully retrieved from 20 of 21 patients (95%) with abnormal
finding on TCC, one of five patients (20%) with failed TCC, and two of three patients (67%) with ERCP but without TCC. Overall
morbidity was 14%, comprising two patients with postoperative hyperamylasemia and two with cystic duct leaks. There were no
deaths in the group. The mean time for the combined procedure was 173 min (range, 50–290). Mean length of hospitalization
was 3.4 days, and mean postoperative stay was 2.2 days.
Conclusions: LC/ERCP can be performed safely. The advantages of the combined procedures include one-stage treatment of cholelithiasis
and choledocholithiasis, avoidance of unnecessary preoperative ERCP and their concomitant complications, and elimination of
potential return to the operating room when postoperative ERCP is technically impossible.
Received: 3 February 1999/Accepted: 10 September 1999 相似文献
8.
Laparoscopic cholecystectomy, Calot's triangle, and variations in cystic arterial supply 总被引:2,自引:0,他引:2
Background: The extrahepatic biliary tree with the exact anatomic features of the arterial supply observed by laparoscopic means has
not been described heretofore. Iatrogenic injuries of the extrahepatic biliary tree and neighboring blood vessels are not
rare. Accidents involving vessels or the common bile duct during laparoscopic cholecystectomy, with or without choledocotomy,
can be avoided by careful dissection of Calot's triangle and the hepatoduodenal ligament.
Methods: We performed 244 laparoscopic cholecystectomies over a 2-year period between January 1, 1995 and January 1, 1997.
Results: In 187 of 244 consecutive cases (76.6%), we found a typical arterial supply anteromedial to the cystic duct, near the sentinel
cystic lymph node. In the other cases, there was an atypical arterial supply, and 27 of these cases (11.1%) had no cystic
artery in Calot's triangle. A typical blood supply and accessory arteries were observed in 18 cases (7.4%).
Conclusion: Young surgeons who are not yet familiar with the handling of an anatomically abnormal cystic blood supply need to be more
aware of the precise anatomy of the extrahepatic biliary tree.
Received: 1 November 1998/Accepted: 22 March 1999 相似文献
9.
The outcome of major biliary tract injury with leakage in laparoscopic cholecystectomy 总被引:2,自引:1,他引:1
Background: Concern has been expressed regarding the increased rates of biliary tract injury (BTI) at laparoscopic cholecystectomy. The
aim of the present investigation was to analyze the outcome of laparoscopic biliary tract injury with leakage.
Methods: Sixteen patients having major laparoscopic BTI with leakage were treated. Thirteen of them were referred to our institution
for further treatment. The follow-up was complete and focused on clinical outcome and biochemical analysis.
Results: Eight BTI were identified at the time of laparoscopic cholecystectomy, and the procedure was converted to a laparotomy. In
eight additional patients, BTI was recognized postoperatively. In this group one patient died because of lately diagnosed
biliary peritonitis, whereas in the seven surviving patients nine attempts to repair the BTI and eight other interventions
were performed. In the conversion group 14 attempts to repair the BTI and 11 other interventions were needed to completely
solve the problems. Final restoration of the BTI was done by Roux-en-Y hepaticojejunostomy in 11 patients and suture repair
with T-tube drainage of the bile duct in 4. During a median follow-up time of 63 months, three patients suffered from recurrent
segmental cholangitis. In the other patients, neither clinical nor biochemical evidence of biliary disease has been found
up to this writing.
Conclusions: Laparoscopic BTI has a high morbidity and mortality rate that seems comparable to BTI at open cholecystectomy. The number
of attempts to repair the BTI as well as additional interventions is too high, but in this patient series the final outcome
seemed to be similar after BTI recognized during and after laparoscopic cholecystectomy.
Received: 3 December 1997/Accepted: 28 May 1998 相似文献
10.
Laparoscopic splenectomy using a wall-lifting procedure 总被引:1,自引:1,他引:0
T. Nishizaki I. Takahashi T. Onohara K. Wakasugi T. Matsusaka K. Kume 《Surgical endoscopy》1999,13(10):1055-1056
A laparoscopic splenectomy using a hanger wall-lifting procedure is herein described. The patient is placed in the right
lateral position. The left lower chest and left abdominal wall are then lifted by three wires in two directions, left laterally
and vertical to the abdominal wall. The view of the operative field thus obtained is excellent. The lifting wires and bars
do not hinder the movement of the forceps, since the angles of the instruments to approach the spleen are different from those
of the wires. A laparoscopic splenectomy using this wall-lifting procedure avoids the usual complications associated with
pneumoperitoneum while still being technically comparable to a procedure with pneumoperitoneum.
Received: 7 October 1998/Accepted: 22 February 1999 相似文献
11.
Background: We evaluated the use of the ultrasonically activated (harmonic) scalpel (HS) in the performance of laparoscopic cholecystectomy
(LC).
Methods: A total of 282 consecutive patients, 64 of whom had acute cholecystitis at the time of surgery, underwent LC using HS dissection.
Indications for surgery included chronic pain (180 cases), episodes of acute cholecystitis (89 cases), pancreatitis (five
cases), and jaundice (seven cases). Twenty-seven patients had preoperative endoscopic retrograde cholangiopancreatography
(ERCP).
Results: The mean operating time was 29 ± 9 mins. Eleven procedures were converted to open surgery, (four due to bleeding, six due
to unclear anatomy, and one due to an inflammatory mass caused by gangrene/perforation). Complications occurred in 14 patients.
They included minor port site infection (four cases), pulmonary atelectasis (three cases), urinary retention (two cases),
intraoperative cathetherization not routinely performed, bile leak (two cases, both from cystic duct; one of the cystic duct
leaks occurred because of dislodgement of the occluding clip, the other may have been due to duct injury from the clip), pulmonary
embolus (one case), and myocardial infarction (one case). Neither of the latter complications were fatal. One patient required
a postoperative transfusion due to a fall in hematocrit of 3.2 gr/dl.
Conclusions: LC performed with the HS is feasible and effective. Operating time and blood loss were minimal, and the conversion rate was
low (3.9%). There were no bile duct injuries. Use of the HS makes dissection easier, thereby helping to reduce operative time
and lower the need for conversion to open surgery.
Received: 30 April 1999/Accepted: 22 November 1999/Online publication: 4 August 2000 相似文献
12.
Background: Advanced laparoscopic procedures require prolonged pneumoperitoneum. Increased intra-abdominal pressure causes a number of
hemodynamic changes including a drop in cardiac output, but it is unclear whether there is a direct effect on cardiac contractility.
In this experimental study, we sought to determine whether there is a direct impact of pneumoperitoneum on cardiac contractility.
We also examined the time-related changes taking place during the insufflation period.
Methods: Six young pigs were anesthetized and mechanically ventilated. Pneumoperitoneum was established by insufflating carbon dioxide
to a pressure of 15 mmHg and maintained for a period of 180 min. Hemodynamic parameters including left ventricular dP/dT were
invasively recorded every 15 min. All hemodynamic changes were statistically evaluated, and parameters were correlated with
time.
Results: Cardiac output decreased with insufflation from a baseline of 3.37 ± 0.34 lt/min and reached the lowest value at 165 min
of pneumoperitoneum (2.86 ± 0.30 l/min; p= 0.023). Systemic vascular resistance (SVR) significantly increased from 2236 ± 227 dyne/s/cm5 to a maximum of 3774 ± 324 dyne/s/cm5 (p= 0.005). Left ventricular dP/dT maximum did not change significantly with insufflation. The decrease in cardiac output strongly
correlated with the increase in SVR (r=−0.949). Time of insufflation correlated with cardiac output (r=−0.762) and dP/dT maximum (r=−0.727).
Conclusions: Pneumoperitoneum at 15 mmHg negatively affects cardiac output without significantly affecting cardiac contractility. A significant
increase in SVR appears to be the driving event for the decreased cardiac output. Prolonged pneumoperitoneum may have an additional
negative effect on hemodynamic parameters.
Received: 5 January 2000/Accepted: 4 May 2000/Online publication: 26 July 2000 相似文献
13.
Background: Advanced age with its concomitant comorbid conditions may be associated with increased postoperative laparoscsopic cholecystectomy
(LC) complications and more frequent conversion to open cholecystectomy (OC). The purpose of this study was to evaluate the
outcome of LC in patients age 65 and older.
Methods: Ninety consecutive patients were studied age 65 and older, of whom 39 (43%) were males and 51 (57%) were females, mean age
74 years (range 65–98), with 20 patients (22%) ≥ 80. Indications for surgery included biliary colic 55 (61%), acute cholecystitis
22 (24%), pancreatitis 10 (11%), and cholangitis 3 (4%). Seventeen patients (19%) had preoperative ERCP, 12 of which were
normal; five had sphincterotomy with stone extraction. Comorbid conditions included hypertension (44%), CAD (17%), cardiac
arrhythmias (18), CHF (9%), and COPD (7%).
Results: Operative time—mean 1 h 51 min ± SD 43 min. Conversion to OC—three patients (3%). Length of stay—mean 5 days (range 1–26).
Mortality—two patients (2%) >80 years old, one patient with septicemia and multiorgan failure whose comorbid diseases included
CAD, C.F., COPPED, and elevated BP, one patient with MI postsurgery, morbid diseases included DM and CAD. Complications—five
patients (5%): bile leak from cystic duct stump (one), postsurgery MI (two), incarcerated incisional hernia (one), septicemia
(one).
Conclusion: Morbidity rates for LC in the elderly population are not different from that reported for patients less than 65 years of
age. (5% vs 6%, Fried et al., Surg Clin North Am 1994;74 [2]: 375–387). Our 2% mortality rate is statistically different from previously reported in a series of patients
of all ages (0.6%, Fried et al.). The 3% rate of conversion to OC in this older population is not significantly different
from the patients in Fried et al. series (4%).
Received: 17 September 1996/Accepted: 14 October 1996 相似文献
14.
Background: The objective of this study was to compare the histology of gallbladders removed prior to the introduction of laparoscopic
cholecystectomy with that found after the introduction of the laparoscopic technique to determine if there has been a change
in the indications for surgical treatment of gallbladder disease.
Methods: A retrospective review of all patients undergoing cholecystectomy during 1989, 1992, and 1993 was completed at two large
community teaching hospitals in two different geographic regions of the United States. Patients who underwent cholecystectomy
as the primary procedure were studied. A total of 1,815 cases met the criteria for analysis. Histological diagnoses were categorized
as acute cholecystitis with or without cholelithiasis, or chronic cholecystitis with cholelithiasis.
Results: The number of cholecystectomies performed increased by 58% from 1989 to 1993 (p < 0.05). The number of cholecystectomies for acute cholecystitis did not change.
Conclusions: With the advent of laparoscopic cholecystectomy, the number of cholecystectomies significantly increased and the proportion
of cholecystectomies performed for chronic disease also increased. There has been a significant change in the surgical management
of gallbladder disease with increased willingness to recommend elective cholecystectomy. Further study is needed to determine
if there is real benefit from earlier elective cholecystectomy.
Received: 25 September 1996/Accepted: 14 March 1997 相似文献
15.
Background: The cardiopulmonary changes experienced by patients who undergo laparoscopic cholecystectomy (LC) and the prognostic value
of patient characteristics are not well understood.
Methods: Cardiorespiratory changes were investigated in 120 patients undergoing LC or open cholecystectomy (OC). The results and their
relation to patient variables were statistically evaluated.
Results: The most significant cardiorespiratory changes were (A-a)PO2 increase during OC; decrease of pH and compliance and increase of peak airway pressure during LC; impairment of arterial
blood gas mean values and respiratory muscle strength; atelectasis and pneumonia (five cases) after OC; and lamellar atelectasis
(two cases) after LC. Significant adverse prognostic factors related to intra- and postoperative LC cardiorespiratory changes
were ASA class greater than I, FEF75–85% < 900 ml, and PaO2 < 10.4 kPa (PPV, 71.4% and 46.6%, respectively).
Conclusions: LC carries no significant cardiorespiratory changes provided that intraoperative monitoring of hemodynamics and respiratory
parameters is done for the study of blood gas values in all patients at risk. 相似文献
16.
Mendoza-Sagaon M Hanly EJ Talamini MA Kutka MF Gitzelmann CA Herreman-Suquet K Poulose BF Paidas CN De Maio A 《Surgical endoscopy》2000,14(12):1136-1141
Background: We designed a prospective controlled animal study to compare the stress response induced after laparoscopic and open cholecystectomy.
Methods: Twelve female pigs (20–25 kg body weight) were anesthetized with ketamine, pentobarbital, and fentanyl. The animals were
randomized into the following four groups: control (C), pneumoperitoneum with CO2 at 14–15 mmHg (P), laparoscopic cholecystectomy (LC), and open cholecystectomy (OC). The average duration of the procedure
in each group was 35 min.
Results: Central venous pressure, mean arterial pressure, pulmonary capillary wedge pressure, and cardiac output were monitored. Measurements
were recorded when animals were anesthetized (baseline), immediately before and after surgery, and thereafter every 30 min
for a maximum of 3 h. White blood cell count (WBC) was determined from blood samples taken before and after 3 h of surgery.
Ultrasound-guided liver biopsies were done preoperatively and after 3 h of surgery. Total RNA was isolated from the liver
biopsy specimens. Steady-state mRNA levels of β-fibrinogen (β-fib), α 1-chymotrypsin inhibitor (α1-CTI), metallothionein (MT),
heat shock protein 70 (Hsp70), and polyubiquitin (Ub) were detected by Northern blot/hybridization. There were no statistical
differences in the hemodynamic parameters among the groups. The number of circulating neutrophils and monocytes decreased
only after LC. Expression of Hsp70 was not induced after any surgical procedure, and the mRNA levels of Ub did not change
after surgery. The expression of α1-CTI and β-fib (acute phase genes) were similarly increased after LC and OC. Steady-state
mRNA levels of MT were slightly increased after P and LC but not after OC.
Conclusion: These data indicate that there are no significant differences between LC and OC in terms of induction of the stress response.
Received: 19 March 1999/Accepted: 2 July 1999/Online publication: 20 September 2000 相似文献
17.
Laparoscopic renal surgery usually involves the use of five or six trocars. This report concerns the authors' technique for
performing such surgery through only three trocars. Semilateral patient positioning, along with additional table rotation,
is utilized to facilitate visceral rotation and optimize exposure of the kidney. Four laparoscopic renal procedures were performed:
one renal cyst decortication and three upper pole partial nephrectomies with ureterectomies for duplications of the collecting
system. Mean operative time was 148 min with no conversions; there were no intra- or postoperative complications. All patients
tolerated a liquid diet on postoperative day 1, and the median hospital stay was 2 days. In selected cases laparoscopic renal
surgery may be approached safety through three trocars.
Received: 29 March 1996/Accepted: 1 July 1996 相似文献
18.
R. Cadrobbi G. Zaninotto P. Rigotti N. Baldan G. Sarzo E. Ancona 《Surgical endoscopy》1999,13(10):985-990
Background: Laparoscopic treatment of pelvic lymphocele secondary to kidney transplant has gained popularity in the last few years, although
lesions of the urinary tract (ureter, renal pelvis, and bladder) have been reported frequently. To evaluate the result of
this treatment and the associated risk of urinary tract lesions, we reviewed our experience and reports in the medical literature
on open and laparoscopic surgery.
Methods: From 1991 to 1999, we laparoscopically treated 12 patients (7 men and 5 women; median age, 43 years; range, 17–59 years)
with symptomatic pelvic lymphocele causing a deterioration of renal function because of compression on the ureter in 10 of
the 12 patients and lymphocele compression of the iliac vein in the other 2 patients. In nine patients, the lymphocele wall
was opened and sutured to the peritoneum to keep the window open. In two patients, an omentoplasty was performed, and in the
remaining patient, both techniques were used. All patients were followed up clinically with ultrasound and biochemistry for
a median period of 33 months (range, 1–96 months). Using Medline, we reviewed the medical literature from 1980 to 1998 and
collected 252 cases in which operations had been performed to drain an internal lymphocele secondary to kidney transplantation.
Results: Laparoscopic treatment was successful in 11 of the 12 patients. One patient was converted to open surgery because of a lesion
in the transplanted ureter. One patient needed repeat laparoscopy 24 hours after the operation because of bleeding from the
peritoneal window. The median duration of the operation was 120 min (range, 70–200 min), and the median postoperative hospital
stay was 5 days (range, 2–12 days). None of the patients needed to discontinue oral cyclosporine assumption. The serum creatinine
level dropped significantly after surgery (p < 0.05). No symptomatic recurrences were observed. Of the 252 patients found in the medical literature, in 129 the procedure
was performed with open surgery and in 123 laparoscopically (our 12 patients included). The prevalence of iatrogenic lesions
to the urinary tract increased threefold with the use of laparoscopic surgery (from 1.6% in open surgery to 7% in laparoscopy).
The recurrence rate of symptomatic lymphocele, however, decreased from 15% to 4%.
Conclusions: Laparoscopic drainage of posttransplantation lymphocele is a relatively simple method for treating this complication, although
it bears the burden of an increased incidence of urinary tract lesions, as confirmed by a review of the literature. The major
advantage of the laparoscopic approach is the absence of postoperative ileus with the opportunity to continue the enteral
immunosuppressive regimen and a lower recurrence rate. These data suggest that laparoscopic lymphocele treatment might be
considered the therapy of choice, provided the iatrogenic lesions of the urinary tract diminish as more experience with this
technique is gained.
Received: 1 March 1999/Accepted: 1 July 1999 相似文献
19.
Laparoscopic cholecystectomy using fine-caliber instruments 总被引:3,自引:0,他引:3
The advantages of laparoscopic cholecystectomy (LC) are based on its low invasiveness due to the small surgical wounds. If
LC could be performed using fine-caliber instruments, these advantages would be amplified. We developed 3-mm-caliber instruments
and performed LC in 20 patients using one 5-mm and two 3-mm instrument ports. The results were retrospectively compared with
those of standard LC. The operating time (107.2 ± 50.0 min), complication rate (0%), number of doses of analgesia (0.80 ±
0.83), and postoperative hospital stay (4.9 ± 1.2 days) were not significantly different between our method and standard LC.
At 6 months postoperatively, the scars were smaller with our method. Surgery using fine-caliber instruments was no more difficult
than standard LC and achieved a superior cosmetic outcome.
Received: 13 March 1996/Accepted: 19 July 1996 相似文献
20.
Microlaparoscopic cholecystectomy 总被引:11,自引:4,他引:7
Background: We set out to compare a prospective evaluation of microlaparoscopic cholesystectomy (MLC) using 5-mm ports for the scope
and operating ports and two 2-mm ports for retracting to the historic results of standard laparoscopic cholecystectomy (SLC).
Methods: Fifty-six consecutive patients were operated electively for symptomatic gallstones between June 1997 and July 1998. Demographics,
history of prior abdominal surgery, operative time, resident level, need to convert, length of stay, and postoperative analgesia
were recorded for each case. In all, 43 women and 13 men aged 21 to 89 (average, 51 years) underwent MLC. Average weight was
78 kg (range, 48–119) and average height was 163 cm.
Results: Operative time for MLC was 72 ± 25 min (range, 35–140), somewhat less than the referenced standard of 79 ± 27 min (p= 0.1). The skin-to-trocar time (6 ± 2 vs 13 ± 77 min) and intraoperative cholangiogram time (9 ± 8 vs 11 ± 6 min) were significantly
shorter (p < 0.01 and p < 0.05, respectively) for MLC. Other partial times were not significantly different. PGY2 residents averaged 74 ± 21 min
(range, 44–118) compared to 75 ± 27 min (range, 35–140) for PGY3 and 53 ± 5 (range, 43–59) for PGY5. Patient weight influenced
time. Patients <65 kg averaged 56 ± 12 min; 66–80 kg, 72 ± 24 min; 81–95 kg, 78 ± 26 min; and >95 kg, 85 ± 22 min. Previous
abdominal surgery did not affect operative time. Nine patients (16%) required conversion from 2- to 5-mm ports because of
adhesions, wall thickening, or need for better retraction. Time in these patients was 95 ± 26 min vs 68 ± 21 min in other
patients (p < 0.01). No patient was converted to an open procedure. Three patients (5%) had a positive cholangiogram and common bile
duct exploration that required placement of an extra 5-mm trocar. Five patients (9%) required insertion of an additional 2-mm
port. All patients received patient-controlled analgesia (PCA). Morphine use was 0.21 ± 0.19 mg/kg (range, 0–0.8). Hospital
stay was 1.31 days (range, 0.5–4). Subjective satisfaction was excellent because of smaller incisions. No additional morbidity
was seen with MLC.
Conclusion: MLC is a feasible and safe approach that provides similar times to SLC with better cosmesis, a less painful recovery, and
possibly an earlier return to normal activity.
Received: 16 February 1999/Accepted: 8 October 1999 相似文献