Pancreatic trauma: Universities of Melbourne HPB Group.

BACKGROUND: Pancreatic trauma is uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. Although the retroperitoneal position of the pancreas confers it some immunity to injury, the force required to do so often results in severe associated injuries to other organs, which may be life threatening. Diagnosis may be difficult and surgery can be a considerable technical challenge. METHODS: All patients with pancreatic trauma who attended one of three Melbourne teaching hospitals from 1977 to 1998 were identified. Injuries were graded and the method of diagnosis and treatment studied. The incidence and causation of postoperative morbidity and mortality was identified. RESULTS: Thirty-eight patients (26 men and 12 women) were studied. Blunt trauma was responsible in 30 patients, stab wounds in five, gunshot wounds in two and iatrogenic injury in one. Injuries to other organs occurred in 30 patients. Surgical procedures were undertaken in 34 patients, resulting in the death of five and complications in 25. CONCLUSION: Complications and death are related to the associated injuries, as much as to the pancreatic injury itself. In this study, we review the experience of the management of pancreatic trauma in three large teaching hospitals in Melbourne over a 21-year period, and suggest a strategy for dealing with these difficult patients. Adherence to the basic concepts of control of bleeding from associated vascular injury, minimization of contamination, accurate pancreatic assessment, judicious resection and adequate drainage can diminish the risk. By approaching the problem in a systematic way and adopting a generally conservative management plan, complications and deaths can be minimized in these complex cases.     

Audit of methods of laparoscopic cholecystectomy

BACKGROUND: The operation of laparoscopic cholecystectomy began the modern era of laparoscopic surgery. Refinements in technique continue to appear. The techniques currently favoured by British surgeons have been reviewed. METHODS: A questionnaire-based survey was carried out among surgeons with a special interest in minimal access surgery. The data collected were entered into a database and analysed. Current literature relating to surgical technique was reviewed. RESULTS: Many aspects were evaluated and the results have shown that there is no uniform approach. It is interesting that only 30.8 per cent of surgeons use the open (Hasson) technique for peritoneal access. In addition, the use of intraoperative cholangiography continues to vary, with 65.8 per cent using the technique in selected cases. Fascial repair is not undertaken by 12.2 per cent of surgeons. CONCLUSION: Some trends are clearly discernible. There is a greater willingness than previously to perform intraoperative cholangiography, but the consensus seems to be against performing it in all cases. Similarly, British surgeons seem to be largely unimpressed by the dangers of the Veress needle; the Hasson technique has not been widely adopted. The need to prevent port-site herniation seems to be generally accepted, with most surgeons performing fascial repair.     

Predicting failure of outpatient laparoscopic cholecystectomy

BACKGROUND: Outpatient laparoscopic cholecystectomy (LC) is safe and feasible, but factors related to the failure of outpatient surgery are poorly defined. We hypothesized that patients in whom same day discharge (SDD) is unlikely may be identified preoperatively. METHODS: Three hundred eighty-seven consecutive patients scheduled for elective LC were prospectively enrolled in an outpatient clinical pathway. RESULTS: In all, 269 (70%) patients successfully underwent outpatient LC. Factors related to failure of SDD were age, American Society of Anesthesiology (ASA) class, surgery start time, and duration of surgery. Body mass index, liver function tests, and ultrasound findings did not predict failure of SDD. Three factors were able to predict more than 50% failure of SDD: age more than 50 years, ASA class 3 or more, and surgery start time later than 1:00 PM. CONCLUSIONS: Outpatient LC is feasible in a large county hospital. These data may be used in scheduling cases and counseling patients.     

门诊单孔腹腔镜胆囊切除术的应用

目的探讨门诊单孔腹腔镜胆囊切除术（OPSILC）的安全性、可行性及优势。方法自2008年12月至2010年10月,共完成41例OPSILC,患者的术前检查及手术均在门诊完成,术中在脐周做一个长2-2.5 cm的半圆形切口,将3个5 mm穿刺器分别经该切口穿刺进腹,采用5 mm可调节角度的腹腔镜以及超声刀、可弯曲的腹腔镜手术器械完成手术。结果本组42例患者,OPSILC 41例,中转行常规腹腔镜胆囊切除术1例。OPSILC平均手术时间为52.5 min,平均术中出血量为16.0 ml。术后平均进食流质时间为10.2 h,进食半流质时间为15.5 h。12例于手术当天出院,其余29例于术后第2天出院,平均术后院内观察时间为18.5 h。术后1例切口轻度感染,1例出现尿潴留。术后4周对全部患者进行电话问卷随访,结果显示患者均对OPSILC的美容效果表示满意,总体满意率为98%。结论 OPSILC是安全的、可行的,具有术前不适少、手术切口小、患者满意度高等优点。使用可调节角度的腹腔镜和弯曲的腹腔镜手术器械使OPSILC更简便易行,手术时间也随之缩短。     

Outcome and patient acceptance of outpatient laparoscopic cholecystectomy.

OBJECTIVE: The aim of this prospective study was to evaluate patients' experience and the outcome of outpatient laparoscopic cholecystectomy performed by a single upper gastrointestinal surgeon at a district hospital. METHODS: Between November 1999 and May 2003, 100 patients underwent outpatient laparoscopic cholecystectomy. Patients were followed up at 2 weeks as outpatients, and a questionnaire was mailed to all patients to assess their experiences. RESULTS: None of the patients required conversion to open cholecystectomy. One patient required admission to the hospital following drain insertion, and one patient was readmitted for pain control. One patient developed an epigastric port infection that resolved with antibiotics. Sixty-eight of the 100 patients completed the postal questionnaire. Thirty-five patients rated their overall experience as excellent. Twenty-three patients experienced very mild or no pain. All patients' right upper quadrant pain subsided or improved following surgery except one patient who stated that it became worse. Sixty-three patients (92.7%) stated they would recommend outpatient laparoscopic cholecystectomy to a friend or relative. CONCLUSION: Laparoscopic cholecystectomy can be performed safely as an outpatient procedure with a high acceptance and satisfaction rate in select patients.     

Is outpatient laparoscopic cholecystectomy wise?

The authors report a prospective analysis of their experience with 506 consecutive laparoscopic cholecystectomies to examine the appropriatenss of outpatient or same-day laparoscopic cholecystectomy. Thirty-eight patients experienced at least one postoperative complication. The complication was clinically evident or suspected in only 4 of these 38 patients within 8 h following surgery. Thirty-nine percent and 76% of complications were clinically detected at 24 and 48 h, respectively. Nausea and vomiting occurred among 32% of all patients on the day of operation and extended into the 1st postoperative day in 10%. Compared to predicted values, forced vital capacity was 61±5% 1 h postoperatively in 32 patients studied. At 6 and 24 h postoperatively, forced vital capacity was 63±7% and 66±7% respectively. Postoperative analgesic medication requirement was determined in 220 patients who were provided with a patient-controlled intravenous morphine analgesia machine with no basal rate. Consumption of morphine was highly variable but substantial on the day of operation: 17±16 mg. Most complications of laparoscopic cholecystectomy, including life-threatening complications, are not apparent by 8 h postoperatively and may not be apparent at 24 h. The potential for delay in the diagnosis and treatment of complications, variable but substantial analgesic requirements, impaired postoperative ventilation, and postoperative gastrointestinal dysfunction argue for the need to use great caution in selecting patients for outpatient laparoscopic cholecystectomy. Criteria are proposed to identify patients who are safest for outpatient laparoscopic cholecystectomy.     

Predictive model of failure of outpatient laparoscopic cholecystectomy

INTRODUCTION: The aim of our study was to review our experience and to determine a predictive model of factors for unanticipated admissions after ambulatory laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: Between January 1999 and June 2003, 410 consecutive LCs were performed as outpatient procedures. We performed univariate analysis and logistic regression models of preoperative and intraoperative variables. The scoring system developed allowed calculating the ambulatorization probability of LC in each patient. Validation and calibration of the model were realized by means of Hosmer-Lemeshow test. RESULTS: Three hundred sixty-three patients were strictly ambulatory (86.8%). Forty-two patients required overnight admission (10.2%), most of them because of social factors, and 5 patients were admitted. Predictive factors related to overnight stay or admission were: age of patient over 65 years [P=0.021; odds ratio (OR)=2.225; 95% confidence interval (CI), 1.130-4.381], operation duration superior to 60 minutes (P=0.046; OR=2.403; 95% CI, 1.106-5.685), and "dissection difficulty" intraoperative score superior to 6 (P=0.034; OR=3.063; 95% CI, 1.086-8.649). The right classification index of the predictive system was 91.7%, reaching a sensibility of 99.7% and specificity of 31.9%. CONCLUSIONS: Outpatient LC is safe and feasible. Age of the patient, operation duration, and complexity of surgical dissection during LC are independent factors influencing ambulatorization rate.     

Audit of laparoscopic cholecystectomy in a single center

A continuous audit is required to ensure laparoscopic cholecystectomy (LC) is performed safely in the surgical community in general. A retrospective review of all LC done in a single center was performed. A total of 1,244 LC were attempted. The conversion rate was 12.4%, the complication rate 3.5%, and the bile duct injury rate 0.4%. Forty percent of bile duct injury occurred after conversion. A decreasing trend of complication rate was seen in the early part of the series, then the rate steadied at about 2.5-3%. A higher threshold of conversion may not increase the bile duct injury rate. However, good laparoscopic technique and adequate experience are prerequisites to safe LC.     

Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy

Background : The aims of the study were to evaluate costs and clinical characteristics of desflurane-based anaesthetic maintenance versus propofol for outpatient cholecystectomy.
Methods : All 60 patients received ketamine 0.2 mg kg^-1, fentanyl 2 μg kg^-1 and propofol 2 mg kg^-1 for induction. Ketorolac 0.4 mg kg^-1 and ondansetron 0.05 mg kg^-1 +droperidol 20 μg Kg^-1 was given as prophylaxis for postoperative pain and emesis, respectively. The patients were randomly assigned into Group P with propofol maintenance and opioid supplements, or Group D with desflurane in a low-flow circuit system.
Results : All the patients were successfully discharged within 8 h without any serious complications. Emergence from anaesthesia was more rapid after desflurane; they opened their eyes and stated date of birth at mean 6.4 and 8.4 min respectively, compared with 9.6 and 12 min in the propofol group (P<0.05). Nausea and pain were more frequent in Group D, 40% and 80% respectively; versus 17% and 50% in Group P (P<0.05). By telephone interview at 24 h and 7 d after the procedure, there was no major difference between the groups. With desflurane, drug costs per case were 10 $ lower than with propofol.
Conclusion : We conclude that desflurane is cheaper and has a more rapid emergence than propofol for outpatient cholecystectomy. However, propofol results in less pain and nausea in the recovery unit. Despite ondansetron and droperidol prophylaxis, there was still a substantial amount of nausea and vomiting after desflurane.     

腹腔镜胆囊切除术在门诊的应用与研究

目的:门诊腹腔镜胆囊切除(outpatient laparoscopic cholecystectomy,OPLC)的可行性和可能性在国内还未被广泛认同.此项连续前瞻性研究探讨门诊腹腔镜胆囊切除是否安全、经济而具可行性.方法:共有55位经选择患者加入此项研究.OPLC组26位,常规腹腔镜组(LC)29位.术前检查、诊断以及术后留院时间、费用和并发症的资料采集后,予"独立样本T检验"(SPSS 10.0统计软件)分析.结果:OPLC患者术后没有发生严重并发症如CBD损伤、出血等.平均术后观察时间为7.19 h,平均总治疗费用4108.73 RMB,较LC患者的5068.17 RMB降低有极显著差异(t=31.664,P<0.001).25/26位OPLC患者对这种治疗方案表示满意,与LC组患者满意度(28/29)无统计学差异(Chi square test:χ2=0.4131,P>0.05).结论:OPLC和住院LC同样安全、可行,而总治疗费用更低.     

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     

单切口腹腔镜胆囊切除术与腹腔镜胆囊切除术的病例对照研究

目的回顾性分析单切口腹腔镜胆囊切除术（SILC）与传统腹腔镜胆囊切除术（LC）的优劣性。方法19例SILC及46例LC患者的临床资料,比较两者的手术时间、术中出血量、术后并发症、中转率、术后疼痛、住院时间、切口长度的差异。结果SILC手术耗时（49．00±8．34）min长于LC（P=0．000）。术中出血量差异无统计学意义。两组均无中转、术后无并发症;SILC与Lc术后患者第一天疼痛评分、术后第三天疼痛评分、总疼痛天数差异均无统计学意义。两者住院时间差异无统计学意义。SILC切口长度（22．5±3．5）mm短于LC切口长度（P=0．000）。结论SILC总切口长度短于LC总切口长度,切口效果更美观。SILC能安全地用于单纯胆囊结石、胆囊息肉。同时对于没有严重合并症和腹部手术史的胆囊疾病患者SILC也是一种理想的手术选择。     

In selected patients outpatient laparoscopic cholecystectomy is safe and significantly reduces hospitalization charges.

The safety of laparoscopic cholecystectomy has been demonstrated through its increased use, and we have performed 114 of these operations as outpatient procedures. These patients have done well and hospitalization charges have been reduced substantially. Of 622 laparoscopic cholecystectomies performed from November 1989 to March 1991, 114 were done on an outpatient basis if the patients were generally healthy, lived nearby, and the operative procedure was uneventful. Other patients were admitted as 23-h observation or as inpatients. Records of 106 outpatients were reviewed and hospital charges obtained. These charges were then compared with those of 337 patients who underwent standard open cholecystectomy as morning admissions and who had no comorbid conditions nor complications. Comparisons are also made with 23-h observation and inpatient laparoscopic cholecystectomies as well as with all standard open cholecystectomy patients. The technique employed is with three punctures using electrocautery and a minimum of disposable products. Of the 106 outpatients, one required admission for postoperative ileus and pain control; 21 (19.8%) experienced nausea and 14 (13.2%) experienced vomiting but were treated successfully with antiemetics; none required admission. One patient required outpatient catheterization for urinary retention. Of the last 100 laparoscopic cholecystectomies performed by three surgeons (M.E.A., C.J.D., A.A.), 43 were performed as outpatients using the above selection criteria. 44 were held for 23-h observation, and 13 were inpatients. The average hospital charge for 377 uncomplicated morning-admitted inpatient standard cholecystectomy patients was $4,250.00, compared with $2,293.02 for 106 outpatient laparoscopic cholecystectomy patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Electrosurgical laparoscopic cholecystectomy.

Though laparoscopic cholecystectomy has become widespread, questions remain as to its success rate, its role in acute cholecystitis, the role of cholangiography, and whether laser use is necessary. To attempt to answer these questions, the first 100 patients undergoing laparoscopic cholecystectomy at Emory University using electrosurgical diathermy were reviewed. Patients underwent cholecystectomy for biliary colic (87), gallstone pancreatitis (1), and acute cholecystitis (12). The average length of hospital stay was 29 hours (range: 12 hours to 5 days). Laparoscopic cholecystectomy was not possible in 7 patients because of gangrenous cholecystitis (2), adhesions from previous surgery (2), equipment failure (2), and choledochoduodenal fistula found at surgery (1). Two patients developed bile leaks from accessory bile ducts that healed spontaneously. There were no other complications. The average time required to complete the laparoscopic cholecystectomy was 115 minutes (range: 45 to 238 minutes) and was not significantly different in those patients undergoing intraoperative cholangiography (117 minutes) versus those without (109 minutes). Common duct stones were uncommon in this series. Thirty-three patients underwent intraoperative cholangiogram. One patient was found to have a common duct stone, which was pushed into the duodenum using a Fogarty catheter (American Edwards Laboratories; Anasco, Puerto Rico) inserted through the cystic duct at the time of laparoscopic cholecystectomy. Twelve patients with acute cholecystitis underwent an attempt at laparoscopic cholecystectomy that was successful in nine. These procedures were difficult and lengthy (mean of 143 minutes). Causes for failure were gangrenous cholecystitis (2) and equipment failure (1). In conclusion, laparoscopic cholecystectomy can be performed with a high success rate (93%) and low morbidity (2%). No complications seemed attributable to electrosurgical dissection.     

Simulated laparoscopic cholecystectomy.

A new simulator specifically designed for practising techniques in laparoscopic cholecystectomy is described. The simulator is inexpensive and utilises pig gallbladders. It allows a surgeon to practice without the need for assistance.