The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

Background: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. Methods: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. Results: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. Conclusions: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain. Received: 24 March 1997/Accepted: 4 September 1997     

Laparoscopic appendectomy—is it worthwhile?

Background: Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis. Methods: Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups. Results: Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005). Conclusions: In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies. Received: 18 March 1996/Accepted: 12 June 1996     

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     

Laparoscopic creation of stomas

Background: Some indications for laparoscopic bowel surgery are still controversial. However, the use of laparoscopic techniques for the treatment of benign disorders is less often challenged. Moreover, the morbidity of nonresectional procedures is less than that encountered with resectional cases. Therefore, stoma creation seems ideally suited to laparoscopy. The aim of our study was to assess the outcome of laparoscopic stoma creation. Methods: All patients who underwent laparoscopic intestinal diversion were evaluated; parameters included age, gender, indication for the procedure, history of previous surgery, operative time, length of hospitalization, recovery of bowel function, and postoperative complications. Results: Between March 1993 and January 1996, 32 patients of a mean age of 42.2 (range 19–72) years (14 males, 18 females) underwent elective laparoscopic fecal diversion (25 loop ileostomy, four loop colostomy, three end colostomy). Indications for fecal diversion were fecal incontinence (n= 11), Crohn's disease (n= 6), unresectable rectal cancer (n= 4), pouch vaginal fistula (n= 3), rectovaginal fistula (n= 2), colonic inertia (n= 2), radiation proctitis (n= 1), anal stenosis (n= 1), Kaposi's sarcoma of the rectum (n= 1), and tuberculous fistula (n= 1). Conversion was required in five patients (15.6%) due to the presence of adhesions (three), enterotomy (one), or colotomy (one). All of these five patients had undergone previous abdominal surgery and were operated on early in our experience. Major postoperative complications occurred in two patients (6%) and in both cases consisted of stoma outlet obstruction after construction of a loop ileostomy. One of the two patients had undergone prior surgery. This patient required reoperation, at which time a rotation of the terminal ileum at the stoma site was found. The other patient had a narrow fascial opening which was successfully managed with 2 weeks of self-intubation of the stoma. The mean operative time was 76 (range 30–210) min; mean length of hospitalization was 6.2 (range 2–13) days; stoma function started after a mean of 3.1 (range 1–6) days. Patients with previous abdominal surgery had a longer mean operative time (14/32; 117 min) compared to patients who had no previous surgery (18/32; 55 min) (p < 0.0002). These longer operative times and hospital stay were attributable to extensive enterolysis, which was required in some cases. Conclusion: In conclusion, laparoscopic creation of intestinal stomas is safe, feasible, and effective. Although the length of the procedure is longer in patients who have had prior surgery, previous surgery is not a contraindication, and even in these cases, a laparotomy can be avoided in the majority of patients. Lastly, care must be taken to ensure adequate fascial opening and correct limb orientation. Received: 25 March 1996/Accepted: 21 May 1996     

The efficacy of laparoscopic surgery in the diagnosis and treatment of peritonitis

Background: Peritonitis continues to be an important cause of morbidity and mortality and often an etiologic diagnosis is unclear. To evaluate the efficacy and safety of laparoscopy the authors analyzed their 5-year experience with this modality of treatment. Methods: A review was made of 107 consecutive nonselected laparoscopic procedures performed between October 1990 and November 1995. The diagnosis was established by clinical, laboratory, and imaging findings and confirmed by laparoscopy and/or laparotomy. Results: An etiologic diagnosis was unclear in 35% of the cases and was established in all by laparoscopy; 94 patients (87.9%) were successfully treated by laparoscopy while 13 (12.1%) required conversion. Mortality was 4.6%; 14% had postoperative complications and 7.4% had reoperations. Conclusions: Laparoscopic surgery is safe and very efficient in the diagnosis and treatment of patients with peritonitis. In most instances a definitive treatment can be carried out without conversion and has the additional and well-known advantages of minimally invasive surgery. Received: 15 March 1996/Accepted: 29 August 1996     

Duration of postlaparoscopic pneumoperitoneum

Background: Patients who present with abdominal pain after recent laparoscopic surgery present a diagnostic dilemma when pneumoperitoneum is present. Previous studies do not define the duration of postlaparoscopic pneumoperitoneum. In this study, we attempted to define the duration of laparoscopic pneumoperitoneum and to identify factors which affect resolution time. Methods: We followed 57 patients who underwent laparoscopic cholecystectomy (34), inguinal herniorraphy (20), or appendectomy (three). Serial abdominal films were taken until all residual gas was resolved. Results: Thirty patients resolved their pneumoperitoneum within 24 h; 16 patients resolved between 24 h and 3 days; nine patients resolved between 3 and 7 days; two patients resolved between 7 and 9 days. Mean resolution time for all patients was 2.6 ± 2.1 days. There was no apparent difference in resolution time between the three types of procedures; however, the sample size may be insufficient. Duration of the pneumoperitoneum did not correlate with gender, age, weight, initial volume of CO₂ used, length of time for the procedure, or postoperative complications. Sixteen patients had bile spillage during cholecystectomy which significantly reduced the duration of postoperative pneumoperitoneum (p < 0.008), resulting in a mean resolution time of 1.3 ± 0.9 days. While 14 patients reported postoperative shoulder pain, no correlation was found between the presence or duration of shoulder pain and the extent or duration of pneumoperitoneum. Conclusions: We conclude that the residual pneumoperitoneum following laparoscopic surgery resolves within 3 days in 81% of patients and within 7 days in 96% of patients. The resolution time was significantly less in patients sustaining intraoperative bile spillage during cholecystectomy. There was no correlation found between postoperative shoulder pain and the presence or duration of the pneumoperitoneum. Received: 22 March 1996/Accepted: 12 July 1996     

Effect of surgical stress on endogenous morphine and cytokine levels in the plasma after laparoscopoic or open cholecystectomy

Background: Endogenous morphine in the brain leads to various biological responses after surgery. The aim of this study was to determine whether morphine levels in the plasma would be enhanced by open laparotomy rather than by laparoscopic procedures. Methods: We compared 19 patients who underwent laparoscopic cholecystectomy with five patients who underwent resection of the gallbladder by open laparotomy. Morphine levels in the plasma were measured by an electrochemical detection system. Results: Postoperative endogenous morphine levels were higher with open laparotomy than with the laparoscopic technique (three h after surgery: open, 200 ± 52.6 fmol/ml vs laparoscopy, 17.6 ± 3.7, p < 0.01). This morphine elevation accounted for higher levels of cytokine, greater pain scores, and longer duration of fasting in open laparotomized patients than in laparoscopic cholecystectomy patients. Stress hormone levels in the plasma were also higher with open laparotomy than with laparoscopy. Conclusion: Morphine synthesis was enhanced by open laparotomy, resulting in greater biological response postoperatively than that seen with laparoscopic cholecystectomy. Received: 21 October 1998/Accepted: 3 April 1999     

Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve

Background: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. Methods: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. Results: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. Conclusions: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time. Received: 18 September 1996/Accepted: 26 December 1996     

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     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

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     

Postoperative complications of laparoscopic-assisted colectomy

Background: This study was performed to prospectively assess the complications of 118 consecutive patients who underwent laparoscopic assisted colorectal resections. Methods: The variables included were: indication for surgery, type of resection, duration of operation, duration of postoperative ileus, length of hospital stay, port-site recurrence, and complications in relation to the laparoscopic technique. Results: 118 Laparoscopic-assisted procedures were performed between July 1992 and October 1995. Surgical indications were: 106 patients for colonic malignancy, six for diverticulitis, two for Crohn's disease, two for benign polyps, one for endometriosis, and one for ischemic colitis. Fifteen patients required conversion to open techniques for completion of the operations (12.7%). The mean operating time was 168.8 min. The amount of operative blood loss was 98 ml. The mean time for passing flatus was 36 ± 16 h. Mean postoperative stay was 5.4 (range 3–13) days. Eight patients (6.8%) sustained complications: four unrelated to laparoscopy (three wound infection, one anastomotic leak); and four complications related to the laparoscopic approach: one small-bowel obstruction, one trocar injury, one rotation of the anastomosis, and one misdiagnosed synchronous adenocarcinoma. Conclusions: We suggest that with the development of improved technical devices and more experience, the indications for laparoscopic colectomy should continue to expand. The low incidence of infectious complications suggests an important role for the laparoscopic approach to colorectal surgery. Received: 25 March 1996/Accepted: 8 July 1996     

Laparoscopic management of mechanical small bowel obstruction

Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear. Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression was used to assess for independent variables. Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation (p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications. Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach. Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion. No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable alternative to conventional surgery in the management of acute small bowel obstruction. Received: 20 July 1999/Accepted: 22 November 1999/Online publication: 17 April 2000     

Efficacy of routine laparoscopy for the acute abdomen

Background: Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen. Methods: After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls. Results: The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest. Conclusions: Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time. Received: 3 April 1997/Accepted: 9 June 1997     

Laparoscopic repair of perforated duodenal ulcer

Background: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. Methods: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. Results: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. Conclusions: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery. Received: 16 August 1996/Accepted: 1 April 1997     

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     

Needle and trocar injury during laparoscopic surgery in Japan

Background: With the growth and sophistication of laparoscopic surgery, increased attention is now being focused on safety and complications. Methods: In an attempt to address questions regarding the safety of laparoscopic surgery, a retrospective study of the time period from January 1991 to December 1995 was conducted by the Study Group of Endoscopic Surgery in Kyushu, Japan. Results: The response rate was 84.4% (152 of 180 hospitals). During the last 5 years 17,626 patients underwent endoscopic operations and 87.5% (15,422 patients) had laparoscopic surgery while 12.5% (2,204 patients) underwent thoracoscopic surgery. In 96.6% of the hospitals a minimal open laparotomy was used. Among the various operations, a cholecystectomy was performed in the largest number of patients (13,787). The total number of complications was 415 (2.7%), of which 156 (37.6%) were related to needle or trocar insertion. Visceral injury was found in 22 patients (0.14%): major vessel injury in 10, gastrointestinal tract injury in 11, and liver injury in one patient. Abdominal wall injury was seen in 79 patients (0.52%), bleeding in 70 (0.46%), and a hernia in 9 (0.06%). Extraperitoneal insufflation occurred in 55 patients (0.36%). There was no mortality. The complication rate significantly decreased year by year after the use of laparoscopic surgery began. Conclusions: The most common complications of laparoscopic surgery are related to needle and trocar insertion. These are preventable by placement under direct vision with verification of the intraperitoneal location of the needle and trocar. Received: 10 February 1997/Accepted: 22 May 1997     

TNM staging and assessment of resectability of pancreatic cancer by laparoscopic ultrasonography

Background: Laparoscopic ultrasonography (LUS) is an imaging modality that combines laparoscopy and ultrasonography. The purpose of this prospective blinded study was to evaluate the TNM stage and assessment of resectability by LUS in patients with pancreatic cancer. Methods: Of the 71 consecutive patients admitted to our department, 36 were excluded from the study, mainly due to evident signs of metastatic disease or another condition that would preclude surgery. Thus, a total of 35 patients were enrolled in the study. All patients underwent abdominal CT scan, ultrasonography, endoscopic ultrasonography (EUS), diagnostic laparoscopy, and LUS. Histopathologic examination was considered to be the final evaluation for LUS in all but three patients, where EUS was used as the reference. Results: The accuracy of LUS in T staging was 29/33 (80%); in N staging it was 22/34 (76%); in M staging, it was 23/34 (68%); and in overall TNM staging, it was 23/34 (68%). In assessment of nonresectability, distant metastases, and lymph node metastases, the sensitivity was 0.86, 0.43 and 0.67, respectively, for LUS alone. Combining the information gleaned from laparoscopy and LUS, the accuracy in finding nonresectable tumors was 89%. Conclusions: Diagnostic laparoscopy with LUS is highly accurate in TNM staging and assessment of resectability of pancreatic cancer and should be considered an important modality in the assessment algorithm. Received: 6 July 1998/Accepted: 13 October 1998     

Elective laparoscopic-assisted sigmoid resection for diverticular disease

Background: Although the laparoscopic-assisted approach to colorectal cancer remains controversial, its use for benign diseases can have important advantages. The purpose of this study is to determine the feasibility of this approach for the treatment of elective diverticular disease and to identify preoperative and perioperative factors which can help to select the best procedure for each patient: either assisted laparoscopic resection (ALR) or dissection-facilitated laparoscopic resection (DLR). Methods: From November 1991 to the present, we conducted a prospective study of 41 patients approached electively for diverticular disease. Results: Twenty-nine patients underwent an ALR, seven were approached by DLR, and another five patients were converted to laparotomy (15%). Morbidity was 17.5% and there was no mortality in this series. The mean hospital stay after operation was 6.5 days. Conclusions: Because of the complexity of this inflammatory process, choice of either an assisted or a more invasive laparoscopic facilitated approach is necessary. The decision is based on the technical difficulty as determined by data collected both preoperatively and during laparoscopy. Received: 26 August 1996/Accepted: 26 November 1996     

Small bowel obstruction

Background: This is a retrospective review of our experience using a laparoscopic approach in the treatment of acute and chronic small bowel obstruction (SBO). Materials and methods: Of 136 patients hospitalized in our institutions for acute (94 cases: 69.1%) and chronic (42 cases: 30.8%) SBO, from January 1994 to March 1998, 63 (46.3%) were approached laparoscopically. The etiology was accurately diagnosed in 58 cases (92%), and it was possible to treat it laparoscopically in 82.5% (52 of 63 cases). In the remaining 11 cases (17.4%), a formal laparotomy was needed for bowel resection, due to an ischemic small bowel or for malignant disease. Results: Overall, 82.5% of our cases were successfully treated laparoscopically. Conclusions: We conclude that, in experienced hands, laparoscopy is an excellent diagnostic and, in the majority of cases, a therapeutic surgical approach in selected patients with acute or chronic SBO. Received: 30 June 1998/Accepted: 12 February 1999