Laparoscopic management of ovarian tumors

Background: Laparoscopy can be used with minimal operative morbidity to evaluate adnexal masses. We report our experience with the endoscopic approach to the diagnosis and treatment of ovarian tumors. In particular, we describe 11 patients who incidentally underwent laparoscopy and in whom the ovarian masses were found to be malignant. Methods: Between September 1994 and September 1996, 292 patients with 316 ovarian tumors were treated laparoscopically in the Department of Obstetrics–Gynaecology, University of Ulm. We assessed vaginal ultrasonography, clinical assessment, the tumor marker CA 12-5, and the intraoperative low-power magnification for their value in predicting the final diagnosis in all laparoscopically treated ovarian tumors. Results: From a total of 292 patients with ovarian tumors, 11 were diagnosed, intraoperatively or after final histologic examination, as having a malignant or borderline ovarian tumor. All applied pre- and intraoperative diagnostic procedures were by themselves too unreliable to exclude early stages of ovarian carcinoma exactly. Conclusions: On the basis of the present findings, we are tempted to conclude that laparoscopic surgery is justified in the management of ovarian tumors. Even with an accurate preoperative selection of suitable patients for laparoscopic surgery, the presence of an undetected ovarian carcinoma cannot be entirely excluded. Received: 23 September 1997/Accepted: 4 December 1997     

Laparoscopic treatment of gastric stromal tumors

Background: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. Methods: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2–6). Conclusions: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones. Received: 30 April 1999/Accepted: 7 October 1999/Online publication: 10 April 2000     

Laparoscopic hand-assisted surgery for hepatic and pancreatic disease

Herein I describe my initial experience with the use of a novel device, the Omniport, in 15 patients undergoing hand-assisted laparoscopic surgery (HALS) on the liver and pancreas. The device, which essentially consists of a hand cuff with a spiral inflatable valve, enables withdrawal and reinsertion of the hand without loss of pneumoperitoneum during the operation. The cuff's effective sealing pressure is equal to the pneumoperitoneal pressure; hence, hand comfort is maintained during the intervention. The device was effective in maintaining pneumoperitoneum in all cases. All but one operation was completed with the HALS approach. The one conversion was due to bleeding from the superior mesenteric vein during a 90% pancreaticosplenectomy. Immediate effective control of the bleeding by compression between the thumb and index finger was achieved, and the cuff of the Omniport was deflated as the incision was enlarged. There were no postoperative complications. The HALS approach has distinct advantages in terms of exposure and safety over the total laparoscopic technique for major surgery on the liver and pancreas, and it is recommended for these interventions. Received: 4 August 2000/Accepted: 4 August 2000/Online publication: 20 October 2000     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Laparoscopic management of acute cholecystitis

Background: Laparoscopic cholecystectomy for acute cholecystitis is considered feasible and safe, but it is associated with a higher rate of conversion to laparotomy than elective cholecystectomy because of technical reasons and anatomical changes related to the inflammatory process. The value of several factors that might influence its successful completion has not been studied completely yet, including the role of residents in operating such cases under attending-surgeon surveillance. Methods: In a retrospective nonrandomized study, the medical charts of 182 patients that were operated for acute cholecystitis (94 of whom via the laparoscopic approach) were studied. The study was also conducted to study the effect of residents as operators. Results: Male sex, duration of right upper abdominal pain, and the severity of the inflammatory process have all been significantly and independently correlated with increased conversion rate to laparotomy. Operation time was not longer than that of the open approach, and hospital stay and complication rate were lower. Operations performed by residents were associated with twofold conversion rate to laparotomy, without increased complication rate (p < 0.012). Conclusions: Laparoscopic management of acute cholecystitis is feasible and safe. Considering the factors discussed above, lowering the threshold for conversion is necessary in selected cases to maintain low morbidity rate. Integrating laparoscopic cholecystectomy for acute cholecystitis into surgical residency should be studied. Received 5 January 1996/Accepted 22 April 1996     

Laparoscopic cholecystectomy in 1994

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     

Laparoscopic liver surgery

Background: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the ``four-hands technique' for simultaneous dissection and control of bleeding and bile ducts during resections. Received: 10 May 1996/Accepted: 26 July 1996     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Laparoscopic four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described. Received: 13 April 1999/Accepted: 11 January 2000/Online publication: 20 July 2000     

Laparoscopic vs conventional Nissen fundoplication

Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Received: 15 May 1996/Accepted: 10 September 1996     

Laparoscopic colposuspension

Background: The laparoscopic approach must be shown to be cost-effective as well as safe and technically effective before being widely adopted. A review of 54 consecutive patients who underwent open and laparoscopic colposuspension is presented and a cost-analysis is performed comparing the two approaches. Methods: This study was a retrospective controlled review of patient records and accounts of in-hospital costs incurred at a private hospital. Results: Theater costs were significantly greater in the laparoscopic group but this was balanced by a shorter length of stay and subsequent reduced accommodation cost. There was no difference in the overall in-hospital costs between the two groups. Conclusion: The laparoscopic surgical approach is safe and effective and by no means more expensive than the open approach. In the future, the laparoscopic approach can only become more cost efficient; techniques will improve and there will be earlier returns to work and, subsequently, greater productivity. Received: 19 August 1996/Accepted: 20 December 1996     

Laparoscopic surgery for diverticulitis

Background: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. Methods: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p= NS). Results: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). Conclusion: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment. Received: 25 March 1996/Accepted: 17 July 1996     

Laparoscopic ligation of testicular veins for varicocele in children

Background: The technique of the laparoscopic treatment of varicocele in children is described, and its outcome is discussed. Methods: A total of 180 patients from 6 to 14 years of age were studied. All of them had left-sided varicocele; 10 of them were recurrences after treatment by other methods. Varicocele was diagnosed on physical examination and confirmed by Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the spermatic artery and tinted lymphatic vessels, followed by double ligation of the spermatic veins. Results: There were no intraoperative or postoperative complications and only one case of recurrence (0.6%). Conclusion: The suggested technique for laparoscopic varix ligation is a highly effective and reliable method for the treatment of pediatric varicocele. It provides the minimal invasiveness of the approach, effective microsurgical quality of visualization, and dissection with guaranteed preservation of the spermatic artery and lymphatic vessels, along with very low rates of complication and recurrence. Received: 2 February 1999/Accepted: 7 October 1999/Online publication: 29 August 2000     

Laparoscopic Nissen fundoplication

Passing the stomach behind the esophagus during laparoscopic Nissen fundoplication is a common source of frustration for the laparoscopic surgeon. It often leads to an incorrect formation of the fundoplication, resulting in a wrapping or twisting of the fundus around the distal esophagus. The correct technique should result in the distal esophagus being enveloped inside the fundus without distorting the orientation of the greater curve. We have developed an easy, precise, and reproducible technique to perform this maneuver. The steps for performance of this maneuver are described. Received: 12 March 1999/Accepted: 24 September 1999     

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     

Laparoscopic splenectomy for splenic hamartoma

Advances in imaging techniques have made preoperative diagnosis of splenic tumors possible. A case of successful laparoscopic splenectomy for splenic hamartoma is described here and the indications of this technique are discussed. Received: 12 January 1996/Accepted: 22 March 1996     

Laparoscopic splenectomy

Background: The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University of California, San Francisco. Methods: The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated open splenectomy patients (OS). Results: Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients (mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group (mean $8,939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications occurred. Complication rates and transfusion requirements did not differ between OS and LS patients. Conclusions: Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in patients of all ages. Received: 16 April 1996/Accepted: 5 July 1996     

Anaesthetic experience with laparoscopic cryotherapy

Background: Laparoscopic cryotherapy is a new technique for treating hepatic tumors that obviates the need for a laparotomy and may reduce the amount of surgical trauma and heat loss associated with the open technique. Liquid nitrogen is applied to the tumor via a cryoneedle probe introduced through a laparoscopic port. The aim of this study was to assess the effect on body temperature and the hematological and biochemical changes associated with this technique. Methods: Five patients who underwent this procedure were studied prospectively under a standardized general anaesthetic. Core and peripheral temperature were measured during the procedure, and blood samples were taken for hematological and biochemical analysis. Results: Freezing time ranged 19–57 min and measured blood loss 0–1000 ml. In one case, bleeding resulted from hepatic surface cracking. Three patients required a blood transfusion. The mean fall in both nasopharyngeal and right atrial temperature was 0.4°C. Postoperatively, all patients showed a large rise in alanine aminotransferase (ALT) and a fall in platelet count. A systemic inflammatory response syndrome was seen in some cases, but all patients survived to hospital discharge. Conclusions: Laparoscopic hepatic cryotherapy can be performed without significant temperature changes, but it entails significant morbidity. Received: 3 March 1997/Accepted: 28 April 1997     

Laparoscopic lumbar sympathectomy

Background: Lumbar sympathectomy retains a role in the treatment of patients with causalgia, Symptomatic vasospasm, and nonreconstructable arterial occlusive disease. Open surgical sympathectomy, with its attendant morbidities, remains the standard. Chemical sympathectomy has been introduced as a less invasive means of achieving sympatholysis. However, this has been associated with incomplete and transient denervation. Methods: We present a series of five lumbar sympathectomies performed laparoscopically. Results: All patients sustained symptomatic relief and no postoperative complications were noted. Postoperative skin thermometry and resistance measurements confirmed adequacy of sympatholysis. Conclusion: We conclude that lumbar sympathectomy can be performed laparoscopically. Our preferred technique is now the extraperitoneal approach. Such an approach combines the durability and reliability of standard open sympathectomy with the minimal invasiveness of laparoscopic surgery.     

Laparoscopic surgery during pregnancy

Background: Laparoscopic surgery is known for its many advantages, but the use of this modality during pregnancy is still under discussion. Methods: The subjects in this discussion are the unknown influence of the pneumoperitoneum and the fear of damaging the uterus while inserting the Veress needle and trocars. In a review of recent literature describing laparoscopic surgery during pregnancy, no complications were seen. We performed four laparoscopic appendectomies and three laparoscopic cholecystectomies between 12 and 33 weeks estimated gestational age (EGA). Results: All pregnancies passed without complications and ended in at-term deliveries of healthy babies. Conclusions: The risks, precautions to avoid them, and the safety of laparoscopic surgery during pregnancy are discussed in the light of our experience and reports in recent literature. Received: 26 September 1995/Accepted 3 May 1996