Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy?

Background: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. Methods: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. Results: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p=0.0001). We attribute this striking difference to significantly more adhesions (p=0.0002) and anatomical difficulties (p=0.003) in males during LC, leading to conversion. Conclusions: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.     

Why laparoscopic cholecystectomy today?

Traditional open cholecystectomy became the gold standard of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%–80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.     

Einfluß der orthograden darmspülung mit Prepacol® und Polyäthylenglykollösung auf die dauer des postoperativen Ileus nach kolorektalen resektionen

Zusammenfassung In einer prospektiv randomisierten Studie wurden bei 100 Patienten mit elektiven konventionellen (n=66) oder laparoskopischen (n=34) kolorektalen Resektionen die präoperative Darmvorbereitung mit einer 2 1-Polyäthylenglykol(PEG)-haltigen Lösung plus Prepacol® (Gruppe A, n=50) und die mit einer 4 1-PEG-Lösung (Gruppe B, n=50) verglichen. Im Rahmen der Studie wurde auch der Einfluß der Art und Qualität der Darmvorbereitung auf die Dauer des postoperativen Ileus untersucht. Die Qualität der Darmvorbereitung wurde wührend der Resektion am eröffneten Darm mit einem 4-Punkte-Score durch den Chirurgen bestimmt. Das Zeitintervall vom Ende der Operation bis zum ersten postoperativen Windabgang und dem ersten Stuhlgang wurden dokumentiert. Die Qualität der Darmvorbereitung wurde in beiden Gruppen als gleich gut beurteilt (Gruppe A: 94%; Gruppe B: 84%; p=0,5). Das postoperative Intervall bis zum Abgang von Winden (A: 3,1 ± 1,2 Tage; B: 3,2 ± 13 Tage; p = 0,6) und zum ersten Stuhlgang (A: 3,9 ± 1,3 Tage; B: 4,1 ± 1,3 Tage; p=0,5) war in beiden Patientengruppen etwa gleich lang. Als einziger Faktor mit eigenständigem Einfluß auf die Dauer des postoperativen Ileus in der multivariaten Analyse (Alter, Geschlecht, Vorbereitung, Operationsdauer, Operation, Operationstechnik) wurde die Operationstechnik (laparoskopisch oder konventionell) identifiziert. Der erste Stuhlgang trat nach laparoskopischeu Resektionen bereits nach durchschnittlich 3,2±1,1 Tagen auf, nach konventionellen Operationen dagegen erst nach 4,3±1,2 Tagen (p=0,001). Die Art (41 PEG oder 21 FEG plus Prepacol®) und Qualität der Darmvorbereitung beeinflußten die Dauer der postoperativen Motilitätsstörung nicht.

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Effect of bowel lavage with prepacol and polyethylene glycol on the duration of postoperative ileus following colorectal resection

In a prospective randomized study in 100 patients undergoing conventional (n=66) or laparoscopic (n=34) colorectal resection, mechanical lavage with 2 1 of a polyethylene glycol (PEG) solution (group A, n=50) combined with a laxative was compared with lavage with 4 1 of PEG alone (group B, n=50). The influence of bowel preparation on postoperative Hens was investigated. The efficacy of bowel preparation was determined intraoperatively by a surgeon blind to the type of preparation. The time interval between the end of the operation an first flatus or bowel movement was recorded. The efficacy of preparation was no different between the groups (group A: 94%, group B: 84%; P=0.5). The time lapse before first flatus (A: 3.1 ± 1.2 days, B: 3.2 ± 1.3 days; P = 0.6) or bowel movement (A: 3.9 ± 1.3 days, B: 4.1 ± 1.3 days; P = 0.5) also did not differ between the groups. The only factor found in multivariate analysis (age, sex, operation, duration and type of surgery, bowel preparation) to prolong the duration of postoperative ileus was the type of surgery. The first bowel movement occurred 3.2 ± 1.1 days after conventional surgery and 4.3±1.2 days (P<0.001) after laparoscopic surgery. The type of preoperative bowel preparation had no influence on the duration of postoperative Hens. The postoperative interval before the first bowel movement was shorter after laparoscopic surgery.

     

喉罩在腹腔镜胆囊切除手术中的临床应用

目的探讨喉罩在腹腔镜下胆囊切除手术对呼吸循环的影响。方法:所有病人均面罩吸氧去氮5分钟后,以Fentaly0.2mg.Norcriun 0.1mg/kg Propofol 2mg/kg静注给药诱导放置I型3号喉罩,术中观察BP、HR、EtCO2、Ppeak、SaO2。结果喉罩通气组循环稳定,BP、HR变化明显较气管插管组小。EtCO2、Ppeak、SaO2,两组无明显变化。结论使用喉罩通气进行腹腔镜下胆囊切除手术是一种安全、可靠和易行的方法。     

腹腔镜手术治疗特殊部位异位妊娠11例报告

目的 探讨特殊部位异位妊娠的临床特点与腹腔镜手术治疗的可行性与安全性。方法 回顾分析1998年1月至2003年1月间经腹腔镜手术治疗的特殊部位异位妊娠的临床资料,包括输卵管间质部妊娠4例,卵巢妊娠4例,腹腔妊娠3例。结果 11例特殊部位异位妊娠的临床特点:平均停经时间以卵巢妊娠较短,而间质部妊娠时间较长;血β-HCG值以卵巢妊娠和腹腔妊娠较低,而间质部妊娠较高;腹腔镜手术治疗特殊部位异位妊娠效果:平均手术时间为(45.0±13.8)min,平均术中失血为(81.0±80.6)mL,平均住院时间为(3.0±0.6)d,腹腔镜手术成功率为91％。结论 腹腔镜手术治疗特殊部位异位妊娠是可行且安全的,但是应根据其特点选择术式并预防并发症。     

腹腔镜腹部手术520例临床分析

目的探讨腹腔镜在腹部手术中的应用及并发症的预防。方法回顾性分析2001年3月～2005年3月腹腔镜下胆囊切除、阑尾切除、溃疡病穿孔修补、肠粘连松解、肝囊肿开窗、直肠癌前切术等520例临床资料。结果腹腔镜手术应用12种类，520例中有5例因胆囊三角解剖不清且胆囊萎缩而中转开腹手术，2例因术中出血而中转开腹。手术并发症3例（0．58％），其中胆管损伤2例。出血1例。结论腹腔镜手术的适应证随技术进步和设备改善将逐步拓宽；严格腹腔镜手术程序，严重并发症发生率可降低。     

Cholecystectomy: costs and health-related quality of life: a comparison of two techniques.

BACKGROUND: Outcomes of previous health economic evaluations comparing minilaparotomy cholecystectomy and laparoscopic cholecystectomy have been inconsistent. OBJECTIVE: To compare costs for minilaparotomy cholecystectomy and laparoscopic cholecystectomy and to study changes in quality of life induced by these operations. DESIGN: Single-blind, randomized controlled trial, run from 1 March 1997 to 30 April 1999. SETTING: One university hospital and four non-university hospitals in Sweden. MAIN MEASURE: : Cost and perceived health estimation according to the global quality of life instrument EuroQol-5D. RESULTS: Of 1719 cholecystectomy patients at five centres, 724 entered the trial and were treated with minilaparotomy cholecystectomy or laparoscopic cholecystectomy, 362 in each group. Total health care costs were less for minilaparotomy cholecystectomy than for laparoscopic cholecystectomy (median values US$2428 for minilaparotomy cholecystectomy versus US$2613 or US$3006 for laparoscopic cholecystectomy with 100 operations per year and reusable trocars or 50 operations per year and disposable trocars, respectively). There was no significant difference in total costs (including costs due to loss of production) between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with 100 operations per year and reusable trocars in laparoscopic cholecystectomy (US$3731 versus US$3649, respectively). However, in calculations assuming 50 operations per year and disposable trocars in laparoscopic cholecystectomy, this technique was more expensive than minilaparotomy cholecystectomy (US$4042 versus US$3731). Health-related quality of life was slightly but significantly lower for the minilaparotomy cholecystectomy group 1 week after surgery. One month and 1 year postoperatively no difference between the randomized groups was found. CONCLUSION: Total costs did not differ between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with high-volume surgery and disposable trocars, whereas laparoscopic cholecystectomy was more expensive with fewer operations and disposable trocars. The gain in health-related quality of life with laparoscopic cholecystectomy compared with minilaparotomy cholecystectomy was small and of limited duration.     

经腹腔镜先天性肥厚性幽门狭窄手术

目的 探讨小儿先天性肥厚性幽门狭窄腹腔镜微创手术操作要点及经验教训。方法 回顾性分析本组20例患儿全麻下经腹腔镜行幽门环肌切开术。结果 18例一次手术成功，1例术中中转开腹，1例3d后二次手术。全部病例随访2月，预后较好。结论 腹腔镜手术治疗先天性肥厚性幽门狭窄是腔镜技术在新生儿外科领域的成功运用，掌握操作要点，可推广使用。     

Comparative study of open tension-free and laparoscopic inguinal hernia repair in hernioplasty and simultaneous laparoscopic cholecystectomy

Objective: To evaluate the clinical value of laparoscopic inguinal hernia repair in hernioplasty and simultaneous cholecystectomy. Methods: Twenty-eight patients with symptomatic chronic calculous cholecystitis and synchronous unilateral primary inguinal hernia were performed combined surgery between October 2001 and March 2005. Of them, 10 cases underwent laparoscopic totally extraperiloneal mesh hernia repair (TEP) and laparoscopic cholecystectomy (LC), 3 cases underwent laparoscopic transabdominal preperitoneal mesh hernia repair (TAPP) and LC, and 15 cases underwent LC and open tension free hernia repair. Results: All the procedures were performed successfully, 2 patients occurred urinary retention in LC + open group and 1 patient occurred scrotum seroma in LC + TEP procedures. During the 6 to 24 months' follow-up, no hernia recurrences occurred in all patients. There were 6 patients (40%) in LC + open group had discomfort pain in the inguinal region and lasted 1 to 3 months. The operating time was longer in the totally laparoscopic group (TEP + LC and TAPP + LC) (104±31 min) than in the LC+open group (80±28 min) (P<0. 05). The intensity of postoperative pain at rest was greater in the LC + open group at 24 h (P<0. 05) and 48 h (P<0. 05). No differences between the 2 groups were found in the mean operating costs and oral intake of the postoperative period. But the time resume to walking (2. 9 vs 1. 8 d) (P<0. 01) and the mean hospital stay (8. 2 vs 4. 6 d) (P<0. 001) was longer in the LC + open group than in the totally laparoscopic group. Conclusion: In the same operating costs, the totally laparoscopic precedure has more advantages of low postoperative pain, quicker resume to walking and less hospital stay than open tension-free hernia repair in hernioplasty and simultaneous LC. Thus, the totally laparoscopic approach is considered to be advantage of the hernioplasty and simultaneous LC.     

Richter’s hernia occurring through a 5-mm laparoscopy sheath incision

We report a case of postoperative Richter’s hernia presenting through a 5-mm sheath incision. A 58-year-old woman having undergone laparoscopic hysterectomy 8 days before presented with severe left abdominal pain, nausea and light-headedness. The hypothesis of a sigmoid volvulus was suggested based on peroperative rectum and sigmoid release, the X-ray finding, and pain evolution. A secondary laparoscopic procedure allowed both diagnosis of a Richter’s hernia through a 5-mm sheath incision and surgical repair of the hernia. The use of this sheath during the laparoscopic vagina suture caused extension of the wound. Large 5-mm sheath defect sufficient for a Richter’s hernia can be created by multiple passes with small instruments and require surgical closure at the end of laparoscopy. Laparoscopy is useful in cases of postoperative complications, particularly when other complementary examinations are less informative.