LAPAROSCOPIC CHOLECYSTECTOMY: THE EXPERIENCE OF A COMMUNITY HOSPITAL

Background: The practice of laparoscopic cholecystectomy in a community hospital is presented. The morbidity of the procedure is analysed and recommendations for improvement are made. Laparoscopic cholecystectomy was introduced into this 200 bed community hospital in October 1990. All five general surgeons accredited to the hospital agreed to participate in a quality assurance programme to determine the incidence of complications and to make recommendations for improvement. Methods: The records of all 534 patients having laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed, and all complications recorded. Results: Of the 534 cases reviewed in the study 470 were considered uncomplicated and 64 patients experienced a total of 85 postoperative complications. The death of one patient was caused by a pulmonary embolus and another patient experienced a myocardial infarction. Twenty patients has postoperative atelectasis or pneumonia and urinary infection or retention occurred in seven. Complications of laparoscopic cholecystectomy requiring a conversion to open cholecystectomy occurred in eight patients, biliary complications occurred in 18 and 11 patients required re-operation. Conclusions: Three areas of concern were identified. They were the incidence of major biliary injury (0.37% of all cases) and its management, the role of cholangiography. and the incidence and prophylaxis of deep venous thrombosis and pulmonary embolism. Recommendations for improvement in these areas were made.     

An alternative technique for laparoscopic cholangiography

The current methods utilized for laparoscopic cholangiography involve cystic duct cannulation and present practical difficulties and potential hazards. An alternative method for intraoperative cholangiography is described which is easy, quick, and safe. The Kumar clamp (a gift from Sabi Kumar, M.D.) is placed across the infundibulum. A 23-gauge sclerotherapy needle is introduced through a side port in the clamp and directed into the infundibulum. The cholangiogram is obtained prior to any dissection in the triangle of Calot, thereby avoiding iatrogenic common bile duct injuries due to misidentification of the cystic duct or anomalous anatomy. To date no pathology has been missed and no complications have resulted from this technique.     

超声刀在腹腔镜胆囊切除术中的应用研究

目的　探讨超声刀在腹腔镜胆囊切除术中的应用价值。方法　将 86例腹腔镜胆囊切除术患者随机分为超声刀组 ( 3 4例 )与电刀组( 5 2例 ) ,分别使用超声刀与单极电刀完成手术 ,比较术中及术后的效果。结果　 86例手术顺利完成 ,无中转开腹。手术时间分别为 ( 4 5±7)min和 ( 62± 9)min(P <0 0 1) ,术中出血量分别为 ( 5± 0 .8)ml和 ( 2 0± 5 )ml(P <0 .0 1) ,术后肠道功能恢复时间分别为 ( 2 0± 4)h和 ( 2 4±6)h(P <0 0 1) ,两组均无胆瘘发生。结论　超声刀在腹腔镜胆囊切除术中较电刀更快捷 ,出血更少 ,术后恢复更快     

Cystic duct and Heister's "valves"

The anatomy and physiology of the cystic duct have been relatively neglected by anatomists and the function of the spiral mucosal folds or "valves" of Heister, first described in 1732, remains obscure. The gross and microscopic anatomy of the cystic duct is reviewed together with results from laboratory investigations into the function of the cystic duct and its spirally arranged folds. The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man and other animals may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.     

Robot-Assisted vs Laparoscopic Right Hemicolectomy in Octogenarians

ObjectiveWith increasing age, there is greater need for right-sided colonic resections than its left-sided counterparts. Older age is associated with limited physical and functional status, which carries greater operative risk. Improvements in robotic surgery questions its role, especially in older adults, compared with laparoscopy. The objective is to investigate whether robotic right hemicolectomy (RRH) is as safe and effective as laparoscopic right hemicolectomy (LHR) in octogenarians (age >80 years).DesignRetrospective cross-sectional analysis.Settings and ParticipantsOctogenarians who underwent elective RRH and LRH by the Tweed Colorectal Group over 5 years.MethodsComplications within 30 days, age, gender, smoking status, immunocompromised status, presence of diabetes, American Society of Anesthesiologists (ASA) physical status score, preoperative Eastern Cooperative Oncology Group (ECOG) performance status, mFI-5 (modified frailty index), operative time, method of anastomosis, postoperative length of stay (LOS), need for rehabilitation, and short-term oncologic data using the TNM criteria were compared using univariate and multivariate analysis.ResultsSeventy-eight elective patients were included. LRH and RRH groups had similar median ages, gender distribution, and comorbidities. Across the entire cohort, 61.5% had no 30-day complications. RRH had nonsignificantly shorter operative time but significantly shorter LOS (5 vs 8 days) and fewer minor complications (24.5% vs 34.5%). Major complications and overall complications were not significantly different between the groups. Lower ASA and ECOG status were associated with lower complication rates across both groups. Oncologic resection outcomes were similar for both approaches.Conclusions and ImplicationsRRH does not confer an increased risk of complications compared to LRH in the octogenarians and may be a viable alternative in the field of minimally invasive surgery for older patients. Future research should focus on intracorporeal anastomoses, as it is a potential confounder leading to the shorter inpatient LOS shown in our robotic group.     

Reduced port laparoscopic surgery using umbilical zigzag incision for Meckel’s diverticulitis

IntroductionReduced port laparoscopic surgery using an umbilical zigzag incision is comparable to conventional multiport laparoscopic surgery. This method is associated with improved cosmesis and decreased wound pain.Presentation of caseA 67-year-old man visited our hospital. He presented emergency room with a chief complaint of right lower abdominal pain by walking. The patient was diagnosed Meckel’s diverticulitis by computed tomography (CT). At first, antibiotics therapy and fasting were performed. Three months later, the patient underwent resection of Meckel’ diverticulum with zigzag transumbilical laparoscopic surgery. The patient’s postoperative course was good, and he rarely felt wound pain. The patient started oral intake three days after surgery, and was discharged 10 days after surgery.DiscussionZigzag transumbilical laparoscopic surgery is very useful for resection of the small intestine. This method is associated with improved cosmesis and decreased wound pain. In the case of Meckel’s diverticulitis, we suggest that interval resection of Meckel’s diverticulum was very useful as it was an operation that could be performed easily.ConclusionReduced port laparoscopic surgery using an umbilical zigzag incision is considered to be an excellent technique in terms of operability and aesthetic outcomes.     

An analysis of the outcome of microsurgical and laparoscopic adhesiolysis for infertility

We evaluated 81 women with adnexal adhesions and no male factorwho underwent microsurgical (n = 59) and laparoscopic (n = 22)adhesiolysis for infertility. The cumulative conception ratesfor all 81 patients at 12 and 24 months were 41 and 44% respectively.The impact of the following variables on cumulative conceptionrates for all patients was examined: age, duration of infertility,type of infertility, ovulatory status, presence and stage ofendometriosis, adhesion grade, adnexal status (bilateral orunilateral disease, unilateral tubal absence), history of previoussurgery, history of pelvic inflammatory disease and treatmentmodality (microsurgical versus laparoscopic). The results ofindependent comparisons of subgroups within each of these variablesmay be biased because of the interrelationships between thevariables. To overcome this problem, a stepwise Cox's proportionalhazards regression analysis was employed. Our analysis showedthat the single most significant variable influencing the cumulativeconception rates was the duration of infertility (P < 0.005).For every additional year of infertility, the probability ofpregnancy after adhesiolysis (microsurgical or laparoscopic)was reduced by 20%. Cumulative conception rates at 12 and 24months after microsurgical adhesiolysis were 36 and 40% respectively,while after laparoscopic adhesiolysis they were 57% at 12 and24 months. When imbalances were adjusted between the two treatmentgroups, there was no statistically significant difference betweenthe cumulative conception rates for microsurgical and laparoscopicadhesiolysis.     

Survey on Torino courses

Since March 1991 a monthly course on laparoscopic cholecystectomy has been organized at the Department of Surgery of the University of Turin. To evaluate the impact of this course and to obtain feedback from surgeons in order to improve the teaching of laparoscopic surgery, detailed questionnaires were sent to the participants of the first 20 courses.The outcome of this survey shows that short-residency hands on courses do not represent a completely satisfactory training, either for practicing surgeons or for residents, mainly because of the constraints of time and the lack of proctoring and supervision. Besides, the present study shows a significant difference in the diffusion of laparoscopic surgery in different areas of Italy.However, clinical results reported by this group of surgeons are satisfactory and comparable to the best multicentric series: 2,127 laparoscopic cholecystectomies were performed by 48 surgeons with a conversion rate of 6% and a complication rate of 2.4%.     

Fundus-first laparoscopic cholecystectomy

Removal of the gallbladder with commencement of dissection at the fundus is well recognized as a safe technique during difficult open cholecystectomy because it minimizes the risks of damage to the structures in or around Calot's triangle. We report here the routine employment of liver retractors and fundus-first dissection during laparoscopic cholecystectomy (LC) as an alternative to techniques previously described.Retraction of the liver and fundus-first dissection was used in 53 patients who underwent laparoscopic cholecytectomy. There were 16 male and 37 female patients. Seven were operations performed during an acute admission and 20 had moderate or severe adhesions involving the gallbladder. Thirteen patients had a preexisting abdominal incision.The procedure was successful in 52 patients (98%), but in one patient it was converted to open operation because of dense adhesions. Median duration of operation was 90 min (range 35–240 min). There was no mortality and two complications (persistent right upper quadrant pain for 2 weeks after operation and bile leakage from the gallbladder bed).The facility to retract the liver and carry out a fundus-first dissection extends techniques developed for open surgery into the laparoscopic arena. It offers the surgeon the safety and versatility during laparoscopic cholecystectomy that it confers during conventional open surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994