Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents.

OBJECTIVE: Pediatric gastric access for long-term enteral feeding may be performed via a laparotomy, laparoscopy, or a percutaneous approach. In children and adolescents, laparoscopic-assisted gastrostomy may be difficult due to a thick abdominal wall. Therefore, if the abdominal wall is estimated to be >2 cm on physical examination, or in children in whom a percutaneous endoscopic gastrostomy was unsuccessfully attempted by a gastroenterologist, we routinely perform a laparoscopic-assisted percutaneous endoscopic gastrostomy. METHODS: From January 1998 through February 2003, we retrospectively reviewed 15 cases of a laparoscopic-assisted percutaneous endoscopic gastrostomy. Instruments used to perform this technique are a percutaneous endoscopic gastrostomy kit, an Olympus flexible endoscope, and one 5-mm STEP port placed through an infraumbilical incision for a 5-mm, 30-degree scope. RESULTS: Age range was 2 years to 20 years (mean, 10). Operative time ranged from 20 minutes to 45 minutes. When a concurrent laparoscopic Nissen fundoplication was performed (n = 6), the percutaneous endoscopic gastrostomy was placed after completion of the Nissen fundoplication. No intraoperative complications occurred, and all tubes were successfully placed. Feeds were instituted the following day and advanced to goal. To date, no postoperative complications have occurred, and revision has not been necessary. CONCLUSIONS: Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents is safe and effective. Utilizing laparoscopy permits evaluation of the peritoneum and lysis of adhesions, if necessary. Moreover, laparoscopy provides excellent exposure for accurate placement of the PEG, while avoiding injury to other organs.     

老年肝内外胆管结石的腹腔镜手术治疗

目的 :探讨老年肝内外胆管结石行腹腔镜手术的可行性、特点及围手术期处理。方法 :应用腹腔镜胆总管切开纤维胆道镜取石治疗老年性肝内外胆管结石 2 0例 ,显露肝门 ,切开胆总管 ,取石 ,胆总管均放置T形管引流。结果 :2 0例手术均获成功 ,1例术后肝内胆管残余结石 ,术后 6周经T管窦道纤维胆道镜取石治愈。 1例 16d拔T管后胆汁性腹膜炎 ,开腹引流治愈。结论 :老年性肝内外胆管结石腹腔镜手术 ,患者创伤小 ,安全 ,疗效满意。     

腹腔镜治疗妇科急症593例临床分析

目的:探讨腹腔镜治疗妇科急症的可行性、安全性及治疗效果。方法:回顾分析2003年7月至2007年10月我院用腹腔镜治疗593例妇科急症患者的临床资料。结果:593例患者均用腹腔镜完成手术,其中异位妊娠512例,手术时间18～75min,平均32min,术中出血10～70ml,平均25ml;盆腔炎、盆腔脓肿47例,手术时间35～90min,平均49min,术中出血45～130ml,平均84ml;黄体破裂、卵巢内膜囊肿破裂、卵巢囊肿蒂扭转34例,手术时间35～80min,平均52min,术中出血20～85ml,平均65ml;术后住院3～7d,平均4.5d,随访12～36个月无复发。结论:腹腔镜手术治疗妇科急症安全可行,且具有良好的效果。     

Spilled Gallstones: the Source of an Enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.     

Role of laparoscopy in identifying the clinical significance and cause of adhesions and chronic pelvic pain: a retrospective review at the Kiel School of Gynecological Endoscopy.

OBJECTIVES: We sought to define the role of laparoscopy in identifying the clinical significance, cause, and association between adhesions and chronic pelvic pain. METHODS: A retrospective chart review was conducted from October 2004 to July 2005, at the Kiel School of Gynecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Germany. Included in the study was the analysis of 462 laparoscopic procedures; 275 (59.5%) of the patients undergoing these procedures had pelvic or abdominal adhesions. Of these, 84 (30.5%) patients were admitted with the main complaint of chronic pelvic pain. Further evaluation and assessment of this group was carried out. RESULTS: Among those patients with adhesions, the second most frequent reason for admission was chronic pelvic pain (30.5%) (P<0.0005). In our study, adhesions were found in 79.2% (n=84) of patients (n=106) with chronic pelvic pain. These adhesions were thin-filmy (19.0%) or thick-fibrous (81.0%) adhesions containing blood vessels. Thick-fibrous adhesions were present in 50.0% of patients at multiple abdominopelvic sites (P<0.005). CONCLUSIONS: Thick-fibrous adhesions that extend beyond the pelvic sidewall can cause significant chronic abdominopelvic pain.     

腹腔镜脾切除术的经验总结

目的:探讨腹腔镜脾脏切除术的手术技巧和临床效果。方法:回顾分析我院2001年7月至2007年1月问33例腹腔镜脾脏切除术的手术时间、术中失血量、术后并发症等。结果:33例病人中有2例因为睥脏明显肿大,直接行腹腔镜下手助脾脏切除;1例因术中脾静脉出血转手助操作完成手术:余30例行完全腹腔镜下脾脏切除术;无中转开腹术。手术平均时间为(86．54±30．43)min(50～200 min),术中平均失血量为(110±171．24)ml(25～800 ml)。术后拔除引流管的平均天数为4．73(2～21)d。术后平均住院天数为8．76(4～55)d。无死亡病例。手术后有1例并发少量胰漏,引流3周后愈合。结论:腹腔镜脾脏切除术安全可行,必要时可以手助下完成手术。     

Laparoscopic mesh repair of incisional hernia: an alternative to the conventional open repair?

Background Tension-free incisional hernia repair using alloplastic material increasingly replaces conventional repair techniques. This change resulted in a decreased recurrence rate (50% vs. 10%, respectively). Recently, laparoscopic approaches for the intraperitoneal tension-free mesh application have been introduced. The decreased trauma at the incision site and the reduction in wound infections appear to be the main advantages. The aim of the present study was to evaluate the early and long-term complications as well as patients’ contentment. Methods Laparoscopic hernia repair with intraperitoneal polytetrafluroethylene (PTFE) mesh implantation was performed on 62 patients at the Klinikum Grosshadern between 2000 and 2005 (29 males, 33 females age 60.7). Intra- and postoperative complications were registered prospectively and retrospectively analyzed. In addition, 57 patients were evaluated for recurrence, postoperative pain and patient contentment (median follow-up 409 days). Results A low complication rate was observed in our patient collective. One trocar bleeding occurred. Three patients presented with wound hematoma. The recurrence rate was 8% (2/25). Sixty-two percent of the patients were free of complaints postoperatively. Eighty-five percent would once again choose the laparoscopic approach for incisional hernia repair. Conclusion The laparoscopic technique was associated with a low recurrence rate, a small rate of wound infections and high patient comfort. Thus, the laparoscopic approach for mesh implantation appears to be a safe and effective method for the treatment of incisional hernias. The efficiency for laparoscopic intraperitoneal mesh implantation, however, should be further evaluated within a prospectively randomized multicenter trial. M. Stickel and M. Rentsch contributed equally.     

Broad ligament hernia-associated bowel obstruction.

BACKGROUND AND OBJECTIVE: We present the case of a female patient 29 years of age with antecedents of laparoscopic laser ablation for endometriosis, laparoscopic appendectomy, and umbilical hernioplasty. METHODS: The patient was admitted to the hospital's emergency room for abdominal pain in the epigastrium, transfixing, irradiating to both upper quadrants and to the lumbar region, accompanied by nausea and gastrobiliary vomiting. Lipase determination was 170 mg/dL. Other laboratory findings were normal. Plain abdominal films on the patient's admission were normal, and computed tomography (CT) showed data compatible with acute pancreatitis. Without improvement during the patient's hospital stay, pain and vomiting increased in intensity and frequency. RESULTS: New abdominal x-rays revealed dilatation of small bowel loops. Management was begun for intestinal obstruction, with intravenous hydration and placement of a nasogastric tube without a good response. At 48 hours, a diagnostic laparoscopy was performed, revealing a 3-cm internal hernia in the left broad ligament in which a 20-cm segment of terminal ileum was encased. We performed liberation of the ileal segment and closed the hernial orifice by using the laparoscopic approach. CONCLUSION: The patient's evolution was excellent.     

Laparoscopic cholecystectomy in a patient with a biventricular cardiac assist device.

Evaluation and management of abdominal pathology in patients with ventricular assist devices is likely to become increasingly important as the utilization of these devices expands. Ventricular assist devices represent a class of intracorporeal or paracorporeal mechanical devices that augment cardiac output in patients with congestive heart failure. Patients with ventricular assist devices supporting both right and left ventricles (biventricular assist devices) are uniquely challenging to the general surgeon because these devices restrict direct access to the abdominal cavity and because of the perioperative implications of biventricular heart failure. We describe herein the first reported successful laparoscopic cholecystectomy in a patient with a paracorporeal biventricular assist device. Cholecystectomy was performed in this patient for acute cholecystitis that occurred while the patient was awaiting heart transplantation. Our results add weight to the small body of evidence that laparoscopy is well tolerated in ventricular assist devices patients. The unique aspects of the biventricular assist device patient make laparoscopic abdominal intervention particularly suitable in this patient population.     

后腹腔镜肾癌根治术并发症7例总结

目的 总结后腹腔镜肾癌根治术并发症的经验. 方法 我院2002年11月～2006年5月行后腹腔镜下肾癌根治术122例,共发生并发症7例,发生率5.7%.第1例精索静脉损伤,中转开放手术止血,出血量约1000 ml,输血800 ml.第2例副肾动脉出血,术中仅用超声刀切断,术后20 h血压下降至90/60 mm Hg,再次手术,用4号线结扎副肾动脉,出血约600 ml,输血400 ml.第3例腔静脉损伤为用直线切割器切割闭合右肾静脉时误将腔静脉切割封闭一半,但未出血.第4例为直线切割器切断肾动脉后残端喷血,又上2个钛夹,出血停止.第5、6例为剪断动脉时误伤肾静脉,1例用Hem-o-lok控制近心端,另1例用10个钛夹纵行夹闭肾静脉止血.第7例为胰尾漏,术后引流液体最多时达300 ml,引流液淀粉酶26 000 U/L. 结果 腔静脉损伤者术后随访30个月,未见异常;胰尾漏者术后随访1年,肾窝无积液,无胰腺炎;其余5例随访20～40个月均未见异常. 结论 腹腔镜下并发症主要是大血管损伤,处理的原则是提高气腹压至18～20 mm Hg,镇静地钛夹夹闭出血点,必要时及时改为开放手术.保持引流管通畅可以有效地治疗胰腺损伤.