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31.
E. Croce M. Golia M. Azzola R. Russo L. Crozzoli S. Olmi C. Pompa M. Borzio 《Surgical endoscopy》1996,10(11):1064-1068
Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described.
Methods: The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations,
and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure
of the main duct. Median duration of surgery was 180 min (range 100–300), including three associated laparoscopic procedures.
Results: There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range
4–14). In May–June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a
successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5–44). Besides
clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography.
Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had
umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative
CBD stricture. At US, CBD was ≤7 mm in 15 patients, 8–10 mm in four patients, and 10–12 mm in three patients. The last group
had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no
change; in nine it decreased; and two had a slight increase (8–10 mm).
Conclusions: We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and
low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of
asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless,
and its specific complications are well known.
Received: 20 October 1995/Accepted: 28 February 1996 相似文献
32.
Stephen D. Scoggin M.D. Richard C. Frazee M.D. Samuel K. Snyder M.D. John C. Hendricks M.D. John W. Roberts M.D. Richard E. Symmonds M.D. Randall W. Smith M.D. 《Diseases of the colon and rectum》1993,36(8):747-750
The use of laparoscopic surgical techniques is now being applied to a variety of operations traditionally performed in an open fashion. Twenty patients underwent laparoscopic-guided large and small bowel surgery at our institution from March 1991 to April 1992. The indications for surgery included polyps, obstruction, bleeding, and perforation, and pathologic diagnoses included benign polyps, lipomas, inflammatory bowel disease, perforation of a jejunal diverticulum, colonic arteriovenous malformations, and adenocarcinoma. Mobilization of the colon, ligation of the mesentery, and closure of the mesenteric defect were performed using the laparoscopic equipment. One trocar site was enlarged to 3 cm to deliver the bowel through the abdominal wall. All anastomoses were hand-sewn. Postoperative hospitalization ranged from 2 to 31 days (median, five days). No mortality was noted, and morbidity was 20 percent. We conclude that laparoscopic-guided bowel surgery is technically feasible and should translate into shorter hospitalization and less patient discomfort. 相似文献
33.
Laparoscopic hysterectomy 总被引:1,自引:0,他引:1
Michel Canis Gerard Mage Charles Chapron Arnaud Wattiez Jean Luc Pouly Maurice Antoine Bruhat 《Surgical endoscopy》1993,7(1):42-45
Summary Thirty-three patients were selected for laparoscopic hysterectomy and operated on in the Department of Obstetrics, Gynecology and Reproductive Medicine of Clermont-Ferrand University Hospital. Surgical techniques included blunt dissection with scissors and bipolar coagulation to achieve hemostasis. A case was considered successful when all the uterine vessels were treated by laparoscopy. Twenty-four cases were completed laparoscopically (72.7%). None of these patients had postoperative bleeding; 22 had an uneventful postoperative recovery. Nine procedures were converted to laparotomy (27.3%), five because of a difficult or unsatisfactory hemostasis. We conclude that in selected cases, a total hysterectomy can be performed safely by experienced laparoscopists. Further technological progress is necessary to make this procedure more acceptable. Its value as compared to the others will have to be demonstrated. 相似文献
34.
Experimental studies demonstrated a severe cardiac load of the CO2 pneumoperitoneum caused by an accelerated after- and a decreased preload. Patients displaying cardiovascular risks are therefore
often rejected from laparoscopic surgery. Hence, the pathophysiological changes and the intraoperative risk of the CO2 pneumoperitoneum in high-risk cardiopulmonary patients (NYHA II–III, n= 15) undergoing laparoscopic cholecystectomy are described. The changes in cardiac after- and preload seem to be due to the
elevated intraabdominal pressure rather than transperitoneally resorbed CO2 and are reversible by desufflation. In one patient conversion to open operation had to be performed because of a severe drop
in cardiac output and right ventricle ejection fraction. Mixed oxygen saturation was predicting intraoperative worsening in
this case. The described pathophysiological changes may seem to be well tolerated even in high-risk cardiac patients. Monitoring
of hemodynamics should include an arterial catheter line and blood gas analyses. Pharmacologic interventions or pressureless
laparoscopic procedures might not be necessary as long as laparoscopic cholecystectomy is performed.
Received: 13 December 1996/Accepted: 8 January 1997 相似文献
35.
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 相似文献
36.
Duration of postlaparoscopic pneumoperitoneum 总被引:4,自引:0,他引:4
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 相似文献
37.
Background: Whether or not laparoscopic cholecystectomy may be performed safely as an outpatient procedure is controversial. In 1993,
a protocol for outpatient laparoscopic cholecystectomy was instituted to determine the benefits and safety of discharging
patients within several hours of surgery.
Methods: The initial 60 outpatient laparoscopic cholecystectomies performed by one surgeon in a hospital-based outpatient teaching
facility between February 1993 to June 1996 were prospectively studied.
Results: Fifty-eight (97%) patients were discharged successfully after an average stay in the recovery room of 3 h. There were no
deaths. Two patients required overnight observation and three patients required readmission. Two patients (3%) had cystic
duct leak. The average hospital stay for all patients undergoing laparoscopic cholecystectomy at the institution (inpatient
and outpatient) decreased from 3.2 to 1.5 days and the average hospital cost decreased from $7,800 to $4,600 during this period.
Conclusion: Laparoscopic cholecystectomy in an outpatient setting is safe and cost-effective in healthy patients.
Received: 3 April 1997/Accepted: 10 June 1997 相似文献
38.
A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones 总被引:3,自引:0,他引:3
J. F. Gigot B. Navez J. Etienne E. Cambier P. Jadoul P. Guiot P. J. Kestens 《Surgical endoscopy》1997,11(7):722-728
Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The
recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim
of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration
(CBDE) for CBDS.
Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial
transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or
by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance
was assessed by choledochoscopy and control cholangiography.
Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion
to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative
complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated
(small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct)
the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative
hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher
success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is
related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications
rate was 15%.
Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between
a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy
is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which
is due to external biliary drainage.
Received: 7 May 1996/Accepted: 19 November 1996 相似文献
39.
Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined
with endoscopic biliary stent placement seems to offer a minimally invasive palliation.
Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy
was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved
preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively.
Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became
necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention;
there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%)
patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain
oral intake during the remaining survival time.
Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional
result while impairing the quality of life only to a minimal extent.
Received: 7 May 1996/Accepted: 12 December 1996 相似文献
40.
Early experience with laparoscopic abdominoperineal resection 总被引:4,自引:0,他引:4
Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and
anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic
abdominoperineal resection at Washington University Medical Center.
Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center.
Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel
disease (two patients), and anal melanoma (one patient).
Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed
and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2%
SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one
trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR
group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the
perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients
(29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%).
There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the
amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization
or complication rates.
Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis
patients.
Received: 23 April 1996/Accepted: 8 July 1996 相似文献