Adrian E. Ortega

A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy

Background While the advantages of laparoscopic cholecyslectomy are clear, the benefits of laparoscopic appendectomy (LA) are more subtle. We conducted a randomized clinical trial to evaluate whether LA is deserving of more widespread clinical application than it has yet received. Materials and methods Two hundred fiftythree patients with a preoperative diagnosis of acute appendicitis were randomized into three groups. LA with an endoscopic linear stapler (LAS) (U.S. Surgical Corp., Norwalk, Connecticut) was performed on 78 patients, LA with catgut ligatures (LAL) on 89, and open appendectomy (OA) on 86. LA was performed with a three-trocar technique. OA was accomplished through a right lower-quadrant transverse incision. Data with normal distributions were analyzed by analysis of variance. Nonparametric data were analyzed with either the Kruskal-Wallis H test or Fishers exact test. Results The mean operative times for the procedures were 66 ± 24 minutes (LAS), 68 ± 25 minutes (LAL), and 58 ± 27 minutes (OA). The relative brevity of OA compared to LAS and LAL was statistically significant ( P P P = NS). Wound infections were more common following OA (n = 11) than LAL (n = 4) or LAS (n = 0) ( P P P P Conclusions Laparoscopic appendectomy appears to have distinct advantages over open appendectomy. The laparoscopic procedures produced less pain and allowed more rapid return to full activities, and LAS required shorter hospital stays. The only disadvantages to the laparoscopic approach were slightly increased operative time for both procedures, and increased emesis following LAL.

Laparoscopic-assisted colectomy learning curve

PURPOSE: The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS: Data were obtained by chart review and by individually completed questionnaires. RESULTS: A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeons operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS: This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.

Wound recurrence following laparoscopic colon cancer resection

INTRODUCTION: Multiple case reports have suggested that laparoscopic resection of colon cancer may alter the pattern or incidence of cancer recurrence. All reports lack a significant denominator to evaluate the incidence of surgical wound recurrence. We hypothesized that wound recurrence incidence is not increased by laparoscopic resection of colon cancer. METHODS: A prospective registry was initiated under the auspices of The American Society of Ccolon and Rectal Surgeons, American College of Surgeons, and Society of American Gastrointestinal Endoscopic Surgeons in 1992. Patients having laparoscopic colon resection were voluntarily entered and followed until June 1995. Recurrences were evaluated by the primary surgeon and reported to the registry. RESULTS: A total of 504 patients treated for cancer were identified in the registry. A minimum follow-up of one year was obtained for 480 of 493 evaluable patients (97.4 percent). Wound recurrence was identified in five patients (1.1 percent). Recurrence status was unknown in 18 patients (3.8 percent). CONCLUSION: Wound recurrence rates appear to be low. Although length of follow-up is limited, patterns of recurrence from previous studies suggest that 80 percent of recurrences should have occurred within one year. Given the limitations of a Phase II study, the hypothesis that recurrence rate is low is supported. However, prospective randomized trials are needed to establish if any difference in wound recurrence rates after laparoscopic or open resection of colorectal cancer exists.

PENETRATING CARDIAC INJURIES

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

Intra-abdominal abscesses following laparoscopic and open appendectomies

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailedP value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an over-all abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%). For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%,P=0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with perforated appendicitis.

Variations in treatment of rectal cancer

PURPOSE: Surgical options for the treatment of rectal cancer may involve sphincter-sparing procedures (SSP) or abdominoperineal resection (APR). We sought to examine variations in the surgical treatment of rectal cancer for a large, well-defined patient population and specifically to determine if differences exist in management and survival based on hospital type and surgical caseload. METHODS: The Cancer Surveillance Program database for Los Angeles County was used to retrospectively retrieve data on all patients who underwent SSP or APR for rectal adenocarcinoma between 1988 and 1992. RESULTS: A total of 2,006 patients with adenocarcinoma of the rectum underwent SSP or APR during the study period. Overall, 55 percent underwent SSP, and the remaining 45 percent underwent APR. Use of SSP remained relatively constant for each year of the five-year period. Substantial variability was seen in the use of SSP at various hospital types. For localized disease, this varied from as low as 52 percent at teaching hospitals to as high as 78 percent at hospitals approved by the American College of Surgeons (P=0.067). To examine the role of caseload experience, hospitals were divided into those completing an average of five or fewer rectal cancer cases per yearvs.those completing an average of more than five cases per year. For localized disease, hospitals with higher caseloads performed SSP in significantly more cases, 69vs.63 percent (P=0.049). Survival was seen to be significantly improved for patients operated on at hospitals with higher caseloads, in cases of both localized and regional diseases (P<0.001). CONCLUSION: Surgical choices in the treatment of rectal cancer may vary widely, even in a well-defined geographic region. Although the reasons for this variability are multifactorial, hospital environment and surgical caseload experience seem to have a significant role in the choice of surgical procedure and on survival.

Reasons for conversion from laparoscopic to open cholecystectomy in an urban teaching hospital.

BACKGROUND Although laparoscopic cholecystectomy has replaced open cholecystectomy for the majority of patients, it is clear that a substantial minority will require laparotomy for safe and successful removal of the gallbladder. PATIENTS AND METHODS Seven hundred forty-six laparoscopic cholecystectomies performed at LAC+USC Medical Center for January 1991 to May 1993 were retrospectively reviewed. Hospital stay, laboratory values, and complications, as well as the need for and reason for conversion to open cholecystectomy were recorded. There were 661 females and 85 males, with a mean age of 38 years (range 15 to 92). RESULTS One hundred one (14%) of the 746 patients were converted to open cholecystectomy. Difficult dissection secondary to inflammation or adhesions and the need to treat common-bile-duct stones were the most common reasons for conversion. Patients requiring conversion to open cholecystectomy were more likely to have been admitted through the emergency department (72% versus 46%, P < 0.0001), have had prolonged hospital stays prior to surgery (mean time from admission to surgery 4.4 days versus 2.8 days, P < 0.0001), and to have had a thickened gallbladder wall on preoperative ultrasound (54% versus 20%, P < 0.001). CONCLUSIONS The most common reasons for conversion to open cholecystectomy are inflammation and adhesions secondary to severe acute and chronic disease and/or the need for clearance of the common bile duct. Patients who were admitted to the emergency department, particularly if they were managed nonoperatively for a period of time and had a preoperative diagnosis of acute cholecystitis, were more likely to require conversion to open cholecystectomy.

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries

BackgroundGeneral surgeons’ recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma.MethodsEntry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared.ResultsTwenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs.ConclusionsDL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.

Laparoscopic bowel surgery registry

Laparoscopic surgery has evolved rapidly since 1989. The American Society of Colon and Rectal Surgeons, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons Commission on Cancer jointly sponsored a registry to identify as early as possible the patterns of practice and acute complications of laparoscopic colectomy. METHODS: Cases were voluntarily registered by community and academic surgeons. Information was entered in the EPI-5 database. RESULTS: One thousand fifty-six cases were contributed by 118 surgeons; 763 patients were completed laparoscopically. The most common indication for surgery was cancer in 453 patients. The right colon (n=364) and sigmoid (n=294) were most frequently resected. Respondents felt adequate cancer resections were performed. Although several unique complications were noted, intraoperative complications were similar in type and frequency to open cases. CONCLUSION: Laparoscopic colorectal surgery can be performed with acceptable complications. It remains unclear if this approach is adequate for long-term management of colon and rectal cancer.

New technique for mesh repair of paracolostomy hernias

Paracolostomy hernias are common and require treatment when symptomatic. Traditional methods of repair have high recurrence rates. We describe a new technique using polytetrafluorethylene mesh, which offers preservation of stoma site, lack of recurrences, ease, and safety.