Chad J. Davis

Lap Aroscopic Inguinal Herniorrhaphy: Techniques and Controversies

Because of the remarkable success of laparoscopic cholecystectomy, numerous investigators have attempted to duplicate this success with laparoscopic herniorrhaphy. This article presents a different view of the preperitoneal anatomy, reviews the rationale behind the various laparoscopic approaches, and presents, in detail, the laparoscopic preperitoneal repair with mesh, including complications and early recurrences. An attempt is made to put the new laparoscopic procedures into perspective with regard to economic issues and safety.

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

SummarySix hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.

In selected patients outpatient laparoscopic cholecystectomy is safe and significantly reduces hospitalization charges.

The safety of laparoscopic Cholecystectomy has been demonstrated through its increased use, and we have performed 114 of these operations as outpatient procedures. These patients have done well and hospitalization charges have been reduced substantially. Of 622 laparoscopic cholecystectomies performed from November 1989 to March 1991, 114 were done on an outpatient basis if the patients were generally healthy, lived nearby, and the operative procedure was uneventful. Other patients were admitted as 23-h observation or as inpatients. Records of 106 outpatients were reviewed and hospital charges obtained. These charges were then compared with those of 337 patients who underwent standard open cholecystectomy as morning admissions and who had no comorbid conditions nor complications. Comparisons are also made with 23-h observation and inpatient laparoscopic cholecys-tectomies as well as with all standard open cholecystectomy patients. The technique employed is with three punctures using electrocautery and a minimum of disposable products. Of the 106 outpatients, one required admission for postoperative ileus and pain control; 21 (19.8%) experienced nausea and 14 (13.2%) experienced vomiting but were treated successfully with antiemetics; none required admission. One patient required outpatient catheterization for urinary retention. Of the last 100 laparoscopic cholecystectomies performed by three surgeons (M.E.A., C.J.D., A.A.), 43 were performed as outpatients using the above selection criteria. 44 were held for 23-h observation, and 13 were inpatients. The average hospital charge for 377 uncomplicated morning-admitted inpatient standard cholecystectomy patients was

Laparoscopic repair for groin hernias

4,250.00, compared with

Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report.

2,293.02 for 106 outpatient laparoscopic cholecystectomy patients. The reduction in cost seems related to length of hospital stay as well as technique employed. Controllable charges approach

A History of Endoscopic Surgery

1,726 per procedure. In selected patients, outpatient laparoscopic cholecystectomy can be safely performed, with a substantial reduction in hospitalization charges, which seems to be directly related to length of hospital stay as well as to technique.

Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia

So where do things stand in 2003? Laparoscopic herniorrhaphy appears to result in less postoperative pain (acute and chronic) and in a shorter convalescence and an earlier return to work, compared with the open repair. It can be performed safely and with a low recurrence rate. However, it takes longer to do, is more difficult to learn, and costs more, all reasons why it is not more commonly performed. Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world. Who can blame the surgeon in a community practice for opting for the open mesh repair, operating on familiar anatomy, and using familiar techniques? Nevertheless, with efforts to cut costs by eliminating disposable equipment and honing skills to decrease operating time, laparoscopic herniorrhaphy will probably continue to be a contender, especially for the younger patient who wants to return to work quickly and for patients with bilateral and recurrent hernias. It is arguable that surgeons should possess skill in both open and laparoscopic techniques and should know the indications for each--some hernias are best repaired laparoscopically. That said, laparoscopic herniorrhaphy will most likely be performed by those with a special interest and proficiency in the technique. At the least, the laparoscopic revolution and laparoscopic hernia repair have helped elevate the study of hernia anatomy and herniorrhaphy to a position it deserves and this has made us all better hernia surgeons. What was once the stepchild of general surgery now occupies a more prominent and respectable place. With the continuing efforts of dedicated, energetic investigators, we should continue to see advances in the safe and effective repair of this most common of surgical maladies.