D. Davides

Laparoscopic surgery combined with preservation of the spleen for distal pancreatic tumors

AbstractBackground: Laparoscopic distal pancreatectomy combined with spleen salvage by preservation of the splenic vessels has been described in selected patients with islet cell tumors. Methods: Laparoscopic resection of the left side of the pancreas with spleen preservation on the vasa brevia was attempted in six consecutive patients. Results: Four distal pancreatectomies with spleen preservation were completed laparoscopically. There were two conversions to laparotomy. The median operating time was 300 min (range, 240–360). There was no mortality, but two patients developed a pancreatic fistula. The median postoperative hospital stay was 34.5 days (range, 5–60). All the patients remain well at a median follow-up of 30 months (range, 22–41). Conclusions: Minimally invasive surgery for distal pancreatic tumors is feasible and appropriate for most benign tumors. The spleen can be safely preserved laparoscopically on its blood supply from the short gastric vessels. The operative technique and especially the closure of the pancreatic stump need further study.

Intraoperative cholangiography during laparoscopic cholecystectomy.

AbstractBackground: The routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy remains controversial. Methods: A retrospective review of 950 consecutive laparoscopic cholecystectomies performed during an 8-year period was performed. For the first 2 years, IOC was performed selectively, and thereafter routinely. Results: Attempted in 896 patients, IOC was successful in 734 (82%). Bile duct stones were found in 77 patients (10%), dilated ducts without stones in 47 patients (6%), and anatomic variations in 4 patients (0.5%). There were four (0.4%) minor intraoperative complications related to the IOC, with no consequences for the patients. There were three (0.3%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients. In two of these patients, the structure recognized and catheterized as the cystic duct was revealed by IOC to be the bile duct. Thus IOC prevented extension to a major common bile duct (CBD) injury. Conclusions: Findings show that IOC is a safe technique. Its routine use during laparoscopic cholecystectomy may not prevent bile duct injuries, but it minimizes the extent of the injury so that it can be repaired easily without any consequences for the patient. The prevention of a major bile duct injury makes IOC cost effective.

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

AbstractBackground: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease.

Laparoscopic cholecystectomy in morbidly obese patients

Background: Morbid obesity is generally regarded as a risk factor for laparoscopic cholecystectomy due to increases in operative time, morbidity, and conversion rate to open cholecystectomy. The aim of this study was to evaluate the feasibility and outcome of laparoscopic cholecystectomy (LC) in morbidly obese patients. Methods: A total of 864 consecutive patients underwent LC at our institution between 1990 and 1997. This series represents a continuing policy of LC for all comers. Data were collected prospectively. There were 659 nonobese (NO: BMI <30 kg/m2), 188 obese (OB: BMI30-40 kg/m2), and 17 morbidly obese patients (MO: BMI >40 kg/m2). Laparoscopic bile duct exploration was performed in 28 (4.2%), nine (4.8%), and one (5.9%) patients, respectively. Results: Obesity and morbid obesity were associated with trends toward an increased conversion rate (2.3% NO; 4.3% OB; 5.9% MO), a longer operative time (median, 80, 85, and 107 mins, respectively), greater postoperative morbidity (4.7%, 5.9%, and 11.8%, respectively), and a reduced ability to obtain cholangiography (86.1%, 80.1%, and 71.4%, respectively). None of these differences, however, were statistically significant (c2 test, p > 0.05). Postoperative hospital stay for LC was similar for all three groups (median, 1 day). Conclusion: LC in morbidly obese patients is a safe procedure, but it may be associated with increased operative difficulty and morbidity, as compared with nonobese and obese patients.

Relaparoscopy for the detection and treatment of complications of laparoscopic cholecystectomy.

BACKGROUND Laparotomy remains the commonest intervention in patients with abdominal complications of laparoscopic surgery. Our own policy is to employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy. The results of using this policy in patients with suspected intra-abdominal complications following laparoscopic cholecystectomy are reviewed. METHODS Data were collected from laparoscopic cholecystectomies carried out by five consultant surgeons in one center. Details of relaparoscopy for complications were analyzed. RESULTS Thirteen patients underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The causes of pain were subhepatic haematoma (1), acute pancreatitis (1), small bowel injury (1), and minor bile leakage (6). In 2 patients no cause was identified. Twelve patients were managed laparoscopically and 1 patient required laparotomy. Median stay after relaparoscopy was 7 days (range 2 to 19). CONCLUSIONS Exploratory laparotomy can be avoided by prompt relaparoscopy in the majority of patients with abdominal complications of laparoscopic cholecystectomy.

Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy

AbstractBackground: Pneumoperitoneum at 15 mmHg results in dangerous hemodynamic disturbances in some patients. The use of low-pressure insufflation may make laparoscopic surgery safer. Methods: Data were collected prospectively from a consecutive series of patients who had undergone an elective laparoscopic cholecystectomy (LC) by the same surgeon, during the years 1993–94 (group 1, 77 patients) and 1996 (group 2, 50 patients). The groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, existence of abdominal scars due to previous surgery, and severity of gallbladder disease. Patients underwent LC with a mean intraabdominal pressure of 10.56 mmHg in group 1 and 7 mmHg in group 2, respectively. Results: The mean operative time was 75 min and 78 min in groups 1 and 2, respectively (NS). Insertion of an additional cannula was required more frequently (24% versus 14%; NS) in group 2. There were no conversions in either group. The morbidity rate and the postoperative hospital stay were similar for both groups. Conclusions: LC can be performed routinely at low intraabdominal pressure, which may contribute to the safety and comfort of the procedure.

Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial.

Background:The aim of this study was to compare micropuncture laparoscopic cholecystectomy (MPLC), with three 3.3-mm cannulas and one 10-mm cannula with conventional laparoscopic cholecystectomy (CLC). Methods: Patients were randomized to undergo either CLC or MPLC. The duration of each operative stage and the procedure were recorded. Interleukin-6 (IL-6), adrenocorticotropic hormone (ACTH), and vasopressin were sampled for 24 h. Visual analogue pain scores (VAPS) and analgesic consumption were recorded for 1 week. Pulmonary function and quality of life (EQ-5D) were monitored for 4 weeks. Statistical analysis was performed using the Mann–Whitney test or Fisher’s exact test. Results are expressed as median (interquartile range). Results: Forty-four patients entered the study, but four were excluded due to unsuspected choledocholithiasis (n = 3) or the need to reschedule surgery (n = 1). The groups were comparable in terms of age, duration of symptoms, and indications for surgery. Total operative time was similar (CLC, 63 [52–81] min vs MPLC 74 [58–95] min; p = 0.126). However, time to place the cannulas after skin incision (CLC, 5:42 [3:45–6:37] min vs MPLC, 7:38 [5:57–10:15] min; p = 0.015) and to clip the cystic duct after cholangiography (CLC, 1:05 [0:40–1:35] min vs MPLC, 3:45 [2:26–7:49] min; p < 0.001) were significantly longer for MPLC. Six CLC patients and one MPLC patient required postoperative parenteral opiates (p = 0.04). Oral analgesic consumption was similar in both groups (p = 0.217). Median VAPS were lower at all time points for MPLC, but this finding was not significant (p = 0.431). There were no significant differences in postoperative stay, IL-6, ACTH or vasopressin responses, pulmonary function, or EQ-5D scores. Conclusions: The thinner instruments did not significantly increase the total duration of the procedure. MPLC reduced the use of parenteral analgesia postoperatively, which may prove beneficial for day case patients, but it did not have a significant impact on laboratory variables, lung function or quality of life.

Laparoscopic cholecystectomy: Are patients with biliary pancreatitis at increased operative risk?

Background: Previous reports of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis suggested increased operative difficulty, high rates of conversion, and greater morbidity and mortality. Methods: Between 1990 and 1997, LC was performed for biliary pancreatitis in 63 patients (Group I) and for other causes in 829 patients (Group II). Results: Patients with biliary pancreatitis were significantly older (median age 57 vs 50 years, p = 0.009), with greater co-morbidity (ASA III/IV 24% vs 11%, p = 0.008). The groups were comparable with respect to the frequency of previous abdominal operations, acute inflammation of the gallbladder, and the frequency of bile duct calculi detected by intraoperative cholangiography. Moderate to severe adhesions involving the gallbladder were significantly more frequent in patients with biliary pancreatitis (46% vs 29%, p = 0.004). No significant differences were observed between the two groups with respect to intraoperative (1.5% Group I vs 6.0% Group II, p = 0.109) or postoperative complications (10% vs 8%, p = 0.426), conversion rate (0 vs 2.7%, p = 0.181), or duration of operation (median 92 vs 85 min, p = 0.33). Conclusion: Despite increased age and co-morbidity and more frequent adhesions, our data showed no evidence that intraoperative or postoperative complications were more frequent in patients with biliary pancreatitis than in other patients undergoing LC.

Micropuncture laparoscopic cholecystectomy.

AbstractBackground: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. Methods: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. Results: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45–180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. Conclusions: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure.

Recurrent septic episodes following gallstone spillage at laparoscopic cholecystectomy.

A 51-year-old woman underwent emergency laparoscopic cholecystectomy. Stone loss occurred during gallbladder dissection. Histology showed empyema of the gallbladder. Postoperatively, she developed a subhepatic abscess that required percutaneous drainage. Two years after surgery, she re-presented with a right paracolic abscess. Transsciatic CT-guided drainage of the abscess was performed. Barium enema excluded colonic pathology. Two weeks later, she developed a right gluteal abscess deep to the recent drain site. Ultrasound-guided drainage was performed followed by a sonogram. The sonogram ruled out communication with the peritoneum. Two further subhepatic abscesses occurred during the next 5 years; the first abscess was drained percutaneously, but the second required open drainage: At laparotomy, gallstone fragments were found within the abscess cavity. The site of the previous gluteal drain continued to discharge intermittently. An MRI scan showed an uncomplicated sinus track. Subsequent sinography of the right gluteal track demonstrated an opacity at the apex of the sinus. The sinus was laid open and a gallstone retrieved. The patient has remained well for 3 years. Complications due to gallstone spillage generally manifest themselves shortly after surgery. This case demonstrates that lost stones may cause chronic abdominal and abdominal wall sepsis. In cases of chronic abdominal sepsis after laparoscopic cholecystectomy, the possibility of lost stones should be considered even if stones are not positively shown on imaging.