D Urbano

Alternative laparoscopic management of perforated peptic ulcers

Surgery—namely, suture closure-is still the treatment of choice for perforated peptic ulcers, despite the proven efficacy of Taylors conservative approach. Such conservative management, however, has been proven less effective in high-risk patients and those with perforations more than 12 h old. Here we suggest alternative laparoscopic treatments for perforated peptic ulcers.We have treated laparoscopically six patients (one F, five M; mean age 57.6 years; range 31–81 years); the mean duration of the operation was 52 min; the median hospital stay was 7 days (6–15 days); H2-blockers, antibiotics, and fluids were administered in the p.o. course; the follow-ups range from 6 to 18 months.On the basis of our experience, the treatment of choice for perforated peptic ulcers is Taylors conservative procedure and laparoscopic drainage of the abdominal cavity when there is mild peritoneal reaction (usually less than 6 h from the onset of perforation). In case of remarkable peritonitis (usually more than 12 h), it is mandatory to add an accurate lavage. When the site of perforation is concealed by the peritoneal inflammation it should not be searched; when visible, it might be obliterated with the round ligament or an omental tissue strand, particularly if larger than 1 cm in diameter.

The role of preoperative investigations in predicting difficult laparoscopic cholecystectomies

AbstractBackground: When we began laparoscopic cholecystectomy (LC) we set up a strict preoperative workup in order to assess whether currently available investigations could help predict difficult laparoscopic procedures. Methods: Reported here are the results of a prospective trial carried out in our first 200 consecutive patients, who underwent routine intravenous cholangiography (IVC), abdominal ultrasound scan (US), blood tests—namely, markers of biliary stasis (MBS)—and preoperative endoscopic retrograde cholangiopancreatography (ERCP) in case of clinically suspected common bile duct stones (CBDS). Results: On the basis of our experience we think that the US findings relate to the difficulty of the laparoscopic procedure more closely than the other preoperative investigations, and the association of US and liver chemistry provides an accurate evaluation of biliary stones. Conclusions: In agreement with data emerging from the literature, the preoperative investigations do not seem to be useful in predicting biliary and vascular complications, whose prevention lies in the adoption of correct surgical technique and a low threshold for conversion.