E. M. Gamal

The influence of intraoperative complications on adhesion formation during laparoscopic and conventional cholecystectomy in an animal model

BackgroundThe aim of this study was to evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy.Materials and methodsQualified surgeons performed 60 experimental laparoscopic cholecystectomies (LC) in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, laceration of the liver bed, or gallbladder perforation) and the formation of adhesions, surviving animals were divided into four groups according to the type of complication occurred. Assessment of the results was made by second-look laparoscopy 4 weeks after LC using the adhesion index (AI; score range, 0–4). The animals then were killed so the extent of adhesion formation could be measured. As a control, open cholecystectomy was performed in 15 dogs without intraoperative complications. The Mann-Whitney rank-sum test and Dunn’s method were used for statistical analysis.ResultsNo adhesion formation or intraoperative complications were registered in the laparoscopic group I. In all the cases wherein bleeding or laceration of the liver bed occurred and was managed with electrocoagulation, adhesions formed. Adhesion formation in these groups was significantly higher than in “ideal LC” or cases of gallbladder perforation alone (p<0.01). All the animals in the control group developed significantly more adhesions than those in the experimental group (p<0.05).ConclusionsIt seems that LC has a lower rate of adhesion formation than the conventional open technique. Complications such as bleeding or laceration of the liver bed during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation to gallbladder perforation during LC.

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract

BackgroundRetained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods.MethodsSince 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26–30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation.ResultsWe performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths.ConclusionPercutaneous video choledochoscopic-assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size.

Laparoscopic unroofing of retroperitoneal lymphoceles after bilateral retroperitoneal lymphadenectomy for testicular cancer

BACKGROUND Symptomatic lymphoceles after retroperitoneal lymphadenectomy for testicular cancer are a rare complication that can be managed by either a computed tomography (CT)-guided subcutaneous aspiration or surgery. One surgical method of choice is laparoscopic unroofing. METHODS One case of two retroperitoneal lymphoceles managed by laparoscopy is presented. After successful creation of pneumoperitoneum, first trocar insertion, and lysis of adhesions, the two lymphoceles were unroofed, and specimens from the wall and fluid were taken. RESULTS Laparoscopic surgery was uneventful, and the patient returned to activity and work within 14 days after the operation. No pathologic signs of malignancy were discovered during biopsy and cytology investigations. At the 1-month follow-up assessment, CT scan demonstrated the regression, and 1 year later the total absence of the lymphoceles. CONCLUSIONS After retroperitoneal lymphadenectomy for testicular cancer, clinical suspicion should remain high to detect and properly treat symptomatic lymphoceles. Large retroperitoneal lymphoceles can be treated effectively by unroofing under the safe direct vision of the laparoscope.