Hisashi Kasugai

Prevention of laparoscopic surgeon's thumb

Laparoscopic surgery is being used in an increasing number of operations today. We have been performing various types of laparoscopic techniques in our department. A problem we sometimes have encountered involves a ring of pressure that develops around the surgeons thumb at the end of the procedure, which is accompanied by an area of paresthesia in the distribution of the lateral digital nerve. We report our own experience and a small review of the literature.

Laparoscopic cholecystectomy: A report of 409 consecutive cases and its future outlook

A retrospective study was conducted on 409 patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital between May, 1990 and October, 1992. The operation had to be converted to an open cholecystectomy in ten of these patients because of uncontrollable bleeding from the cystic artery in one, venous bleeding due to portal hypertension in one, extensive adhesions of the omentum and the duodenum to the gallbladder in two, extensive adhesions around the gallbladder in four, and extensive adhesions between the gallbladder and the common bile duct (CBD) in two. The time taken to complete the procedure ranged from 30 to 235 min, the average time being 81 min, and the postoperative hopital stay ranged from 3 to 56 days, the average stay being 6.5 days. Eleven patients developed complications intra- or postoperatively: bile duct injury which became manifest after the operation and required laparotomy in three patients; injury to the right hemidiaphragm resulting in a right pneumothorax in one; periumbilical subcutaneous emphysema in one; mild bile leaks which resolved in a few days in two; and a severe bile leak which resolved after 6 days in one. The indications for laparoscopic cholecystectomy have widened with experience and now, CBD stones and a history of previous gastrectomy are no longer contraindications for laparoscopic cholecystectomy. Thus, it seems that laparoscopic cholecystectomy can be performed as safely as a standard cholecystectomy, provided the patients are selected properly and appropriate caution is exercised.

Common bile duct stones: management strategies in the laparoscopic era.

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.

Laparoscopic cholecystectomy — key technical points to prevent bile duct injury

During the period May, 1990 to the end of December, 1992, 434 patients (203 males and 231 females; aged 16–87 years; mean 49.4 years) underwent laparoscopic cholecystectomy at our Department, Teikyo University Hospital, Mizonokuchi. Eleven out of these 434 patients were converted to open cholecystectomy, due to uncontrollable bleeding from the cystic artery (n=1), venous bleeding due to portal hypertension (n=1), extensive adhesions of the omentum and the duodenum to the gallbladder (n=2), extensive adhesions around the gallbladder (n=4), and extensive adhesion between the gallbladder and the common duct (n=3). The time taken to complete the procedure ranged from 25 to 235 min, the mean being 74 min. Seventeen complications manifested intra- or postoperatively. Three cases of bile duct injury which manifested after operation required laparotomy. In 1 patient, injury to the right hemidiaphragm resulted in a right pneumothorax. One patient had periumbilical subcutaneous emphysema, 2 patients had mild bile leaks that cleared up within a few days, and 1 patient had considerable bile leaks which stopped 6 days later. Indications for laparoscopic cholecystectomy widened as our experience grew. Common bile duct stones and previous gastrectomy are no longer contraindications for this procedure. Based on our experience with laparoscopic cholecystectomy, we describe here our technique and the rules we consider important for the successful accomplishment of this procedure.

Experience with Laparoscopic Appendectomy —The Technique and Our Views of its Indications—

Abstract: Since June, 1991 a laparoscopic appendectomy (LA) was performed on eleven patients with suspected appendicitis which could not be confirmed by the conventional diagnostic methods. The patients included 7 males and 4 females, with a mean age of 27, 9, ranging from 16 to 46 years. No postoperative complications were encountered. The laparoscopic diagnoses included gangrenous appendicitis in 2, suppurative appendicitis in 2, catarrhal appendicitis in 4, salpingitis in 2 and an appendiceal mass in one patient (Case 7). Histopathological diagnoses were phlegmonous appendicitis in 3, mucinous cystadenoma in one and catarrhal appendicitis in 7 patients. Two cases of salpingitis and a case with ovarian bleeding were treated conservatively after incidental laparoscopic removal of the appendix. Case 7 was histopathologically diagnosed as having mucinous cystadenoma. The patients’postoperative hospital stay was from 5 to 8 days, with an average of 6.9 days. All patients had been given the permission to be discharged by the third POD but they stayed longer because of benefits given by the health insurance system very specific to Japan.

A Case with Intrahepatic Stones followed up for Over 22 Years after Complete Cholangioscopic Stone Extraction

Abstract: In this paper, we describe the technological know‐how, diagnostic and therapeutic significance of cholangioscopy. In addition, a case who had had recurrent stones after 22 years in the sites different to those of the previous stones was presented, and therapeutic strategy for the management of intrahepatic stones was discussed. The main value of cholangioscopy lies in the fact that retained or unsuspected stones are readily removed with endoscopically‐guided instruments. Moreover, cholangioscopy not only resolves the question as to the presence or the absence of stones, but also indicates inflammation or minute carcinomatous lesions in the biliary tract which would otherwise go undetected. Percutaneous transhepatic cholangioscopy is especially useful for management of intrahepatic stones, because it provides very important information on the location and extent of lesions which is necessary for deciding appropriate therapeutic procedures. The authors firmly believe that better therapeutic results of biliary surgery can be expected if this reliable endoscopic approach becomes more routinely used by surgeons. (Dig Endosc 1999; 11: 169–173)

Laparoscopic Cholecystectomy in Patients with Previous Gastrectomy

Abstract: This study was designed to assess outcome, morbidity and mortality in patients with a previous history of gastrectomy who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi.