L. K. Nathanson

Laparoscopic Cardiomyotomy for Achalasia

A technique of laparoscopic cardiomyotomy is described. The procedure has been performed in a patient with manometrically confirmed classical achalasia with complete relief of episodic total dysphagia and no untoward symptoms including reflux. The procedure was followed by minimal postoperative discomfort and the patient was discharged on the third postoperative day. Laparoscopic cardiomyotomy has the advantage of diminished surgical trauma with accelerated recovery, constitutes definitive therapy comparable to standard myotomy, and by being less disruptive of the lower oesophageal fixation it is prone to precipitate gastro-oesophageal reflux.

Laparoscopic repair/peritoneal toilet of perforated duodenal ulcer

SummaryLaparoscopic techniques have been refined to the point where exposure, haemostasis and tissue approximation by suture approach those obtained at open access surgery. We report a patient with acute perforation of an ulcer in the first part of the duodenum who was successfully treated by laparoscopic oversewing and omental patching. The clinical indications for contemplating use of laparoscopic surgery for acute ulcer perforation, techniques employed and the areas for potential improvement of instruments, needles and sutures are discussed.

Videothoracoscopic Ligation of Bulla and Pleurectomy for Spontaneous Pneumothorax

A thoracoscopic technique to ligate pleural bullae and perform parietal pleurectomy is described. The procedure has been performed on 2 patients, allowing definitive treatment of recurrent spontaneous pneumothoraces. Both patients have been cured of their problem and benefited from the decreased trauma of access by reduced postoperative pain, rapid recovery, and decreased scarring of the skin.

Ligation of the structures of the cystic pedicle during laparoscopic cholecystectomy

Advances in optics, endotelevision monitoring, and instrumentation have led to the development of laparoscopic cholecystectomy. As in the open, standard operation, the crucial step is the dissection of the cystic pedicle containing the respective duct, artery, and lymph node. All the groups involved in laparoscopic cholecystectomy have to date opted for the use of applicators to clip the cystic duct and artery. As there are intrinsic disadvantages to the use of clips, we report an alternative method which involves ligation of these structures using the Roeder slip knot with dry chromic catgut. The safety margin of this knot was initially tested in vitro using a Instrom tensiometer. Under these experimental conditions, the Roeder slip knot tied with #0 dry chromic catgut ligature started to yield at 225 g. As the estimated tension on the cystic duct (1.1 g) and a 4-mm artery (6.0 g) in vivo is well below this figure, the safety of this knot with dry catgut in clinical practice is beyond question. The technique of Roeder slip-loop knotting was used to ligate the cystic artery and duct in a consecutive series of 80 patients undergoing laparoscopic cholecystectomy. This clinical experience has confirmed its safety and ease of execution. The particular advantages of Roeder loop ligation include execution through a 5.5-mm cannula and accurate placement of the knot. In addition, the technique requires less length of mobilized duct and artery, which is an important practical consideration in patients with a fibrosed gallbladder and shortened cystic pedicle.

Intraoperative cholangiography during laparoscopic cholecystectomy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intra-operative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.

The falciform lift: a simple method for retraction of the falciform ligament during laparoscopic cholecystectomy

Recent reports on laparoscopic cholecystectomy [1-4] have generated widespread interest in this procedure. This operation is currently being evaluated in a number of centres and is indicated in patients with symptomatic uncomplicated gallstone disease and a functioning gallbladder. However, it would seem likely that as experience with the procedure is gained, the indications for laparoscopic cholecystectomy will be extended to include patients with a non-functioning gallbladder, provided the preliminary laparoscopic inspection confirms the technical feasibility of this approach. Several aspects of the laparoscopic operation require further development. One technical problem frequently encountered in obese patients is a thickened fat-laden falciform ligament which hangs down and obscures the field of vision. This structure also gets in the way of the accessory cannulae and instruments which periodically get caught within it. Damage to the falciform ligament in these patients with bleeding and haematoma formation is particularly likely during insertion of pointed instruments such as scissors, dissectors, electrocautery instruments, etc. This problem can easily be overcome by a simple manoeuvre that is quick to execute and which has the added advantage of lifting the liver by the round ligament, thus improving access to the subhepatic region and in particular to the cystic duct pedicle. The technique involves the insertion of a heavy suture around the falciform ligament. The two external ends are pulled and either tied or held in traction by an artery forceps (Fig. 1). A heavy suture (1/0, 0/0) attached to a 60 mm straight cutting needle is selected for this purpose. Under laparoscopic visual control of the anterior abdominal wall, the needle is introduced through the skin to the left of the linea alba some 5 cm from the costal margin and is advanced through the abdominal wall to emerge on the left side of the falciform ligament. A needle holder, inserted through the right lower axillary cannula, is used to grasp the needle tip and draw it inside the peritoneal cavity. The needle is then passed round to the other side of the falciform ligament and pushed through the abdominal wall to emerge on the skin on the right side of linea alba. The needle is grasped as it emerges through the skin and pulled out. With moderate traction applied to the two ends of the suture, the falciform and round ligament are pulled up to the anterior abdominal wall. The two ends of the suture are either tied to each other across the intervening bridge of abdominal wall or held with an artery forceps. At the end of the procedure the suture is simply cut and removed.