Nobuyasu Kano

Experience with laparoscopic double gallbladder removal.

Double gallbladder is a rare congenital anomaly and an encounter with it while performing cholecystectomy laparoscopically is a challenge to the laparoscopic surgeon. A 28-year-old man complaining of epigastric pain was evaluated at Teikyo University Hospital, Mizonokuchi, Japan. There were no abnormal laboratory findings. Ultrasonography revealed an acoustic shadow in each compartment without any inflammatory changes in the gallbladder. No lesions were endoscopically noted in the stomach. CT scan could not demonstrate the anomaly. ERCP revealed a duplication of the gallbladder shadow with a stone in each vesicle and also the confluence of two cystic ducts from both the gallbladders draining into the common bile duct (CBD). Laparoscopic cholecystectomy was performed successfully in this case. This paper presents this particular case because of double gallbladders rarity in the literature and to emphasize the importance of preoperative cholangiographic evaluation for double gallbladder. The laparoscopic surgeon is given an idea of the meticulous dissection at the “hepatocystic triangle” due to the various other vascular and other congenital anomalies associated with it. An account of the classification of this congenital abnormality and its various types is also discussed here.

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.

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.

Laparoscopic Cholecystectomy: Treatment o Choice in Elderly Patients

Abstract: The application of laparoscopic] cholecystectomy, first reported in 1987, has grown rapidly worldwide, replacing the open cholecystectomy. This trend is attributable to the benefits of minimal surgical access, i. e. a smaller incision, less postoperative pain and faster recovery. However, doubts persist concerning the role of laparoscopic cholecystectomy in elderly patients. The purpose of this study was to assess morbidity and mortality in elderly patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi. Forty‐eight patients, 65 years or older, underwent attempted or successful laparoscopic cholecystectomy. To assess operative risk in these patients, the American Society of Anesthesiologists Surgical Risk (A. S. A.) category was used. The risk ranged from 1 to 3 with a median of 2. Twenty‐five percent of the patients were defined as A. S. A. I, 61% as A. S. A. II and 14% as A. S. A. III. Four patients required intraoperative conversion of the procedure to open cholecystectomy (conversion rate of 8.3%). The indications for conversion in three patients were severe adhesion and thickened gallbladder wall and in the other were secondary to gallbladder bed oozing. This conversion rate is similar to that reported in other series. The conversion was not related to the surgical risk. The morbidity rate was 4.5%. the mortality rate zero. These results compared favorably with those reported for open cholecystectomy in elderly patients and with the overall published morbidity‐mortality rate of laparoscopic cholecystectomy in large series. We conclude that laparoscopic cholecystectomy is a suitable procedure for elderly patients.

The future of NOTES from the conservative point of view

Recently, the unfamiliar term natural orifice transluminal endoscopic surgery (NOTES) appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper, I will review some references and try to establish my position toward NOTES. The author has been skeptical and ironical about the clinical potentiality of NOTES since hearing the presentation about NOTES for the first time. I have been concerned about making a puncture in the gastrointestinal tract as an old surgeon who believes that intestinal injury must not occur during surgery. However, recent advances in the research of NOTES are changing my stubborn belief. What I have to do is to avoid interrupting or disturbing young surgeons challenges to develop NOTES. I remember that some senior surgeons were against us when we started laparoscopic surgery around 1990. Senior surgeons and physicians must be generous, considerate, helpful and supportive to our followers. I have been enthusiastic about the development and spread of laparoscopic surgery since 1987 and have been doing various surgical procedures myself, including those involving the biliary tract, pancreas, spleen, upper and lower gastrointestinal tract, adrenal, kidney and gynecologic organs. Recently, the unfamiliar term NOTES appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper I will review some references and try to establish my position toward NOTES.

Ureteral illumination tube for laparoscopic colo-rectal surgery

Laparoscopic colonic surgery especially requires surgeons to be versed in video depth perception and in the usage of special instruments. Moreover, thorough understanding of the varieties of anatomy laparoscopically observed is very important to perform an accurate operation. In our department a ureteral illumination tube is placed in the ureter of the patient with the risk of injury of the ureter at the time of surgery. The ureteral illumination tube facilitates a sufficient understanding of the laparoscopic anatomy and the dissection of the proper layer of mesenterium.

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.

Usefulness of dilator of the abdominal wall incision in laparoscopic surgery.

In laparoscopic surgery, the resected specimen is sometimes too large to be removed through the established ports. In cases in which ports 12, 10, or 5 mm in diameter are not large enough for extraction of organs through the abdominal wall, extension of the stab wounds is required. However, additional incision for extension using a scalpel or electrocautery may lead to bleeding or postoperative pain. In this situation, dilators with diameters of 25 mm and 35 mm (produced by Aesculap, Germany) are useful for blunt enlargement of the abdominal port to remove the resected organ without injury of the specimen, which can cause contamination of the wound. A technique for using the dilator is described. A dilator sleeve is placed in the 10-ram trocar and the trocar is removed. A dilator is placed on the sleeve and squeezed into the abdominal cavity through the abdominal wall (Fig. 1). A dilator, 35 mm in diameter, especially facilitates removal of the spleen in laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Fig. 1. Dilators with sleeves in them, 35 mm and 20 mm in diameter from top.