P. Sayad

Major vascular injuries during laparoscopic cholecystectomy. An institutional review of experience with 2589 procedures and literature review.

AbstractBackground: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. Methods: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. Results: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. Conclusions: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.

Incidence of incipient contralateral hernia during laparoscopic hernia repair.

AbstractBackground: In addition to its well-known benefits of decreased postoperative pain and shorter recovery time, laparoscopic hernia repair has the major advantage of allowing the surgeon to explore the side contralateral to the clinically diagnosed hernia. The purpose of this study was to evaluate the incidence of incipient unsuspected contralateral hernia during totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy and to analyze the risks and benefits of identifying these hernias at the time of the initial surgery. Methods: We did a retrospective review of the charts of all of the 724 male patients who underwent laparoscopic TEP repair of 958 groin hernias between September 1991 and September 1999. The initial clinical impression of the existence of unilateral or bilateral hernias was noted and compared to our operative findings. The same surgeon performed all the repairs. Exploration of the contralateral side was performed in a systematic fashion. A second mesh prosthesis was placed if a contralateral hernia was found. Results: Bilateral hernia repair was performed on 234 patients (32.3%). In 62 of them (11.2%), the contralateral hernia was diagnosed only at the time of the procedure. Operative time ranged from 14 to 185 min (median, 38.6). The operative time for the contralateral exploration ranged from 2 to 5 min (median, 2.8). The rate of complications was 4.1%, but no complications were directly related to the exploration of the asymptomatic side. Conclusion: Our study shows that a large number of inguinal hernias are undiagnosed by physical examination (11.2%). Systematic contralateral exploration using the TEP approach is safe and does not greatly increase the operative time. Early identification and repair of a contralateral hernia obviates the need for reoperation, reduces overall costs to the health care system, and eliminates any further work loss for the patient.

Endoscopic extraperitoneal herniorrhaphy : A 5-year experience

AbstractBackground: This report reviews our experience with 512 groin hernias treated by a laparoscopic extraperitoneal approach over the past 5 years. We detail the modifications that have been made to this procedure and compare our morbidity and recurrence rates with other laparoscopic and open herniorrhaphy techniques. Methods: Between September 1991 and September 1996, 395 male patients underwent 512 hernia repairs by an endoscopic total extraperitoneal approach (TEP). Their ages ranged from 18 to 82 years. There were 267 indirect, 218 direct, 17 pantaloon, and 10 femoral hernias. Of these, 117 were bilateral and 54 were recurrent. All repairs were done with polypropylene mesh. All patients were given general anesthesia except 16 (4.05%) who had epidural anesthesia. Results: Of 512 hernia repairs, seven required conversion to an open procedure (1.3%). There were 19 complications (4.8%), including eight cases of urinary retention, six of groin collection, one bladder injury, one trocar site infection, one transient neuralgia, one cardiac arrhythmia, and one laryngospasm. Follow-up on 354 patients (41 were lost to follow-up) ranged from 6 to 66 months (mean, 38). There were six hernia recurrences (1.69%), but no deaths. Operative time ranged from 15 to 185 min. Conclusions: The endoscopic extraperitoneal approach to groin hernia repair has a recurrence rate comparable with open and other laparoscopic techniques. Operative time has decreased considerably with experience. Familiarity with the technique has eliminated the need for balloon dissectors, cauteries, suction irrigation, Foley catheters, and stapling of the mesh. These advances, along with shortening of the operative time and employment of reusable trocars, have permitted a significant decrease in the cost of the procedure. This study provides the longest follow-up reported with this technique. In experienced hands, the TEP repair produces results that are comparable with the open, tension-free repair and represents a reasonable alternative.

Laparoscopic distal pancreatectomy for blunt injury to the pancreas

Laparoscopic pancreatic resection has not been reported for traumatic injuries to the pancreas. We present the case of a laparoscopic distal pancreatectomy performed on a 10-year-old boy after he sustained a distal transection of the pancreas due to blunt abdominal trauma. The spleen and its vessels were preserved. The patient was sent home on postoperative day 3 without any postoperative complications. Performing an advanced laparoscopic pancreatic procedure is feasible, in the trauma setting, particularly in children.

The feasibility of laparoscopic extraperitoneal hernia repair under local anesthesia

AbstractBackground: Laparoscopic preperitoneal herniorrhaphy has the advantage of being a minimally invasive procedure with a recurrence rate comparable to open preperitoneal repair. However, surgeons have been reluctant to adopt this procedure because it requires general anesthesia. Methods: In this report, we describe the technique used in the laparoscopic repair of inguinal hernias under local anesthesia using the preperitoneal approach. We also report our results with 10 inguinal hernias repaired using the same technique. Results: Ten patients underwent their primary inguinal hernia repairs under local anesthesia. None were converted to general anesthesia. Four patients received a small amount of intravenous sedation. Three patients had bilateral hernias. There were five direct and eight indirect hernias. The average operative time was 47 min. The average lidocaine usage was 28 cc. All patients were discharged within a few hours of the surgery. There were no complications. Follow-up has ranged from 1 to 6 months. There has been no recurrences to date. Conclusions: The extraperitoneal laparoscopic repair of inguinal hernia is feasible under local anesthesia. This technique adds a new treatment option in the management of bilateral inguinal hernias, particularly in the population where general anesthesia is contraindicated or even for patients who are reluctant to receive general or epidural anesthesia.

The routine use of diagnostic laparoscopy in the intensive care unit

Background: Delay in the diagnosis of intraabdominal pathology is a major contributor to the morbidity and mortality of intensive care unit (ICU) patients. Laparoscopy is a valuable diagnostic tool that can be used safely and efficiently in the evaluation of intraabdominal processes that may be difficult to diagnose with conventional methods. Our goal was to show that laparoscopy performed at the bedside in the ICU could be used as a routine diagnostic tool in the evaluation of critically ill patients, just as computed tomography (CT), ultrasonography (US), and radiography are. Methods: We present 11 patients who underwent 12 bedside examinations in the ICU of a community teaching hospital. Several different surgeons with varying degrees of laparoscopic experience performed these procedures over a 1-year period. Results: Four patients had previously undergone recent abdominal operations. Nontherapeutic laparotomy was avoided in six patients because of diagnostic laparoscopy. One patient also underwent a therapeutic maneuver at the time of diagnostic laparoscopy. None of the patients required general anesthesia, although local anesthetics and sedation with midazolam or propofol were used. One patient underwent the procedure without endotracheal intubation. There were no complications or mortalities directly related to the procedure. Conclusion: We conclude that bedside laparoscopy in the ICU under local anesthesia is a diagnostic and potentially therapeutic tool that can be used safely in the work-up of potential abdominal pathology in critically ill patients.

The extraperitoneal approach and its utility

Early after the introduction of the laparoscopic preperitoneal inguinal hernia repair, surgeons have realized the many potential applications of this approach. Since then, the access of the preperitoneal space has been used for many other laparoscopic procedures, which include the pelvic lymph node dissection, the bladder neck suspension, the varicoselectomy, and the radical prostatectomy. We discuss the different techniques used to create the preperitoneal space and then we describe our experience in the dissection of this space. The extraperitoneal endoscopic access provides a safe and minimally invasive approach to a variety of procedures and we believe that it is essential to introduce it as an integral part of the surgical training program.

Cost effectiveness of routine type and screen testing before laparoscopic cholecystectomy

AbstractBackground: The aim of this study was to assess the cost effectiveness of routine preoperative blood type and screen testing before laparoscopic cholecystectomy. Methods: All 2,589 laparoscopic cholecystectomies and 603 open cholecystectomies performed at our institution between January 1990 and December 1996 were retrospectively reviewed to identify the incidence and causes of blood transfusions. With the use of ICD-9-CM coding, a computerized retrospective research was done to match the corresponding codes for the aforementioned operations and blood transfusion. Individual charts were reviewed to identify the indications for blood transfusion. Results: Of the 2,589 laparoscopic cholecystectomies performed, 12 patients required blood transfusion, and of the 603 open cholecystectomies, 33 patients required blood transfusion. The incidence of blood transfusions was 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy. Two of the blood transfusions given intraoperatively were due to major vascular injury in the laparoscopic cholecystectomy group. The remaining blood transfusions were found to be the result of preexisting medical conditions including sickle-cell anemia, end-stage renal disease, and chronic iron deficiency anemia. Conclusions: Laparoscopic cholecystectomy has become a widely used therapeutic modality in general surgery. The procedure is safe, effective, and well tolerated by the patient. In the era of managed healthcare, the cost effectiveness of commonly ordered tests is frequently questioned. In the absence of preoperative indications, routine preoperative blood type and screen testing should be eliminated for laparoscopic cholecystectomy. The elimination of routine preoperative blood type and screen testing could have saved our institution

Needlescopic extraperitoneal repair of inguinal hernias

79,800 during a 6-year period.

Laparoscopic transabdominal lumboperitoneal shunt

Abstract. Laparoscopic inguinal herniorrhaphy has traditionally been performed using one 5-mm and two 11-mm trocars. In this report, we evaluate the feasibility of the preperitoneal repair of inguinal hernias using the needlescopic method (2-mm ports) and describe the technique used in this repair. A total of 11 inguinal hernias were treated with needlescopic extraperitoneal repair. There were five direct and six indirect hernias. One patient had a bilateral hernia. The average operative time was 54 min. One patient was converted to the standard laparoscopic extraperitoneal method. All patients were discharged a few hours after the procedure. They were able to resume activity within a few days and required only minimal analgesic intake. Follow-up ranged from 1 to 6 months. All patients were followed up by one of the surgeons at 1, 3, and 6 weeks, and then at 6 months. No complications were encountered. There have been no recurrences to date. Overall, needlescopic extraperitoneal repair of inguinal hernias is a feasible procedure in male patients seeking better cosmetic results than can be achieved with standard laparoscopic extraperitoneal repair. This procedure is technically more demanding. The operative time is longer. The cosmetic aspect is the only advantage of this technique.