Pascal Fabiani

Laparoscopic management of benign solid and cystic lesions of the liver.

OBJECTIVE The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome. SUMMARY BACKGROUND DATA Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined. METHODS Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. RESULTS The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy. CONCLUSION Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.

Recommandations pour la pratique clinique dans la prise en charge et le traitement de la constipation chronique de l'adulte

(1) Service d’Hepato-Gastroenterologie et Nutrition Clinique, Nice ; (2) Service d’Hepato-Gastroenterologie, Clermont-Ferrand ; (3) Laboratoire de Nutrition Humaine, CRNH Auvergne ; (4) Service de Geriatrie, Rouen ; (5) Service de Gastroenterologie, Hopital Louis Mourier, Paris ; (6) Service de Chirurgie Viscerale, Rennes ; (7) Service de Chirurgie Viscerale, Nice ; (8) Service de Gynecologie Obstetrique, Clermont-Ferrand ; (9) Service de Gastroenterologie, Vichy ; (10) Service de Gynecologie Obstetrique, Tours ; (11) Hepato-Gastroenterologie liberale, Châteauroux ; (12) Service d’explorations fonctionnelles digestive, Lyon ; (13) Service de Gastroenterologie, Mont-de-Marsan ; (14) Medecine Generale, Villeneuve-le-Roi ; (15) Proctologie, Hopital Leopold Bellan, Paris.

Laparoscopic liver surgery. A report on 28 patients.

AbstractBackground: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the “four-hands technique” for simultaneous dissection and control of bleeding and bile ducts during resections.

Laparoscopic liver surgery

AbstractBackground: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the “four-hands technique” for simultaneous dissection and control of bleeding and bile ducts during resections.

Laparoscopic cholecystectomy in cirrhotic patient.

Cholecystectomy is associated with increased risk in patients with liver cirrhosis. Moreover, cirrhosis and portal hypertension have been considered relative or absolute contraindication to laparoscopic cholecystectomy. As experience with laparoscopic cholecystectomy increased, we decided to treat cirrhotic patients via this approach. Between January 1994 and April 1995, nine patients with a Child-Pughs stage A cirrhosis underwent elective laparoscopic cholecystectomy with intraoperative cholangiography. There was no significant per- or post-operative bleeding and no blood transfusion was necessary. There was no mortality and very low morbidity. Median hospital stay was 3 days. This series suggests that wellcompensated cirrhosis can not be considered a contraindication to laparoscopic cholecystectomy.

Laparoscopic Repair of Intrathoracic Mesenterioaxial Volvulus of the Stomach in an Adult : Report of a Case

Intrathoracic gastric volvulus is an uncommon entity, in which the stomach undergoes organoaxial torsion occurring in the chest due to the concomitant presence of an enlargement of the hiatus. We herein report an unusual case of acute intrathoracic mesenterioaxial volvulus of the stomach. Gastric rotation occurred at the transverse axis and the mobile pylorus herniated in the chest through a large hiatal defect. Following a reduction of the volvulus through the use of a nasogastric tube, the patient underwent an elective laparoscopic repair. The mechanisms of volvulus with the relative diagnostic and therapeutic implications are discussed.

Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen.

BACKGROUND At present, laparoscopy is used mainly as a diagnostic tool in patients with abdominal stab wounds. PATIENTS AND METHODS Thirty-two hemodynamically stable patients with isolated stab wounds of the anterior abdomen, thought to be penetrating, were prospectively selected to undergo treatment via a laparoscopic approach. When possible, parenchymal wounds were coagulated or sealed, and wounds to the intestines were sutured or stapled. RESULTS The results of laparoscopy were negative in 6 (18.8%) of the cases: nonpenetrating wounds in 4 cases and nonsignificant organ injury in 2 cases. A hemoperitoneum was identified in 13 (40.6%) of the cases, and significant organ injuries in 26 (81.3%) of the cases: stomach, 2; small bowel, 5; colon, 2; pancreas, 1; vascular injuries, 4; liver, 5; mesentery, 9. Laparoscopy was therapeutic in 20 (62.3%) of the cases. Conversion to open surgery was required in 6 (18.8%) of the cases. No injuries were missed, and no mortality occurred. Postoperative complications developed in 2 (6.2%) of the cases. The mean hospital stay was 4 days, with no late complications. CONCLUSIONS Laparoscopy can avoid a number of unnecessary laparotomies and can treat most of the lesions found in hemodynamically stable patients with anterior abdominal stab wounds.

Small bowel volvulus resulting from a congenital band treated laparoscopically

In recent years, laparoscopy has dramatically changed the approach to the patient with acute abdominal pain. We report the case of a patient with small bowel volvulus caused by a congenital band binding the greater omentum to the mesentery, which was promptly diagnosed and treated using laparoscopy. Early intervention averted irreversible ischemic lesions of the intestine and the need for bowel resection. With the routine use of laparoscopy in the setting of acute abdominal pain, rare affections can be easily diagnosed and effectively treated.

Therapeutic laparoscopy for blunt abdominal trauma with bowel injuries.

In the setting of abdominal trauma, laparoscopy is used mainly for diagnosis, and its role in definitive operative repair is still debated. We report the case of a 50-year-old woman who underwent diagnostic and therapeutic laparoscopy after being subjected to blunt abdominal trauma in a traffic accident. Multiple injuries to the small bowel and colon were repaired laparoscopically with a favorable outcome. Surgeons with experience in advanced laparoscopy and trauma care can use laparoscopy in the diagnosis and treatment of selected patients with blunt abdominal trauma.

Laparoscopic subtotal colectomy with cecorectal anastomosis for slow-transit constipation

Abstract Subtotal colectomy with cecorectal anastomosis represents an interesting alternative to total colectomy with ileorectal anastomosis. Several technical variants to the methods for performing the anastomosis between the cecum and the rectal stump after subtotal colectomy have been reported. The mechanical, antiperistaltic, end-to-end cecorectal anastomosis is safe and easy to perform. The authors aimed to assess the safety and feasibility of this technique performed laparoscopically in a series of four patients. All the procedures were completed laparoscopically. The mean time for surgery was 200 min (range, 180–220 min). There was no mortality and no postoperative complications. The mean hospital stay was 4 days (range, 3–5 days). This technique can be performed laparoscopically with all the advantages inherent to the minimally invasive approach.