Wing-Tai Siu

Routine use of laparoscopic repair for perforated peptic ulcer

Laparoscopic repair of perforated peptic ulcer was reported in 1990 but has not gained wide acceptance. The aim of this study was to evaluate the safety and efficacy of laparoscopic repair for perforated peptic ulcer in routine clinical practice.

Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis

Background:Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC.Methods:This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy.Results:During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years.Conclusion:This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Laparoscopic choledochoduodenostomy: an effective drainage procedure for recurrent pyogenic cholangitis.

Background: This article reports the technical aspects of laparoscopic choledochoduodenostomy (LCD) in patients with recurrent pyogenic cholangitis (RPC) and the perioperative results are also evaluated. This is a retrospective review of a prospectively maintained database. Methods: Twelve patients diagnosed to have RPC with the absence of intrahepatic stricture were selected for LCD during the period from 1995 to 2002. The majority of our patients had repeated attacks of cholangitis and had already undergone multiple sessions of endoscopic and operative lithotripsy. The LCD was performed using a five-port approach with the patient lying in the supine position. The stones were first cleared through the longitudinal supraduodenal choledochotomy followed by construction of a side-to-side diamond-shaped anastomosis of at least 15 mm between the bile duct and the first part of the duodenum using 2/0 monocryl in the single-layer method. Results: During the period from 1995 to 2002, 12 patients with RPC underwent LCD. There were 3 male and 9 female patients with a mean age of 62 (40–77). The median operation time was 137.5 min (90–270) and the median postoperative stay was 7.5 days (5–20). All cases were successful using the laparoscopic approach. Average analgesic requirement post operation was 126 mg (50–200 mg) intramuscular pethidine. There was one postoperative bile leak, and this complication was settled by conservative measures. Upon a mean follow-up of 37.6 months (6–91), there was no recurrent attack of cholangitis or any evidence of sump syndrome in this group of patients. Conclusion: LCD is a safe and effective drainage procedure for patients with RPC. Complications are uncommon and postoperative results are promising.

Risk of Deep Vein Thrombosis Following Laparoscopic Rectosigmoid Cancer Resection in Chinese Patients

OBJECTIVE The aim of this study was to evaluate the incidence of postoperative deep vein thrombosis (DVT) in Chinese patients who underwent laparoscopic resection of rectal or sigmoid cancer in the absence of thromboprophylaxis. METHODS Patients with adenocarcinoma of the sigmoid colon or rectum scheduled for laparoscopic resection were recruited. Neither chemoprophylaxis nor mechanical methods against DVT were employed. They were scheduled to have routine duplex ultrasound of both lower limbs perioperatively. RESULTS In a 12-month period, 50 patients were recruited. Postoperative DVT occurred in 19 (38%) patients. None needed anticoagulation. Complete resolution of the thrombus was noted in 10 (53%) patients 12 weeks after operation, and in six patients 36 weeks after operation. Female sex was identified as being associated with a higher incidence of DVT. Age, smoking, preoperative neoadjuvant chemoirradiation, preoperative metastasis, duration of operation, conversion and postoperative complications did not appear to be risk factors for DVT. CONCLUSION The incidence of asymptomatic calf vein DVT is relatively high after laparoscopic resection for rectosigmoid cancers in the Chinese population. However, complete resolution occurred without the use of anticoagulant therapy in the majority of cases. It is thus difficult to advocate the routine use of anticoagulant prophylaxis.

Hand-assisted D2 subtotal gastrectomy for carcinoma of stomach.

We report a case of hand-assisted D2 subtotal gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer. This case shows the advantages of hand-assisted laparoscopic surgery for gastric cancer. Extended lymph node dissection and intracorporeal anastomosis are feasible and easier with the presence of the internal hand. Our method is an alternative to total laparoscopic radical gastrectomy.

Endo-Lap OR: an innovative "minimally invasive operating room" design.

BackgroundA newly constructed Endoscopic-Laparoscopic operating room (Endo-Lap OR) started to operate in our department in January 2005. A prospective study was conducted to evaluate its feasibility, efficacy, and safety, as well as the staff’s satisfaction.Patients and methodsFrom January 2005 to September 2005, all patients undergoing operation in this Endo-Lap OR were included in the study. The patient’s diagnosis, types of operating procedures, incidents of operating failure (either due to the hardware or the software of Endo-Lap OR) that led to a delay in the patient’s transfer or that extended the total operating time were recorded. In addition, questionnaires regarding staff satisfaction with the new operating room were distributed to nurses, anesthetists, and surgeons.ResultsA total of 640 cases were included in the study period, 245 cases of open surgery, 282 cases of laparoscopic surgery, 82 cases of endoscopic surgery, 17 cases of video-assisted thoracoscopic surgery, and 14 cases of combined endoscopic-laparoscopic surgery. There were no reported incidents of operating failure related to hardware or software problems. The overall staff satisfaction was excellent.ConclusionsThe integration of endoscopic and laparoscopic surgery into this newly constructed Endo-Lap OR is feasible and safe. The running of the operating room was smooth and it received a high level of acceptance and satisfaction from different staff members.

Routine laparoscopic single-stitch omental patch repair for perforated peptic ulcer: experience from 338 cases

We read with great interest the recent article on laparoscopic repair of perforated duodenal ulcers: the simple onestitch suture with omental patch technique by Song et al. [1]. Their experience of this minimally invasive treatment of a common surgical emergency further substantiates its role in routine practice. We would like to congratulate the authors on their excellent results and to share with them our experience of this simple technique. Our centre first reported on the technique and early experience of laparoscopic single-stitch omental patch repair of perforated peptic ulcer in 1997 [2]. Since then, we have adopted this approach as routine. We believe that stringent selection and conversion criteria are paramount to ensure safety and satisfactory outcome with this technique. As mentioned by Song et al., this single-stitch method is straightforward and is therefore suitable for oncall surgical staffs that have acquired basic laparoscopic skills. Our earlier reported series, in which trainees under supervision performed approximately 80% of cases, demonstrated an overall morbidity rate of 16.3% and mortality rate of 6% with a conversion rate of 22% [3]. We have further validated the use of this technique in a randomized controlled trial reported in 2002 [4]. Our study showed that, when compared with open repair (n = 58), laparoscopic repair (n = 63) is associated with shorter operative time (mean 42.0 vs. 52.3 mins, p = 0.025), reduced postoperative pain (p \ 0.001) and analgesic requirements (median 0 vs. 6 injections, p \ 0.001), shorter hospital stay (median 6 vs. 7 days, p = 0.004), and earlier return to normal daily activities (mean 10.4 vs. 26.1 days, p = 0.001). To date, we have performed 310 cases of laparoscopic patch repair for noniatrogenic perforated peptic ulcers. Our unpublished multivariate statistical analysis showed that predictive factors for mortality in laparoscopic repair included; age C 70 years, American Society of Anesthesiologists (ASA) C 3, delayed presentation ([24 h), and severe contamination (p \ 0.05). Although conversion to open repair was associated with high mortality (p = 0.03), this was not considered as a predictive factor in multivariate analysis. Although current evidence for laparoscopic repair for perforated peptic ulcer disease is inconclusive because of methodological weakness in the trials and overall small number of participants, laparoscopic surgery could be the first therapeutic option in patients with perforated peptic ulcer after considering other variables such as experience, costs, and availability [5]. Further randomized controlled trials are required to establish its role as treatment of choice in the management of perforated peptic ulcer disease.

A man with recurrent lower abdominal pain: Spigelian hernia.

Recurrent abdominal pain due to spigelian hernia (SH) is rare and notoriously difficult to diagnose. This is particularly true when patient present with pain only without visible or palpable mass. Ultrasonic scanning and computed tomography is valuable in diagnosing this rare condition. However, for a small hernia with its content reduced spontaneously during examination, even computed tomography will miss the diagnosis. In the era of laparoscopic surgery, the role of laparoscopy in the management of recurrent abdominal pain of unknown origin has become more and more important. It is especially true in the management of SH as it is both diagnostic and therapeutic. We report a case of SH presented as recurrent lower abdominal pain of unknown origin and its successful diagnosis and treatment by laparoscopic approach.

Acute gastric volvulus: an unusual cause of gastric outlet obstruction.

Gastric outlet obstruction initiated by acute gastric volvulus is rare but potentially fatal. An unusual case of intrathoracic acute gastric volvulus complicated by distal stomach and transverse colon herniation into retrocardial space is reported. Prompt clinical diagnosis was followed by emergency laparoscopic de‐rotation and gastropexy.

Unusual Cause of Acute Abdomen—Ruptured Retroperitoneal Paraganglioma

Ruptured retroperitoneal paraganglioma is a rare cause of acute abdomen. Its clinical presentation and laparoscopic features have seldom been reported in the literature. Herein, we report a case of ruptured retroperitoneal paraganglioma that presented as acute abdomen, and its subsequent management.