1 MID-TERM RESULTS OF LAPAROSCOPIC LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA(HCC) IN PATIENTS WITH CHRONIC LIVER DISEASE (CLD)
Laurent A, Cherqui D, Tayar C, Chang S, Service de Chirurgie Generale et Digestive, Hopital Henri Mondor, Creteil, France
INTRODUCTION AND AIM: Surgical resection for HCC in CLD remains controversial due to high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. We report the mid-term results of laparoscopic resection for HCC in CLD. PATIENTS AND METHODS: From 1998, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were Child's A cirrhosis and solitary tumor 55 cm located in antero-lateral segments of the liver. RESULTS: 27 patients were included. Liver resections included anatomical resection in 17 cases and non-anatomical resection in 10. Seven conversions to laparotomy (26%) occurred. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range 1–47 mm). After a mean follow-up of 2 years (range 1.1–4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%) including liver transplantation in 1 and repeat resection in 1. Reoperations were made much easier by previous laparoscopy. Overall and disease-free 3-year survival rates were 93% and 64%, respectively. CONCLUSION: Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good mid-term results. This approach could have an impact on the therapeutic strategy for HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.
2 COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY: 1991–2004
Nikas K, Pappas-Gogos G, Karfis I, Koulas S, Tsimoyiannis J, Tsimoyiannis E, Surgery, G. Hatzikosta General Hospital, Ioannina, Greece
INTRODUCTION AND AIM: Our study is a retrospective analysis of the complications in all patients who underwent laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: From 1991 to 2004, 3090 LC were performed; 2174 were in women (70.35%) and 916 were in men (29.65%). The mean age of patients was 53.8 years (9–84). Hasson's pneumoperitoneum was performed in all cases. Intraoperative choledochoscopy was performed (a) in 11 cases through the cystic duct, (b) in 28 cases through the common bile duct (with placement of Kehr-tube), and (c) in 1 case a laparoscopic choledochoduodenostomy was performed. Pre-operative ERCP-ES was performed in 60 cases and postoperative ERCP-ES in 21 cases (in all cases because of choledocholithiasis). RESULTS: Conversion to open surgery was performed in 50 cases (1.63%). The main causes of conversion were the presence of adhesions in 25 cases (0.83%), non-recognition of Callot's triangle anatomy in 13 cases (0.44%), hemorrhage from the cystic artery or hepatic trauma in 3 cases (0.09%), injury of the bile duct in 2 cases (0.06%), suspicion of malignancy in 4 cases (0.12%) and empyema in 3 cases (0.09%). There were 75 complications (2.38%): bile leak in 31 cases (1.03%), rupture of bowel in 3 (0.09%), hemorrhage in 11 (0.33%), hemorrhage from the trocar's site wound in 3 (0.09%), injury of the bile duct in 5 (0.15%), paralytic ileus in 6 (0.18%), subhepatic abscess in 2 (0.06%), trauma abscess in 8 (0.24%), postoperative hernia in 6 (0.18%). The mortality rate was 0.13% (4 deaths in the first 30 postoperative days). The mean hospital stay was 1.3 days and all patients returned to their normal activities in 10 days. CONCLUSION: LC is the procedure of choice in the treatment of chronic or acute cholecystitis. The avoidance of complications during LC is difficult to achieve. The acquisition of experience in the anatomy of Callot's triangle could lead the surgeon to minimize hepatobilliary tree complications.
3 IS LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY THE WAY TO GO?
Chang SKY, Laurent A, Cherqui D, Service de Chirurgie Generale et Digestive, Hopital Henri Mondor, Creteil, France
INTRODUCTION AND AIM: We have adopted the laparoscopic approach for left lateral sectionectomy (LLS) in preference to open surgery. This retrospective study assesses this policy. PATIENTS AND METHODS: Between 1997 and 2004, 32 laparoscopic LLS were performed. Laparoscopic procedure involved the use of CO2 pneumoperitoneum, 5 trocars and a lower abdominal incision for specimen retrieval in a bag. Resections were performed using harmonic scalpel for parenchymal transection and stapler for portal pedicles and hepatic veins. Pringle maneuver was used in 20 cases, mostly in the earlier series. During the same period, there were 4 open LLS because of contraindication to laparoscopy or concomitant nonhepatic procedure. RESULTS: 13 male and 19 female patients (age 31–80 years, mean 56) had 17 malignant lesions (HCC 11(10 with cirrhosis), colorectal metastasis 3, peripheral cholangiocarcinoma 2, breast metastasis 1) and 15 benign lesions (FNH 8, adenoma 1, cystic lesions 4, angiomyolipoma 1, hemangioma 1). Lesions ranged from 5 to 100 mm (mean 41). There was one case (5th case) of conversion for hemostasis. Operating time ranged from 90 to 240 minutes (average 172 min, < 2 h in the most recent cases). Average blood loss was 216 ml (100–600). No intraoperative transfusion was required. There were no deaths. There were 3 complications (incisional hernia 1, pneumonia 1, pyoderma gangrenosum at port site 1). Average hospital stay was 5.8 days (range 3–9). CONCLUSION: The results of this study suggest that laparoscopic LLS is a safe and feasible procedure with a reasonable learning curve and can possibly replace the open procedure as routine.
4 STAGING LAPAROSCOPY AND INTRAOPERATIVE ULTRASOUND FOR POTENTIALLY RESECTABLE COLORECTAL LIVER METASTASES
Mann C, Pattenden C, Neal C, Metcalfe M, Stephenson J, Dennison A, Berry D, Department of Hepatobiliary Surgery, Leicester General Hospital, Leicester, UK
INTRODUCTION AND AIM: Resection offers the only realistic chance of cure for hepatic colorectal metastases, but is precluded by the presence of extrahepatic or extensive intrahepatic disease. The aim of this study was to review the potential for laparoscopy and intraoperative ultrasound for detecting unresectable disease. PATIENTS AND METHODS: Our hepatobiliary database was searched for patients over a 3-year period (October 2001–October 2004) with potentially resectable colorectal liver metastases on standard pre-operative imaging. All then underwent staging laparoscopy and IOUS to determine resectability. Data extracted included findings at laparoscopy and subsequent operability in those proceeding to laparotomy. RESULTS: 159 patients underwent staging laparoscopy and IOUS for potentially resectable colorectal liver metastases. Of these, 14 procedures (9%) were inadequate due to extensive adhesions. 29 (18%) were deemed unresectable at laparoscopy; 10 (35%) due to peritoneal disease and 19 (66%) due to extensive hepatic disease. 116 (73%) were considered resectable at laparoscopy. Of this group, 92 (79%) were resectable at laparotomy. One patient with potentially resectable disease declined surgery. Of the unresectable group, 5 (22%) were due to extensive hepatic disease, 4 (17%) due to peritoneal disease, 11 (48%) due to nodal disease, and 3(13%) due to both nodal and peritoneal disease. In all, laparoscopy detected 52% of unresectable disease. CONCLUSION: Staging laparoscopy and IOUS detected over half of unresectable disease from this cohort of patients. Laparoscopy is an invaluable part of preoperative work-up and can prevent unnecessary laparotomy in 18% of patients with potentially resectable disease.
5 LAPAROSCOPIC CHOLECYSTECTOMY IN ELDERLY PATIENTS
Fragiadaki E, Karatsis P, Kostakis G, Petridis E, Vlastos I, Sfakiotakis E, Seremeti C, Spiraki C, Tsapakis N, General Surgery, Agios Nikolaos General Hospital, Agios Nikolaos, Greece
INTRODUCTION AND AIM: Laparoscopic cholecystectomy is the treatment of choice in symptomatic cholelithiasis because of the low number of complications. The purpose of this study is to determine the safety of laparoscopic cholecystectomy in elderly people >75 years old. PATIENTS AND METHODS: During the period 1995–2003, laparoscopic cholecystectomy was performed in 106 patients > 75 years old. ASA status was I in 58 patients, II in 34 and III in 14 patients. The mortality, the morbidity, the operative time and the conversion to open surgery were evaluated. RESULTS: There was no perioperative death. The mean operative time was 95 min and the postoperative stay in hospital was 5 days. Conversion to open laparotomy occurred in 8.5%, while postoperative complications occurred in 13.3% and were urological or cardio-pulmonary. CONCLUSION: Elderly patients who undergo LC can recover fast with less pain and low complication rate. This approach offers aged patients a short hospital stay and low mortality rates.
6 LAPAROSCOPIC LIVER RESECTION FOR BENIGN AND MALIGNANT LIVER DISEASES
Lee KH, Lee SK, Kim EK, Department of Surgery, College of Medicine, Catholic University of Korea, Incheon, South Korea
INTRODUCTION AND AIM: Laparoscopic surgery is considered the standard method for many kinds of pathologies, including gallbladder and splenic disease. However, in liver disease, application of the laparoscopic method has been limited due to technical difficulties and the risk of bleeding and air embolism. The objective of this study was to analyze the feasibility of the laparoscopic approach in liver disease and to present different laparoscopic methods of treatment. PATIENTS AND METHODS: A retrospective analysis of 45 patients who underwent laparoscopic liver resection for benign and malignant liver diseases between Nov. 1995 and Sept. 2002 was carried out. Laparoscopic-assisted liver resections were performed in 41 patients, hand-assisted laparoscopic resections in 3, and totally laparoscopic resection in 1. Eighteen patients had benign liver disease and 27 patients had malignant disease, including hepatocellular carcinoma and metastatic liver tumor. RESULTS: The mean age of the patients was 55.8 years, and there were 28 men and 17 women. Range of resection was from wedge resection to hemihepatectomy, left lateral sectionectomy being the most frequent type of resection. Mean operative time was 261.5 min and mean hospital stay was 10.7 days. Complications occurred in 10 (22.2%) patients, including bile leaks, acute fluid collections, pulmonary problems and hepatic failure. One patient died of postoperative liver failure. CONCLUSION: Laparoscopic liver resection is feasible and relatively safe for benign and carefully selected malignant liver tumors, especially for those who are not good candidates for a formal liver resection. Accurate preoperative evaluation and meticulous surgical technique are essential for a successful surgery.
7 LAPAROSCOPIC CHOLECYSTECTOMY: OUR 8-YEAR EXPERIENCE ON ASMALL ISLAND IN GREECE
Capsambelis P1, Kosmadakis N1, Palli E2, Kartsaklis P1, Chatziantoniou A1, Gouzelis A1, Tsimara M1, Griparis I1, Kordeloy I1, (1) General Surgery, General Hospital of Zakynthos; (2) Anestesiologist, General Hospital of Zakynthos, Zakynthos, Greece
INTRODUCTION AND AIM: Laparoscopic cholecystectomy (LC) is now the treatment of choice for the symptomatic cholelithiasis. The aim of this study is to present our experience over the last 8 years. PATIENTS AND METHODS: From May 1996 until May 2004 we performed 689 laparoscopic cholecystectomies. 420 patients were female (61%) and 269 male (39%). Their mean age was 44.2 years (22–84 years).The cause of the operation was symptomatic cholelithiasis in all patients. The patients with choledocholithiasis were submitted to ERCP procedure before the operation. In addition, patients with pancreatitis were operated after 6–8 weeks. Cases of acute cholecystitis were operated either during the first 48 h or 1 month later. The mean hospital stay was 2.7 days (1–16 days). RESULTS: 10% patients had a pre-existing abdominal incision; 13.2% patients had abdominal wall adhesions; 2% patients underwent emergency LC. LC was successful in 98.1%. Conversion to open surgery was 1.9% due to intraoperative difficulties, such as unclear anatomy, adhesions, bleeding and biliary injury. There were no lethal cases in our series, while the complication rate was 1.2% (wound infection, bile leak, bleeding). CONCLUSION: LC is an adequate method of treatment of symptomatic cholelithiasis and acute cholecistitis; mortality and morbidity rates are comparable to those in conventional surgery, especially when the operation takes place at the onset of the symptoms, or later, when the acute inflammation does not exist.
8 REOPERATIVE LAPAROSCOPIC EXPLORATION OF COMMON BILE DUCT IN PATIENTS WITH PREVIOUS OPEN GASTRECTOMYAND BILIARY OPERATIONS
Tang CN, Li MKW, Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
INTRODUCTION AND AIM: To evaluate the results of LECBD in patients with previous open gastrectomy and biliary operations. PATIENTS AND METHODS: This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994–2004. The cases of LECBD with history of open gastrectomy and biliary operations were sorted out and analyzed. The indications for operation included unsuccessful endoscopic extraction due to alteration of upper gastrointestinal anatomy, which included Billroth II gastrectomy and even end-to-side choledochojejunostomy. Some of these explorations were performed with choledochoenterostomy so as to eliminate the biliary stasis and decrease stone recurrence. The operation steps involved careful open creation of pneumoperitoneum to avoid injury to abdominal viscera, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. Patients with frequent stone recurrence and clinical pictures of recurrent pyogenic cholangitis were offered additional side-to-side chole-dochoduodenostomy; otherwise the common bile duct was just closed with T-tube diversion. The perioperative parameters were analyzed and were compared to those open explorations of common bile duct due to previous open surgery in the same period of time. RESULTS: Of the 148 LECBDs performed during the 10-year period from 1994 to 2004, 26 patients (27 LECBDs) had previous open upper gastrointestinal operations which included Billroth II gastrectomy (12), open cholecystectomy (8), open exploration of CBD/sphincteroplasty (5) and open bilio-enteric bypass (2). There were 13 males and 13 females of mean age 72.2 (44–97). Diagnostic ERCP was successful in 12 patients (44%). Among the 27 LECBDs, 10 were laparoscopic choledochotomy only and 17 patients were offered choledochoenterostomy as well. Mean operating time was 155.3 minutes (60–270). Open conversion was required in 3 patients (11.1%) due to (1) jammed basket, (2) extensive adhesion and (3) lost broken tip of ultrasonic dissector. Postoperative complications occurred in 6 patients (22.2%) which included 4 bile leaks, 2 residual stones, 1 collection and 1 patient with lost broken tip of ultrasonic dissector requiring open conversion and it was also complicated with wound infection. The mean hospital stay was 12.5 days (4–58 days). Upon a mean follow-up of 16.2 months, there was only 1 patient found to have recurrent common bile stone and that was managed by another LECBD and choledochoenterostomy. When the results of LECBD were compared to those 13 open explorations due to previous open gastrectomy and biliary surgery, less blood loss (58.1 vs 138.5 ml, p = 0.002), longer operation time (155.3 vs 85.0 min, p = 0.000) and shorter hospital stay (12.5 vs 14.3 days, p = 0.080) were noted without increased complication rate (22.2% vs 30.7%, p = 0.559). CONCLUSION: The favourable results of our series speak in favour of attempting LECBD in patients with previous open gastrectomy and open biliary operations.
9 ADOUBLE-BLIND EVALUATION OF SUBDIAPHRAGMATIC PRE-EMPTIVE LIDOCAINE INSTILLATION TO CONTROL POSTOPERATIVE PAIN AND HEMODYNAMIC CHANGE IN LAPAROSCOPIC CHOLECYSTECTOMY
Yun SS1, Kim HJ1, Lee DS1, Kwun KB1, Song SO2, (1) Surgery, Yeungnam University Hospital; (2) Anesthesia, Yeungnam University Hospital, Taegu, South Korea
INTRODUCTION AND AIM: Although laparoscopic cholecystectomy (LC) is accepted as a standard operation for benign gallbladder disease with many advantages compared to open chole-cystectomy, one-third of our patients still need opioids after LC and hemodynamic changes-systemic vascular resistance (SVR), cardiac index (CI), blood pressure (BP), etc.-induced by CO2 pneumo-peritoneum during LC can cause serious problems in patients with advanced cardiopulmonary disease. We designed this study to evaluate the efficacy of pre-emptive subdiaphragmatic lidocaine instillation in postoperative pain and hemodynamic changes during LC. PATIENTS AND METHODS: Twenty patients(25–65 years old) were enrolled in this study with informed consent and protocol was designed with prospective, randomized, double-blind method. Patients with cardiopulmonary disease (hypertension, COPD, etc.) were excluded. Ten minutes before CO2 pnemoperitoneum, the control group received normal saline 200 ml and the lidocaine group received 0.2% lidocaine 200 ml in both subdiaphragmatic spaces (150 ml in right side, 50 ml in left side). Hemodynamic changes (SVR, BP, CI, etc.) were monitored every 5 minutes during LC with NICO system. Postoperative pain was monitored 1, 3, 6, 12, 18 and 24 h after LC with visual analogue and numerical pain scale. We also observed adverse effects (nausea, vomiting, shoulder pain and bowel movement, etc.). Independent sample T-test and repeated measures of ANOVA in SPSS 10.0 version were used for statistical analysis. RESULTS: Pre-emptive lidocaine instillation attenuates adverse hemodynamic effects of CO2 pnemoperitoneum. In the lidocaine group, systolic blood pressure and SVR were lower but CI was higher than those observed in the control group (data at 25, 30 minutes after CO2 pneumoperitoneum were statistically significant, p < 0.05). Preemptive lidocaine instillation also minimized the postoperative pain, especially 1 and 3 h after LC (p<0.05). No significant side effect was observed after lidocaine instillation. Nausea, vomiting and return of bowel movement were not significantly different between the two groups. CONCLUSION: Pre-emptive subdiaphragmatic lidocaine instillation before CO2 pneumoperitoneum induction may help patients with advanced cardiopulmonary disease to attenuate the adverse hemodynamic effects and to have less pain in LC.
10 LAPAROSCOPICALLY ASSISTED MINI-INVASIVE CHOLEDOCHODUODENAL ANASTOMOSIS
Sabau D1, Smarandacke CG2, Bratu D1, Dumitra A1, (1) Surgery, Lucian Blaga ‘University Sibiu’, Sibiu, Romania; (2) Surgery, University of Medicine and Pharmacy ‘Carol Davila’, Bucharest, Romania
INTRODUCTION AND AIM: The authors present a total of 50 cases of approaching the main biliary duct by means of laparoscopic transcystic drainage or Kehr or laparoscopically assisted mini-invasive choledochoduodenal anastomosis. PATIENTS AND METHODS: The necessary instruments are also presented: retractor with cold light projection, Brunner retractor, Kocher-Langenbeck retractor, Kasper, Cushing, McGee, Overholt, Meeker, Foerster forceps, Metzerbaum-Fino, Dietrich, Schmieden-Taylor, Olivecrona scissors, Johnson, Potts-Smith, Bozemann needle-holder, etc. The authors discuss the three types of drainage, all of them having a mini-aggressive component towards the patient. RESULTS: This drainage increases the rate of recovery, shortens the duration of the hospitalization, decreases the expense, increases the patient's comfort, offering at the same time more technical skills, particularly in the case of the laparoscopically assisted anastomosis. CONCLUSION: The laparoscopically assisted anastomosis increases the patient's comfort and shortens the hospitalization.
11 HAND-ASSISTED LAPAROSCOPIC LIVER RESECTIONS: INITIAL EXPERIENCE
Burns AC,Wu A, Department of HPB Surgery, University Hospital Aintree, Liverpool, UK
INTRODUCTION AND AIM: Open liver resection is an established technique, but laparoscopic liver resections are technically demanding due to difficulty in liver mobilisation, resection margin assessment and haemorrhage control. We have conducted a pilot study to assess the feasibility and advantages of hand-assisted laparoscopic liver resections for solid lesions. PATIENTS AND METHODS: Five Patients (3M, 2F), age range 23–78 years (mean 56.8) underwent hand-assisted laparoscopic liver resections of hepatomas × 2, colorectal metastases × 2, cavernous haemangioma x 1, from 2 to 10 cm in size in the left lateral and leading edge segments. Resections ranged in extent from 5 to 20% (lateral segmentectomy × 1, non-anatomical segmental/bisegmental resections × 4). Four also had cholecystectomies, and one additionally had a gastric wedge resection (for GIST). One hand port and 3 or 4 instrument ports were employed with low pressure CO2 pneumoperitoneum. Parenchymal division was performed with the harmonic scalpel and vascular pedicles were divided with an EndoGIA. RESULTS: Mean operating time was 180 minutes (range 115–210). Average blood loss was 205 ml. Pringle manoeuvre and blood transfusions were not required. One patient had a transient intrao-perative CO2 embolism with rapid correction. No other complications occurred. Mean length of hospital stay was 5.6 days. Resection margins were tumour-free, with no evidence of recurrence during follow-up for a mean of 16.8 months (range 12–23). CONCLUSION: Hand-assisted laparoscopic liver resections are feasible and safe for peripheral solid lesions with minimal blood loss, short hospital stay, clear margins and no short-term recurrence. This technique may facilitate major laparoscopic hepatic resections.
12 COMPLICATIONS DURING AND AFTER LAPAROSCOPIC CHOLECYSTECTOMY. AN AUDIT OF 1042 CASES
Tsalis K, Zacharakis E, Sapidis N, Vasileiadis K, Blouchos K, Angelopoulos S, Botsios D, Betsis D, 4th Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
INTRODUCTION AND AIM: Since the introduction of laparoscopic cholecystectomy (LC), it has rapidly become the dominant procedure for gallbladder surgery. This audit attempts to give an overview of the incidence and nature of complications during and after LC in our department. PATIENTS AND METHODS: This is a retrospective study from 1992 until 2004. The laparoscopic approach was applied to 1042 patients with symptomatic cholelithiasis confirmed by ultrasound without common bile duct stones, and with no signs of acute cholecystitis or history of previous abdominal operations. RESULTS: Eleven patients (1.05%) required conversion to open cholecystectomy. In 4 cases the conversion was due to intraoperative bleeding. The overall mortality was 0%. The morbidity reached 1.9%, as complications were present in 20 patients. Complications consisted of bile duct injuries (BDI) in 7 patients (0.6%), mild bile leakage in 2 patients, postoperative pancreatitis in one patient, iatrogenic perforation of right colic flexure in one patient, postoperative bleeding in one patient and subhepatic abscess in one patient. Of the seven patients with BDI six of them had minor BDI and one patient with major BDI had transection and ligation of common hepatic duct. Moreover, three patients developed port wound infection. CONCLUSION: The evaluation of our results shows that laparoscopic cholecystectomy is a safe procedure as it is followed by low morbidity. In order to maintain the complication rates low, properly trained laparoscopic surgeons with adequate experience in open billiary surgery are essential.
13 PORT SITE TUMOR METASTASIS AFTER LAPAROSCOPIC CHOLECYSTECTOMY IN A TRANSPLANT PATIENT: ACASE REPORT
Yildirim S3, Ezer A1, Colakoglu T1, Cal[ygrave]skan K1, Bal N2, Noyan T1, Moray G1, (1) General Surgery, Baskent University; (2) Pathology, Baskent University; (3) Baskent University Adana Hospital, General Surgery, Adana, Turkey
INTRODUCTION AND AIM: Laparoscopic cholecystectomy has become the gold standard for symptomatic cholelithiasis. However, port site metastasis after laparoscopic cancer surgery is seen rarely and is a serious problem. PATIENTS AND METHODS: We present an unusual case of port site adenocarcinoma metastasis from unknown origin following laparoscopic cholecystectomy. RESULTS: A 52-year-old woman underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. She had undergone cadaver renal transplantation 3 years previously and her medication included cyclosporine (100 mg BID), azathioprine (100 mg daily) and corticosteroid (5 mg daily). Histopathology examination of the gallbladder revealed chronic cholecystitis. She was admitted to hospital with complaints of pain, tenderness and mass at the four trocar site 6 months after the first operation. Incisional biopsies were done from port sites and the diagnosis of adenocarcinoma metastasis was shown on histopathological examination. She was investigated with abdomen and thorax CT, upper gastrointestinal endoscope, colonoscopy, abdomen US, small bowel barium enema, magnetic resonance pancreoticocolangiography, mammography, repeat histopathologic examination of gallbladder was revealed to find the primary foci of cancer, and no tumor focus was found. She received postoperative chemotherapy. Peritoneal carcinomatosis and new port site metastasis were detected 12 months later. CONCLUSION: Port site metastasis after laparoscopic cholecystectomy is seen especially after gallbladder cancer and less frequently intra-abdominal malignancy independent of tumor stage. Our patient illustrated that port site metastasis probably spread from early stage intra-abdominal or gallbladder tumor and immunosuppresion may be associated with an increase in the likelihood of tumor seeding to the port site metastasis.
14 LAPAROSCOPIC HEPATECTOMY USING RADIOFREQUENCY ABLATION IN APORCINE MODEL
Felekouras E, Kontos M, Papakonstantinou I, Prassas E, Pikoulis E, Papalois A, Diamantis T, 1st Department of Surgery, University of Athens, Laiko General Hospital, Athens, Greece
INTRODUCTION AND AIM: Radiofrequency energy is used for the treatment of metastatic tumors in the liver and in hepatectomies. Laparoscopic hepatectomies are already performed, presenting certain advantages against the open approach. This study proves the feasibility of radiofrequency ablation (RFA)-assisted laparoscopic left lateral hepatectomy (LLH) in pigs. PATIENTS AND METHODS: Eight white male domestic pigs were used. An RFA-assisted LLH was performed laparoscopicaly with the RFA needle electrode inserted transcutaneously. The hepatic parenchyma was first ablated and then sharply divided. The animals were sacrificed at 0, 7, 21 and 60 days and examined. RESULTS: RFA-assisted LLH was performed successfully in all animals. Complete hemostasis was achieved in all cases. No other means of hemostasis was used. Mortality and morbidity were zero. No blood, pus or bile was found in the abdomen at sacrifice. CONCLUSION: Laparoscopic RFA-assisted LLH is feasible. The exact indications for its application remain to be determined.
15 LAPAROSCOPIC PARTIAL HEPATECTOMY AND LEFT LATERAL SECTIONECTOMY
Park IY2, Won Y1, Lee K1, Kim K1, (1) Surgery, Catholic University of Korea, Bucheon; (2) Holy Family Hospital, Catholic University of Korea, Bucheon, Korea
INTRODUCTION AND AIM: Laparoscopic liver resection has been limited because of fear of gas embolism, difficult procedure and lack of instrumentation. Recently, it was accepted in selected cases. PATIENTS AND METHODS: We report two cases of laparoscopic liver resection in hepatocellular carcinoma and intrahepatic stone patient. RESULTS: Case 1: A 52-year-old man was diagnosed with a hepatic mass. Ultrasonography (US) and computed tomography (CT) showed a lesion measuring 3.5 cm in diameter in segment V of the liver. Angiography demonstrated a stained nodular tumor mass in segment V. Partial liver resection was completed laparoscopically. The specimen was removed with an endobag via an enlarged port site. Operative blood loss was about 100 ml. He was discharged at 11 days postoperatively. Case 2: A 39-year-old woman was admitted with right upper quadrant abdominal pain. US and CT revealed common bile duct and left intrahepatic stones. Left lateral sectionectomy, cholecystectomy and T-tube choledochostomy were performed totally laparoscopically. Estimated blood loss was 200 ml. The specimen was removed through the port site. She was discharged 10 days postoperatively. No transfusion was required. There was no bile leakage and gas embolism. CONCLUSION: Laparoscopic liver resection is safe and an effective method of treatment of various liver lesions, but we have few cases and need further evaluation.
16 TROCAR PENETRATION OF TRANSVERSE COLON AFTER LAPAROSCOPIC CHOLECYSTECTOMY: CASE REPORT
Zandes N, Chatzimisios K, Doulgerakis M, Kechagia T, Koytsimani T, Dakis K, Vizas K, General Surgery, General Periferal Hospital of Kozani, Greece, Kozani, Greece
INTRODUCTION AND AIM: The aim of our project is to present our experience in relation to contraindications of laparoscopic cholecystectomy. One of these is previously performed open laparotomy. PATIENTS AND METHODS: A 70-year-old patient who had been operated previously by open laparotomy for umbilical hernia was admitted to our clinic for laparoscopic cholecystectomy. As the previous scar was subumbilical, laparoscopic cholecystectomy was decided. RESULTS: Laparoscopic cholecystectomy had been performed. It was very hard to perform due to pericystic adhesions. During endoscopy adhesions of the small and large intestine were observed, due to previously performed laparotomy. On the 2nd postoperative day the patient experienced abdominal pain, tachycardia, tachypnia, meteorism, leukocytosis. During exploratory laparotomy nothing pathological was found and a subhepatic drainage was placed. On the 6th postoperative day the quantity of drain output was stercoraceous material. A 2nd exploratory laparotomy was performed. The bowel was examined without particular point of perforation. The sigmoid was obstructed by hands so the enteric content could not pass the rectum. Starting by the ascending colon, partially pressing so that distention was caused, in the hepatic flexure, a small shunt was found. The penetration was probably due to the small trocar which had been put in the left. Lavage had been done and a Foley catheter had been placed, which was withdrawn on the 15th postoperative day. During the 18th postoperative day the patient was discharged in a very good condition. CONCLUSION: The contraindication for laparoscopic cholecystectomy should be strictly respected by the surgeon, otherwise complications threatening the life of the patient will occur.
17 LAPAROSCOPIC TREATMENT OF NON-PARASITIC CYST OF THE LIVER
Rossi L, Secchi MA, Quadrelli L, Surgical Division and CECG, Hospital Italiano-IUNIR, Rosario, Argentina
INTRODUCTION AND AIM: We advocate videolaparoscopy as the treatment of choice for non-parasitic, symptom-producing simple hepatic cysts. We will present a video with two case reports and surgical technique. PATIENTS AND METHODS: Case I: 67-year-old female patient who underwent urgent standard cholecystectomy 5 years ago. A 5-cm diameter single hepatic cyst in the 4th segment was diagnosed in the procedure. She has been followed by ultrasonography since then. She is currently symptomatic revealing pain in the right hypochondrium. The cyst is 10 cm in diameter according to the last follow-up ultrasonographic and CT scans. Videolaparoscopic management was decided on. Case II: 56-year-old male patient with a history of single hepatic cyst diagnosed 10 years ago. The cyst is currently 10 cm in diameter and symptomatic producing pain and post-prandial dyspepsia. Videolaparoscopic surgery, cyst identification, cyst puncture with intraoperative bilirrubin concentration measurement, cyst aspiration and draining, dome resection. Cholangiography (in case I because the patient had not been previously cholecystectomised and cholecystectomy because gallbladder was in close contact with the cyst). Dome frozen biopsy, which ruled out the presence of cystoadenoma. Cyst cavity filling with omentum majus. Drainage. RESULTS: Both patients were discharged at 24 h without drainage or complications. At present, follow-up ultrasonographic examinations do not show cyst recurrence at 18 and 5 months postoperatively, respectively. Six other cases were managed similarly at the Surgical Division “B” Hospital Italiano de Rosario, with the same results. CONCLUSION: We advocate videolaparoscopic management for giant and symptomatic single hepatic cysts.
18 LAPAROSCOPIC CHOLECYSTECTOMY IN ANOMALOUS GB POSITION AND NUMBER
El-Shobari MEM, El-Shobari M, Surgery, Gastroenterology Center, Mansoura, Egypt
INTRODUCTION AND AIM: Abnormal position and number of the gallbladder is a rare entity. Laparoscopic cholecystectomy remains the gold standard treatment of GB. Evaluation of laparoscopic surgery as a line of treatment in anomalous GB. RESULTS: Laparoscopic cholecystectomy was successful in all the 4 cases but with difficulty and prolonged operative time. Abnormal cystic duct and artery are reported. There were no complications. CONCLUSION: Laparoscopic cholecystectomy remains the first line of treatment of GB stones even if there is congenital anomaly
19 TREATMENT OF BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Zandes N, Chatzimisios K, Doulgerakis M, Koytsimani T, Kechagia T, Dakis K, General Surgery, General Periferal Hospital of Kozani, Greece, Kozani, Greece
INTRODUCTION AND AIM: The aim of our project is to present our experience as far it concerns the treatment of bile duct injury during laparoscopic cholecystectomy. PATIENTS AND METHODS: A 56-year-old woman underwent laparoscopic cholecystectomy successfully. She was discharged from our clinic on the 2nd postoperative day. RESULTS: On the 3rd postoperative day she returned complaining of intense abdominal pain. The condition was characterized as acute abdomen. The patient underwent exploratory laparotomy and bile duct injury was observed. It was estimated that there was only a small region of little fluid collection by biliary fluids, non-inflammatory. The wall of the gallbladder was intact, so it was decided that suturing the region of the shunt was enough. On the 7th postoperative day she returned with acute abdomen. Again exploratory laparotomy was performed and breakage of the suturing had occurred. A T-tube (kerh) had been placed. On the 8th postoperative day she was discharged in a good clinical condition. CONCLUSION: The T-tube is the only treatment in bile duct injury, although it is suggested that in cases where the injury is small, and the region non-inflammatory, the suturing of the shunt is enough.
20 LAPAROSCOPIC LIVER RESECTIONS
Laurent A, Cherqui D, Tayar C, Chang S, Service de Chirurgie Generale et Digestive, Hopital Henri Mondor, Creteil, France
INTRODUCTION AND AIM: Laparoscopic liver resections remain limited to a few centers. We report here our experience. PATIENTS AND METHODS: Prospective study 1996–2004. Patients were selected for laparoscopy based on size and location of the lesions (>5 cm, segments 2–6). RESULTS: 102 patients were included among 392 resections during the same period (26%) including 44 men and 58 women with a mean age of 53 years (14–80). There were 44 benign lesions and 58 malignant tumors (36 primary cancers (28 associated with cirrhosis), and 22 metastases including 11 colorectal). There were 88 minor resections (MiR) and 19 major resections (MaR). Operative duration was 199±70 (30–360) and 313±72 (180–480) min for MiR and MaR, respectively. Intermittent Pringle maneuver was used in 26 patients. There were 21 conversions, 13 among MiR (15%) and 8 in MaR (42%), for hemorrhage in 6 cases and another technical reason in 15. Blood loss was371±377 (50–2000) and500±400 (100–1700) ml for MiR and MaR, respectively and 5 patients received transfusions. There were no deaths. 11 complications occurred. Mean hospital stay was 9.2±4.2 (2–76) and 9.5±2.5 (5–13) days for MiR and MaR, respectively. CONCLUSION: Laparoscopic liver resections are feasible and safe in selected patients with favorable lesions. Malig nant lesions are not a contraindication to a laparoscopic approach. Laparoscopic approach can be recommended for minor resections. The high rate of conversion in major resections and the length of the procedures do not allow their recommendation at the present time, but their continuing evaluation is warranted.
21 HYDRODISSECTION WITH ADRENALINE-LIDOCAINE-SALINE SOL UTION IN LAPAROSCOPIC CHOLECYSTECTOMY
Çalýpkan K1, Haberal M1, Nursal T1, Yýldýrým S1, Moray G1, Törer N1, Noyan T1, Haberal MA2, (1) General Surgery, Baskent University Faculty of Medicine, Ankara; (2) Baskent University Faculty of Medicine, General Surgery and Division of Transplantation, Ankara, Turkey
INTRODUCTION AND AIM: In this study we investigated the effect of a solution (consisting of saline, adrenaline and lidocaine) injection to the gallbladder fossa and its effect on operative time, the amount of intraoperative bleeding, gallbladder perforation rate and postoperative pain. PATIENTS AND METHODS: 164 consecutive patients with cholelithiasis were randomized into two clinically comparable groups: Group I included hydrodissected patients (84 patients) and group II was the control (80 patients) group. Two ml of jetokain® which contains adrenaline (%0.125 mg) and lidocaine (2%) was added to 40 ml of saline. This solution was injected between gallbladder and liver to create an edematous area of 1–1.5 cm separating the gallbladder and the liver. In group II laparoscopic cholecystectomy was performed without hydrodis-section. RESULTS: The mean dissection time (p = 0.827), amount of gas used (p = 0.521), gallbladder perforation (p = 0.713), spillage of stones (p = 0.185), and liver bed bleeding (p = 0.085) was not significantly different between the groups. There were no conversions to open cholecystectomy in the two groups. In group II, one patient was reoperated because of a small intestinal perforation on the first postoperative day. There was also no significant difference between the two groups regarding postoperative pain, analgesic use and pain localization. CONCLUSION: Hydrodis-section did not reduce dissection time of the gallbladder from liver and risk of gallbladder perforation. Similarly, adrenaline injection between gallbladder and liver did not affect bleeding from the dissection area but edema seems to impair electrocoagulation. Local anesthetic drug injection at the dissection area did not alter postoperative pain.
22 RADIOFREQUENCY-ASSISTED LAPAROSCOPIC HEPATECTOMY: SHORT-TERM CLINICAL OUTCOME
Hompes D, Topal B, Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
INTRODUCTION AND AIM: Laparoscopic hepatectomy requires experience in both laparoscopic and liver surgery. Blood loss can be limited by radiofrequency (RF)-assisted hepatectomy in open surgery. Short-term clinical outcome of patients undergoing laparoscopic hepatectomy with and without RF assistance is evaluated in the present study. PATIENTS AND METHODS: Twenty-nine patients (M/F 13/16; age 55 years (26–75)) underwent laparoscopic hepatectomy for 8 benign and 28 malignant tumours. Median number (1, range 1–3) and max. diameter (45 mm, range 12–170) of tumours were comparable in patients treated with or without RF assistance. Additional surgery was performed in 9 patients. RESULTS: No mortality occurred. In 2 patients conversion to an open procedure was necessary. The clinical outcome was comparable in patients undergoing hepatectomy with or without RF assistance. CONCLUSION: Radiofrequency-assisted laparoscopic hepatectomy is associated with minimal blood loss, low morbidity, and no mortality in this relatively small patient series. Bleeding from major hepatic vessels remains difficult to control and is responsible for urgent conversion to an open procedure in a small proportion of the patients.
| Surg. Procedure | RF-assisted | No RF-assistance |
| Segmental hepatectomy | 8 | 9 |
| Left lobectomy | 5 | 3 |
| Right hepatectomy | 1 | 2 |
| Left hepatectomy | 1 | 1 |
| Blood loss (ml) | 75 (5–3000) | 100 (20–4000) |
| Tumour free surgical margin (mm) | 11 (1–18) | 11 (1–30) |
| Operation time (minutes) | 135 (50–270) | 113 (45–360) |
| Intraoperative complication (bleeding) | 2 | 2 |
| Postoperative complications | 2 | 1 |
| Hospital stay (days) | 7 (5–41) | 8 (3–18) |
23 BILE DUCT INJURY DURING CHOLECYSTECTOMY: NO INCREASE IN INCIDENCE DURING LAST DECADES, INTRAOPERATIVE CHOLANGIOGRAPHY PROTECTIVE EFFECT
Waage A, Nilsson M, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
INTRODUCTION AND AIM: After introducing the laparoscopic technique, an increased incidence of bile duct injury (BDI) during cholecystectomy has been reported. The aim was to study the incidence of BDI during the last decades, and to determine the influence of age, sex, hospital volume and intraoperative cholangiography (IOC) on the risk of BDI. PATIENTS AND METHODS: From the Swedish Inpatient Register, BDIs were identified by selecting patients that had undergone cholecystectomy and within 365 days also reconstructive surgery of the biliary tract. Patients who previously or during the same period had been diagnosed with cancer in the liver, biliary tract or pancreas were excluded. Incidence proportion for BDI was calculated in 5-year intervals. Cholecystec-tomies identified with BDI were then compared with non-BDI cholecystectomies using multivariate logistic regression analysis. RESULTS: From 1967 to 2002, 322,254 cholecystectomies were performed. 1269 BDI (0.39%) patients were identified. The incidence increased from the beginning of the register period successively until the last 5-year interval before introduction of the laparoscopic technique where it reached its maximum of 0.54%. A slight decrease was noted until 1995, when it again rose, but without reaching the pre-laparoscopic level. Male gender and age were significant risk factors for BDI, while IOC significantly reduced the risk by half. The number of cholecystectomies performed yearly at each hospital was no predictor for BDI. CONCLUSION: In this population-based study we found no increased incidence of BDI after the introduction of the laparoscopic technique. Male gender and high age increase the risk while IOC is protective against accidental BDI during cholecystectomy.
24 CAN THE MELD SCORE PREDICT PERI-OPERATIVE MORBIDITY FOR PATIENTS WITH LIVER CIRRHOSIS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY?
Bingener-Casey J1, Esker D1, Mejia A2, (1) Surgery, University of Texas Health Science Center San Antonio; (2) Transplant Center, University of Texas Health Science Center San Antonio, San Antonio, USA
INTRODUCTION AND AIM: The MELD (Model for End Stage Liver Disease) score has been previously validated as a mortality predictor in patients awaiting liver transplantation; however, the use of the MELD score for risk stratification is a novel and potentially useful tool in clinical practice. Aim: To evaluate the ability of the MELD score to predict the peri-operative morbidity and mortality for laparoscopic cholecystectomy in patients with cirrhosis. PATIENTS AND METHODS: From 3/1991 to 2/2004 data of all patients undergoing an attempted laparoscopic cholecystectomy at a teaching institution were prospectively entered into a database. Data of patients with a secondary diagnosis of liver cirrhosis were reviewed for demographics, reason for cirrhosis, MELD score, morbidity, mortality and length of stay. The MELD score was calculated by: (0.957 × ln creat + 0.378 × lnbili + 1.12 × ln INR + 0.643) × 10 from the admission laboratory values (all values < 1.0 were rounded up to 1). The MELD score was correlated with outcome variables. Morbidity was classified into stages as described by Clavien. The study was considered exempt by the Institutional Review Board for Human Subject research. RESULTS: Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) were diagnosed with liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range 28–92). Indications for cholecystectomy were chronic cholecystitis in 70%, acute cholecystitis in 17% and biliary pancreatitis in 11%, biliary dyskinesia in 2% of the patients. Eleven patients had their laparoscopic procedure converted to open cholecystectomy (11%). Complete laboratory values on 55 patients were available to calculate a MELD score. The mean MELD score was 11 (range 6–24). There was no significant difference in MELD scores between men and women, alcoholic and non-alcoholic liver cirrhosis (p>0.05). The mortality rate was 2%, the overall morbidity was 28%. More than half of the complications were serious in nature (> Clavien class 2b). 11 of 55 men had a complication (20%), as did 3 of 44 women (7%) (p = 0.12). CONCLUSION: Patients with liver cirrhosis undergoing laparoscopic cholecystectomy have a substantial risk for peri-operative morbidity. Male gender appears to be a contributing factor but a larger patient population is needed to achieve statistical significance. MELD score can be used as a tool to estimate the degree of surgical complications in cirrhotics. Further studies are needed to determine if the MELD score should be considered part of the preoperative counseling of cirrhotic patients undergoing laparoscopic cholecystectomies.
25 LAPAROSCOPIC CHOLECYSTECTOMY –AN AUDIT OF OUR TRAINING PROGRAMME IN SINGAPORE
Tay KH, Department of Surgery, Changi General Hospital, Singapore, Singapore
INTRODUCTION AND AIM: Laparoscopic cholecystectomy is a common procedure but has an inherently steep learning curve. The training of surgeons presents a challenge to teaching hospitals, which have to strike a balance between effective training and patient safety. This study aims to assess the safety of the structured training program for this procedure at the Department of Surgery, Changi General Hospital and to audit the conversion and bile duct injury rates among the laparoscopic cholecystectomies performed by the department, and the factors which influence these. PATIENTS AND METHODS: Notes of all patients who underwent laparoscopic cholecystectomy in the department over an 18-month period were reviewed retrospectively and the relevant data prospectively collected. Demographics, as well as details of cases of conversion to open operation and of bile duct injury were identified and the reasons recorded. RESULTS: 443 patients underwent laparoscopic cholecystectomy in the 18-month period. The most common indication was biliary colic/dyspepsia (61.4%), followed by cholecystitis, cholangitis, pancreatitis and common bile duct stone. The overall conversion rate was 11.5%. 355 patients were operated on by consultant surgeons, while 88 were by registrars who had been through the structured training program. There was no statistically significant difference in the conversion rates between these two groups (p = 0.284). 22 of the 268 female (8.2%) patients had conversion to open operation, while 29 of the 175 male patients (16.6%) underwent conversion (p = 0.007). Amongst cases of cholecystitis and cholangitis, the conversion rate for patients operated on within 7 days of onset of symptoms was 35%, while those operated on 8 or more days later had a conversion rate of 29.7% (p = 0.639). There was a solitary case of bile duct injury among the 443 cases, equating to a bile duct injury rate of 0.23%. CONCLUSION: A structured training program involving stepwise progression of training, with close supervision by consultant surgeons and a built-in system of audit, can effectively train junior surgeons in laparoscopic cholecystectomy without exposing patients to undue risks.
26 RANDOMIZED CLINICAL TRIAL OF DAY-CARE VERSUS OVERNIGHT STAY LAPAROSCOPIC CHOLECYSTECTOMY
Thune A, Nelvin L, Bratlie SO, Ruiz F, Surgery, Sahlgrenska University Hospital, Surgery, Molndal, Sweden
INTRODUCTION AND AIM: Laparoscopic cholecystectomy has been performed regularly as a day-care procedure for many years. Although the safety and feasibility of the day-care setting have been firmly established, there are very few randomized clinical trials, with primary aim to focus on patient acceptance and preferences in terms of quality of life, compared to the practice of overnight stay. PATIENTS AND METHODS: 100 patients with symptomatic gallstones were randomised to LC performed either as a day-care procedure or with an overnight stay. Complications admissions/ readmissions, quality of life, and health economic aspects were assessed. RESULTS: 52 patients were allocated to the day-care group, of whom 48 (92) were discharged 4–8 h after the operation. In the overnight-stay group 42 patients (88) went home on the first postoperative day whereas the others were discharged the following day. Overall conversion rate was 2 (2 patients in the day-care group). Two patients had complications after surgery, both in the day-care group. No patients were readmitted in other of the groups. To assess quality of life two instruments were used: Hospital Anxiety and Depression Scale (HADS) and Psychological General Well-being Index (PGWB). HADS was assessed preoperatively, 1 day and 1 week after surgery and showed no significant differences between the groups. PGWB was measured 1 day and 1 week postoperatively. There was a significant difference in the dimensions of vitality and general health (p<0.01) on the first postoperative day in favour of overnight stay, but no significant difference in total score. Direct medical costs were [euro]3085 for day-care and [euro]3394 for overnight stay. CONCLUSION: LC as a day-case procedure can be performed with a low rate of complications and admissions/readmissions. Patient acceptance in terms of quality of life variables show a significant difference in favour of overnight stay in some dimensions, but no major differences can be demonstrated. The reduction of cost using a day-care strategy was [euro]310/patient.
27 HAND-ASSISTED LAPAROSCOPIC VERSUS OPEN LEFT LATERAL SEGMENTECTOMY FOR RECURRENT PYOGENIC CHOLANGITIS
Tang CN, Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
INTRODUCTION AND AIM: Recurrent pyogenic cholangitis (RPC) is a common disease in south-east Asian countries. Patients frequently present with repeated attacks of cholangitis and multiple stone recurrence in the biliary tree. The stones are preferentially situated in the intrahepatic hepatic duct of left lateral segment (segments 2 and 3) and therefore difficult to completely clear by either endoscopy or surgical exploration of common bile duct. The definitive treatment is liver resection and the recent advances in laparoscopic instrumentation and techniques have made hand-assisted laparoscopic left lateral segmentectomy feasible. This study is to compare the clinical results of hand-assisted laparoscopic and open left lateral segmentectomy for RPC. PATIENTS AND METHODS: From July 1998 to July 2003, patients with recurrent pyogenic cholangitis and left intrahepatic ductal stones which were not amenable to endoscopic treatment were recruited for left lateral segmentectomy. Cholecystectomy and exploration of common bile duct were also performed for those with concomitant gallbladder stones or common bile duct stones. Suitable patients would have drainage procedure during the same operation. Satisfactory liver reserve and absence of coagulopathy were important prerequisites and the preoperative investigations included transabdominal US, ERCP, CT scan, liver and HIDA scan. Operation was performed by either hand-assisted laparoscopic or open approach using ultrasonic shears and ultrasonic surgical aspirator. Patients were then regularly followed up with monitoring of liver function tests and symptoms. RESULTS: Sixteen patients underwent left lateral segmentectomy for RPC during the study period. Nine of them received hand-assisted laparoscopic resection and seven had open resection. There was no difference in age and sex distribution between the two groups. The median blood loss was similar in both groups (400 ml vs 400 ml, p = 0.787). The median operating time was shorter in the open group (225 min vs 150 min, p = 0.011]. The median postoperative stay was 8 days in the hand-assisted group vs 14 days in the open group (p = 0.031). There was 1 open conversion in the lapaorsocpic group due to left hepatic vein bleeding. There was 1 postoperative bile leak in each group. There were 1 incisional hernia and 1 wound infection in the hand-assisted group whereas 3 wound infections occurred in the open group. There was no recurrent cholangitis in both groups of patients upon a median follow-up of 36 months. CONCLUSION: The preliminary results confirm the feasibility of hand-assisted laparoscopic liver resection for recurrent pyogenic cholangitis. This new treatment approach is associated with shorter hospital stay due to reduced access trauma compared with open resection without significant increased risk to the patient. However, it takes a longer time to perform the procedure and we would expect skill refinement and improvement of ancillary technology will further improve the results in the future.
28 THE DURATION OF HEMODYNAMIC DEPRESSION DURING LAPAROSCOPIC CHOLECYSTECTOMY AND THE EFFECT OF PRE-EMPTIVE SUBDIAPHRAGMATIC LIDOCAINE INSTILLATION
Yun SS1, Kim HJ1, Lee DS1, Kwun KB1, Song SO2, (1) Surgery, Yeungnam University Hospital, Taegu; (2) Anesthesia, Yeungnam University Hospital, Taegu, South Korea
INTRODUCTION AND AIM: Although laparoscopic cholecystectomy (LC) is accepted as a standard operation for benign gallbladder disease with many advantages, hemodynamic changes induced by CO2 pneumoperitoneum during LC can cause serious problems in patients with advanced cardiopulmonary disease. We designed this study to evaluate the extent of hemodynamic changes and the effect of subdiaphragmatic lidocaine instillation during LC under CO2 pneumoperitoneum. PATIENTS AND METHODS: Twenty four patients (25–65 years old) were enrolled in this study with informed consent and protocol was designed with prospective, randomized, double-blind method. Patients with cardiopulmonary disease (hypertension, COPD, etc.) were excluded. Ten minutes before CO2 pnemoperitoneum, the control group received normal saline 200 ml and the lidocaine group received 0.2% lidocaine 200 ml in both subdiaphragmatic spaces (150 ml in right side, 50 ml in left side. Blood pressure (BP), cardiac index (CI), systemic vascular resistence (SVR), central venous pressure (CVP) and endotracheal CO2 (ET CO2) were monitored every 5 minutes during LC with the NICO system. Independent sample T-test and repeated measures of ANOVA in SPSS 10.0 version were used for statistical analysis. RESULTS: In the control group, all parameters were compared to baseline value. Baseline was defined as 5 minutes after induction of anesthesia. Ten minutes after 14 mmHg CO2 pneumoperitoneum, CI fell maximally (31.8%) from 3.7–0.9 to 2.9–1.1 L/min/m2 (p<0.05), but returned to base line level 20 minutes after pnemoperitoneum. SVR was increased maximally (46.8%,p<0.05) 10 minutes after pnemoperitoneum and recovered to base line level 20 minutes after pnemoperitoneum. Mean arterial pressure, CVP, ET CO2 were increased gradually after pnemoperitoneum but returned to baseline level 10 minutes after desuffla-tion of pneumoperitoneum. Subdiaphragmatic lidocaine instillation attenuated the adverse cardiac depression, SVR and mean arterial bleed pressure; data at 25,30 minutes after CO2 pneumoperitoneum were statistically significant (p<0.05). CONCLUSION: Maximal adverse hemodynamic changes were observed 10 minutes after CO2 pnemoperitoneum but recovered 10 minutes later in healthy patients. Pre-emptive subdiaphragmatic lidocaine instillation before CO2 pnemoperitoneum induction may help the patients with advanced cardiopulmonary disease to attenuate the adverse hemodynamic effects during LC.