Abstracts SLS Annual Meeting 1997

JSLS. 1997 Oct-Dec;1(4):363–394.

The Difficult LAVH

Andrew Brill

Abstract

Objective:

To present a safe and sound strategy to perform Laparoscopic Assisted Vaginal Hysterectomy (LAVH).

Presentation Highlights:

The sole purpose of LAVH is the conversion of abdominal to vaginal surgery. Its only proven benefits over vaginal hysterectomy are the panoramic view afforded by the laparoscope and the ability to perform extensive adhesiolysis. Regardless of uterine size or conformation, the surgical conduct during LAVH should strictly follow a preemptive and strategic methodology. After normalization of the anatomy, the most fundamental and pivotal issue is whether there is safe and ready access to the uterine vessels. In fact, the "art" of performing a difficult LAVH is the ability to relinquish the panoramic view in favor of using magnification to incrementally dissect and mobilize tissue to access these structures. Lower segment distortion from myomata or dense posterolateral endometriosis should signal time for reassessment. After reduction of the adnexal attachments and the broad ligament tissues, adequate bladder reflection and thorough skeletonization of the uterosacral ligaments are paramount steps to maximize access to the uterine vessels and minimize the risk of bladder or ureteral injury. Adequate uterine torque with a reliable intrauterine manipulator is crucial for the tension-countertension maneuvers required during this procedure. Since anterior vaginal dissection and bladder mobilization are usually the most difficult and morbid portion of vaginal hysterectomy, it behooves the surgeon to perform an anterior culdotomy prior to completing the procedure vaginally. In most cases, the hysterectomy should be completed vaginally as soon as it is feasible, thereby further reducing the risk of incomplete hemostasis and lower urinary tract injury. After securing the uterine vessels laparoscopically, large uteri and myomata can be laparoscopically morcellated in situ before vaginal delivery.

Conclusion:

Success and the minimization of complications during LAVH are dependent on preemptive anatomic recognition and strategic surgical technique.

JSLS. 1997 Oct-Dec;1(4):363–394.

New Approaches to Stress Incontinence

James E Carter

Abstract

Objective:

To describe the three major new approaches to the treatment of stress incontinence: a) laparoscopic procedures, b) needle procedures with bone anchors, and c) biofeedback and office based neuromuscular conditioning procedures.

Presentation Highlights:

Laparoscopic bladder suspension can be accomplished in the following ways: 1) modified Burch procedure with suture, 2) modified Burch procedure with mesh, or 3) modified Gittes procedure. The success rate of these procedures has been demonstrated to be equal to that of the open surgical corrections. In addition, the laparoscopic approach, although requiring additional training on the part of the surgeon, provides the benefit of shorter hospitalization and faster recovery time on the part of the patient.

The new needle procedures with bone anchors can be accomplished with the following techniques: 1) bone anchors placed in the superior aspect of the pubic bone (Microvasive^TM), or 2) bone anchors placed in the following manner: a) transcutaneously through the abdominal wall to the pubic bone and inserted into the superior aspect of the pubic bone, b) transvaginally into the posterior surface of the pubic bone (In-Fast^TM procedure) or, c) transabdominal/cutaneous placement through a 6 cm incision with bone anchor placement into the posterior aspect of the pubic bone.

The conservative technique of biofeedback and neuromuscular retraining is accomplished with a number of similar devices all of which have the following characteristics: 1) a probe designed for electromyographic recording and neuromuscular stimulation, 2) a computer system for recording the electromyogram of the levator muscles and the abdominal muscles, and 3) a device for providing neuromuscular stimulation to the levator muscles.

Conclusion:

The treatment of stress urinary incontinence has undergone major changes in the last 10 years. These changes will redefine the manner in which stress urinary incontinence is approached in the next millennium.

References:

1. Benderev TV. Anchor fixation and other modification of endoscopic bladder neck suspension. Urology. 1992;40:409–418 [DOI] [PubMed] [Google Scholar]
2. Nativ O, Levine S, Shahar M, et al. Incisionless per vaginal bone anchor cystourethropexy for the treatment of female stress incontinence: experience with the first 50 patients. J Urology. In press [DOI] [PubMed] [Google Scholar]
3. Vancallie TG, Schuessler W. Laparoscopic bladder neck suspension. J Laparoendosc Surg. 1991;1:169–173 [DOI] [PubMed] [Google Scholar]
4. Nezhat F, Seidman DS, Nasserbakht F, et al. A new method for laparoscopic cystourethropexy. J Urol. 1996;155:19l6–1918 [PubMed] [Google Scholar]
5. Gittes RF, Loughlin KR. No incision pubovaginal suspension for stress incontinence. J Urol. 1987;138:567–568 [DOI] [PubMed] [Google Scholar]
6. Carter JE. Laparoscopic bladder neck suspension. Endoscopic Surgery and Allied Technologies. 1995;3:81–87 [PubMed] [Google Scholar]
7. Schussler B, Laycock J, Norton P, Stanton S. eds. Pelvic Floor Re-Education, Principles and Practice. Springer-Verlag; 1994 [Google Scholar]

Medical education and clinical practice are undergoing dramatic evolutionary processes in response to the availability of new technologies. Well designed, computer interactive technologies may enhance the educational process by providing more flexibility and greater control over one's learning environment. The use of 3-D computer generated human reconstructions, such as the Visible Human Project, will revolutionize teaching, visualization and application of anatomy.

Seventeen patients underwent laparoscopic pyloroplasty along with Nissen fundoplication. Two had diabetes mellitus, and five patients exhibited gas-bloat syndrome following Nissen fundoplication which eventually failed. The remaining ten patients had no apparent rationale for poor gastric emptying. None had an esophageal motility disorder. One patient with diabetes mellitus exhibited less intense, but persistent inability to empty the gastric pouch postoperatively. Patients with pyloroplasty and Nissen fundoplication had an average hospital stay of 1.8 days longer than patients with Nissen fundoplication alone. Operative procedures lasted approximately 55 minutes longer.

Conclusions:

This series of 17 patients undergoing Nissen fundoplication and laparoscopic pyloroplasty represent 9% of our total group of anti-reflux operative procedures. Patients with prior failed anti-reflux procedures, those with a history of bloating and frequent eructations, and those with diabetes mellitus should be studied preoperatively for delayed gastric emptying. Laparoscopic pyloroplasty has been uniformly successful without serious complications. We recommend laparoscopic pyloroplasty along with Nissen fundoplication in circumstances described herein.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Remediation of Acid-Peptic Disease and Gastric Outlet Obstruction

Larry Stevens, Douglas Paget

Abstract

Six patients underwent laparoscopic procedures for acid-peptic disease between November 1994 and November 1996. Indications for operation included three patients with intractable peptic ulcer disease and gastric outlet obstruction, two patients suffering from intractable ulcer disease and severe gastroesophageal reflux, and one patient with cerebral palsy with severe gastroesophageal reflux resulting in episodic aspiration and poor gastric emptying. All patients were refractory to medical management and disabled by their symptoms (Visik Grade IV). Three laparoscopic posterior truncal vagotomy and anterior seromyotomy procedures (Taylor modification of highly selective vagotomy) were performed for intractable ulcers (one with prepyloric obstructing ulcer), with two of these patients undergoing concomitant Nissen fundoplication for severe reflux disease. Two patients underwent laparoscopic truncal vagotomy and pyloroplasty for intractable ulcer with gastric outlet obstruction. One patient had laparoscopic Nissen and pyloroplasty performed for severe reflux and delayed gastric emptying. Two patients had postoperative symptoms of poor gastric emptying requiring pyloric balloon dilatation. All are currently asymptomatic in regards to ulcer disease (Visik Grade I). The patient with cerebral palsy who underwent Nissen and pyloroplasty has no recurrent reflux problems and has tolerated feeding well. Laparoscopic therapy for acid-peptic disease appears to be efficacious in this early series.

JSLS. 1997 Oct-Dec;1(4):363–394.

Treatment Algorithm for Severe Gastroesophageal Reflux Disease Based on Efficacy and Cost Analysis

Shawn Nesse, John Holcomb, Tonkinson Brien, Stephen P Hetz

Abstract

Objective:

Sixty to 80% of patients treated medically for gastroesophageal reflux disease (GERD) relapse after treatment. Indefinite treatment with omeprazole is the current recommendation for these patients. We propose a treatment algorithm which emphasizes surgical intervention based on cost analysis, efficacy of treatment, and the current literature.

Methods and Procedures:

Patients who received Nissen fundoplication since 1990 were asked to quantify pre and post operative symptoms, return to baseline activity, medications, lifestyle changes, and if they would recommend the procedure to others. Concurrent chart review of patients treated with omeprazole was conducted to analyze cost.

Results:

Patients receiving open Nissen fundoplication average 7.38 hospital days and those receiving laparoscopic Nissen fundoplication (LNF) 2.70 days (P<.05). Return to baseline activity in the open group was 353 days and 17.90 days in the laparoscopic group (P<.05). Medical management with omeprazole averaged 11 weeks. The annual cost of omeprazole (40 mg) at the government rate is $1,500.71. The cost of LNF is $2,276.58 based on 1995 rates.

Conclusion:

An algorithm based on patient satisfaction, cost analysis, acceptable complication rate, and efficient use of time and resources was developed. Based on this algorithm, laparoscopic Nissen fundoplication is the appropriate treatment in patients who develop recurrent esophagitis after two months of treatment with omeprazole.

JSLS. 1997 Oct-Dec;1(4):363–394.

A New Esophageal Bougie for Safe Laparoscopic Hiatal Hernia Repair

David Edelman

Abstract

Objective:

The increased use of laparoscopy for repair of reflux esophagitis (GERD) has been associated with a 3% complication rate. Perforation of the esophagus from bougie placement, wrap breakdown or a tight wrap are some of the complications seen. A new, safe esophageal dilator was created to overcome the problems.

Methods:

Since 1993, one-hundred twenty-one laparoscopic fundoplications have been performed. There were two esophageal perforations, two gastric perforations and two wraps that had to be taken down for being too tight. Over the past year, a new bougie system was developed and utilized in which a dilator is placed over a 16F oro-gastric tube. The clear dilator allows a light source to be placed within it.

Results:

Thirty patients had the esophageal dilator system used without any major complications. Intraoperative esophago-gastroscopy documented the wrap to be appropriately secured in place with an adequate lumen. There was no morbidity associated with the dilator. Gastroscopy revealed no perforation, hemorrhage or concomitant pathology and was helpful in confirming proper wrap position.

Conclusions:

This study found that the multi-purpose Cook Esophageal Dilator System is a safe and cost-effective means of protecting the esophagus during laparoscopic repair of hiatal hernia.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Management of Paraesophageal Hernia

Michael Alberts, Michael Fenoglio

Abstract

We present 18 patients with paraesophageal hernias, all of whom were repaired laparoscopically. Sixteen patients had primary repair of the hiatal opening, two required reinforcement with marlex mesh. Twelve of the 18 patients had a concomitant antireflux procedure. One patient developed recurrence of her hernia which required an open repair.

Laparoscopic repair of paraesophageal hernias is possible. Preoperative workup should include motility evaluation to evaluate esophageal peristalsis as the majority of these will need a concomitant antireflux procedure. This helps one in determining whether or not a complete or partial wrap should be done. Repair of the diaphragmatic defect can be accomplished in the majority of patients without the use of prosthetic material, with excellent results.

Objective:

This study was initiated to analyze the effectiveness of an adjustable gastric band device utilizing a laparoscopic approach (Lap-Band) for the treatment of morbid obesity.

Methods and Procedure:

Twelve patients were protocolised for this study in 1996. Average weight was 113 kg (range 90-157 kg) and an average Body Mass Index (BMI) of 44 (range 40-52). The Lap-Band procedure has been described elsewhere.

Results:

The patients have been evaluated every three months. One case experienced postoperative complications and required reconversion to an open technique. Average hospital stay was 3.3 days. Average drop in BMI was 15.1 as regards their initial values. A descending curve of BMI has been seen in all patients similar to that of gastroplasty over the same time period. Surgical intervention has been well tolerated. No complications have been noted from the band, and there have been no respiratory difficulties or problems in those patients with diabetes.

Conclusion:

This initial experience with the Lap-Band device has been promising. The Lap-Band functions as a gastroplasty, but has the advantage that it can be adjusted, is not invasive and can be applied with laparoscopic technique.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Adjustable Gastric Banding is a Safe and Effective Treatment for Morbid Obesity

Ashraf Bakr

Abstract

Objective:

Surgery has been recognized as an effective long-term treatment for morbid obesity. The purpose of this study is to present our experience of laparoscopic adjustable gastric banding (LAGB) as a safe and effective treatment for morbid obesity.

Methods and Procedure:

This study involved 23 morbidity obese patients, defined as having a Body Mass Index (BMI) > 40 Kg/m2. Conventional dieting failed to maintain weight loss in all patients. Patients were informed about the hazards of the procedure. The procedure was performed through a five-trocar technique. A sixth trocar was used in two patients for traction of the greater momentum. The procedure involves gastric partitioning with an inflatable band. Follow-up GI series was performed in all patients one month after operation to assess the size of the proximal gastric pouch and size of the stoma. The stoma was adjusted, if necessary, by injection of saline in the band reservoir. Weight loss was assessed at one, three and six month intervals.

Results:

Mean age of the patients was 30 years. Mean BMI was 42.5 Kg/m2. All procedures were completed laparoscopically. Conversion rate was 0%. Mean operative time was 167 minutes, and mean hospital stay was 2.8 days. The morbidity rate was 8.6% (2/23); there was no mortality in this series. All patients experienced significant weight loss. Mean BMI after six months was 34.6 Kg/m2.

Conclusion:

Laparoscopic adjustable gastric banding is a safe and effective method for the laparoscopic treatment of morbid obesity. Longer follow-up is needed to assess the long-term results of the procedure.

Objective:

In recent literature, complications resulting from gallstones lost in the peritoneum during laparoscopic cholecystectomy are being reported with increasing frequency. To these, we report two additional cases. We seek to collate all available case reports and analyze them for common characteristics and end-results.

Methods and Procedures:

A multi-language literature review was conducted covering the period between January 1990 to December 1996 to identify these case reports.

Results:

We identified 80 cases reported to date, with a wide spectrum of presentations. Abdominal pain was the most commonly reported initial symptom (70%). Over 60% presented as symptomatic intra-abdominal masses or collections. The remainder presented as abdominal wall abscess, sinus/fistula formation, pelvic mass, chronic cystitis, intestinal obstruction, hernias, and pleural effusion/emphysema. The interval between the initial surgery and the presentation of complications ranged from 2 to 30 months (mean =21 months). Although not uniformly reported, several authors admitted technical difficulties in the initial surgical dissection as a reason for stone spillage. All patients underwent another operation to treat these complications, some requiring intestinal resection and bypass. Thirty percent of the cases were considered aseptic inflammatory foci, lacking any evidence of microbiologic involvement. No fatalities have been reported.

Conclusions:

These reports dispel the notion that "dropped" gallstones in the peritoneum can be left with impunity. Meticulous effort should be made to remove the gallbladder intact whenever possible. Most complications tend to emerge by two years from the initial surgery. Although litigious issues may ensue, operative reports should document spillage of stones in the subsequent event that the patient presents with such complications. The majority of complications are well-defined intra-abdominal masses or collections but some remain unpredictable, with additional reports of stone erosion into the femoral canal, sigmoid colon and urinary bladder.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Choledochoduodenostomy

Muhammad A Jawad

Abstract

Management of dilated common bile duct from multiple large stones or impacted stone is best handled by drainage of the common bile duct with either sphincteroplasty or a choledochoduodenostomy. Most surgeons prefer a Choledochoduodenostomy because it is easier and has less morbidity than the sphincteroplasty procedure.

This operation can be easily achieved laparoscopically. The first step, after doing a cholangiogram and finding the dilated, common bile duct packed with stone(s), is to perform a choledochotomy with subsequent removal of the stone(s). The anastomosis is then done. It is important not to remove the gallbladder until the end of the operation to maintain retraction on the liver, opening the space over the common bile duct. The cystic duct should be ligated by an endo loop, because it is usually dilated and clips may not stay secure.

Intracorporeal tying technique is imperative in this procedure to prevent tearing of the common bile duct wall or the duodenal wall by the sawing effect of the extracorporeal knot tying.

This video illustrates this operation, performed on an 80-year-old white female who presented with obstructive jaundice. The patient had an endoscopic retrograde cholangiopancreatography (ERCP) with papillectomy and stone removal preoperatively. An intra-operative cholangiogram performed at the time of the laparoscopic cholecystectomy revealed a very dilated common bile duct with residual stones. This required a choledochotomy, removal of the stone, and performing a Choledochoduodenostomy. The patient was discharged two days postoperatively with no complications.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Choledochoduodenostomy

Derek S Watson, A Tayfun Gurbuz, Michael E Fenoglio

Abstract

Laparoscopic cholecystectomy has become the gold standard for treatment of patients with symptomatic cholelithiasis. Management of common bile duct stones in the era of laparoscopy is an area of controversy. Although perioperative endoscopic retrograde cholangiopancreatography (ERCP) remains the most commonly employed procedure, experience is accumulating with laparoscopic common bile duct exploration.

A biliary drainage procedure is indicated in selected patients with choledocholithiasis. Initially described by Reidel in 1892, the side-to-side Choledochoduodenostomy has been employed widely in the last century for biliary-enteric anastomosis.

The authors here describe two patients with recurrent choledocholithiasis and biliary obstruction due to benign biliary strictures. Both patients underwent laparoscopic common bile duct exploration and stone extraction. Side-to-side Choledochoduodenostomy was then performed laparoscopically as a drainage procedure. This resulted in resolution of jaundice and biliary obstruction. These are the first two cases of laparoscopically performed Choledochoduodenostomy we have found reported in the literature.

JSLS. 1997 Oct-Dec;1(4):363–394.

Needlescopic Cholecystectomy

B Todd Heniford, David A lannitti, James T Mayes, Marjorie Acra, Michel Gagner

Abstract

The enduring interest to minimize patients' surgical trauma has persuaded many laparoscopic surgeons to pursue miniaturization of instruments. The new technologies that have led to instruments that are 2.3 mm in diameter or smaller have, in-turn, demanded change in operative techniques. Since June of 1995, we have used these implements to perform over 60 cholecystectomies.

The operative time ranged from 40 to 210 minutes with an average of 86.75 minutes. All patients could tolerate oral feeding within 9 hours. Analgesic requirement was minimal. The post-operative hospital stay ranged from 1 to 5 days with an average of 1.78 days. It was not necessary for the small wounds, 2 mm in length, to be sutured. Neither complications nor surgery-related mortality were seen.

A pseudocyst of the pancreas is a rare complication of acute pancreatitis only present in three to five percent of patients with acute pancreatitis. It is more common in alcoholics than other sources of pancreatitis. It usually develops as a result of a major duct disruption. Early drainage is difficult because the wall is not mature. Some advocate percutaneous external drainage, but this is associated with a high infection rate. Cyst drainage is imperative to prevent future complications, such as eroding of the cyst into major blood vessels (resulting in hemorrhage) or due to gastric or duodenal obstruction.

The cyst usually presents in the lesser sac posterior to the stomach, but it may form in the head or the tail of the pancreas as well.

Drainage of the cyst internally, either by a Cystogastrostomy or a cystojejunostomy, is the treatment of choice. This requires waiting two to three months after the acute attack. This period allows for observation of the cyst to see if it is subsiding or enlarging, as well as, maturation of the cyst wall.

Laparoscopic drainage of the cyst by Cystogastrostomy can be accomplished. This video describes the technique through anterior gastrostomy.

JSLS. 1997 Oct-Dec;1(4):363–394.

A Prospective Randomized Trial of Laparoscopic versus Open Appendectomy

Thomas McCrorey, Stephen Hetz, John Holcomb

Abstract

Objective:

To evaluate the differences between laparoscopic and open appendectomy, our service undertook a prospective randomized trial of the two methods of appendectomy. We were interested in comparing the operative times, complications rate and hospital stay.

Methods and Procedures:

Inclusion criterion was any patient judged to have acute appendicitis other than an appendiceal abscess. The only excluded patients were those in the 3rd trimester of pregnancy or who did not desire participation in the study. Patients were randomized on the basis of their social security number, and given a preoperative dose of cefotetan. Patients were discharged when they could tolerate oral food and pain medicine.

Results:

There were 56 patients who entered the study. Twenty-eight underwent laparoscopic surgery, of which three were converted to open. The two arms of this study were similar with respect to age of patient, distribution of pathologic findings, time of hospitalization, and complication rates. The average operative time was 71 minutes for laparoscopic appendectomy and 75 minutes for the open procedure. The average hospital stay was 3.3 days for the laparoscopic group and 3.1 days for the open group. There were three complications in the laparoscopy patients and one in the open group. The patients who were converted from laparoscopic to open appendectomy were significantly older, and the older patients in both groups had more severe pathology. The procedures converted from laparoscopy to open were associated with a higher morbidity.

Conclusions:

Laparoscopic appendectomy in most patients is an equivalent surgical procedure to open appendectomy with regards to surgical time and outcome. The older patient with more severe disease may be better served by an open procedure at the outset of the operation.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Diagnosis and Management of Acute Abdominal Conditions

Muhammad A Jawad

Abstract

Laparoscopy can be very instrumental in diagnosing and managing acute abdominal conditions. If used appropriately, it can eliminate a delay in surgery, which may be detrimental in some cases (for example, ischemic bowel disease). This technique is also useful in evaluating difficult dilemmas regarding intensive care patients admitted with sepsis, lethargy, and who are, overall, difficult to evaluate.

Most acute abdominal conditions can be treated safely by using laparoscopy, thus reducing hospital stay and enabling patients to return to normal activity within a shorter period of time. If proper clinical judgment is used, the techniques of laparoscopy may eliminate many unnecessary, expensive work-up procedures.

During a three-year period, 160 patients were diagnosed by laparoscopic technique. One hundred thirty three patients were treated by laparoscopy, with 27 patients requiring conversion to open technique. There was no mortality and no complications related to the laparoscopic procedure. The patients who were seen early and were operated on within 24 - 48 hours of admission had a reduced length of hospital stay. A large number of diagnostic tests can be eliminated when this technique is used for diagnostic purposes. Laparoscopy has been proven to reduce the cost of hospital admissions, as well as improving patient comfort and outcome.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopy in the Management of Children with Chronic Recurrent Abdominal Pain

Gustavo Stringel, Stuart Berezin, Howard Bostwick, Michael Halata

Abstract

Objective:

The purpose of our study is to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain.

Methods and Procedures:

Eleven children with chronic, recurrent abdominal pain were subjected to diagnostic laparoscopy. Ages varied from 10 to 17 years old. There were six males and five females. Abdominal pain was present from two weeks to 12 months with a median of six weeks. Investigations included abdominal ultrasound in nine children, upper gastrointestinal endoscopy in six, colonoscopy in three patients, CT of the abdomen in five, upper GI series in five, small bowel follow through in two, contrast enema in two and Meckel's scan in one patient. All investigations were not contributory to the diagnosis. Laparoscopic findings included cecal adhesions in five patients, Crohn's disease in two, large mesenteric lymph nodes in two, kink in the appendix in two, salpingitis in one, and a fallopian tube cyst in one patient. Laparoscopic appendectomy was performed in all patients. Pathology reports included acute appendicitis in three patients, periappendicitis in two, congested appendix in two, eosinophilic infiltrate in one, no histological diagnosis in three cases. An appendicolith was found in four children.

Results:

All children recovered uneventfully. There were no operative complications. There were no postoperative complications in 10 children. One child presented three months following laparoscopy with incomplete small bowel obstruction which resolved with conservative management. The two patients with Crohn's disease and the patient with salpingitis were treated. Follow-up varied from three months to 2.5 years. Abdominal pain resolved in all cases.

Conclusions:

Chronic recurrent abdominal pain in children can be distressing and disrupting for the child and the family, especially when the etiology is unclear. These children are admitted to the hospital for extended periods of time and are subjected to innumerable tests and procedures. Diagnostic laparoscopy is a valuable procedure in this situation. With laparoscopic examination, a cause for the abdominal pain was found in most of our patients. Abdominal pain resolved in all children. We recommend appendectomy to be done even if the appendix looks normal.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Management of Acute Appendicitis with Perforation

Muhammad A Jawad

Abstract

Laparoscopic appendectomy has proven its safety in the treatment of acute non-perforated appendicitis, but, until recently, the advantage of laparoscopic management of acute appendicitis with perforation has remained in question.

Incarcerated inguinal hernias are safely reduced and repaired laparoscopically. Acutely incarcerated hernias require intraperitoneal reduction so as to examine the viability of bowel, whereas elective cases can be reduced extraperitoneally. The bowel can be inspected after the hernia has been repaired. This provides the opportunity to assess the bowel over a prolonged period of time. The mesh can be placed in uncontaminated pre-peritoneal space with excellent results even in acutely incarcerated hernias.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Management of Incarcerated Obturator Hernia

Anthony Leo

Abstract

Objective:

This case report will demonstrate the safety and efficacy of laparoscopic management of a complicated obturator hernia in an elderly patient.

Methods and Procedures:

An elderly female patient, presenting with acute left lower quadrant abdominal pain and weakness of left thigh adduction, exhibited clinical findings of partial small bowel obstruction. Pelvic CT scan clearly demonstrated evidence of a soft tissue mass within the left obturator canal. At diagnostic laparoscopy, an acutely incarcerated left obturator hernia was confirmed, involving a single loop of ileum. Via a transabdominal perperitoneal approach, the viable ileum was reduced, the pelvic floor anatomy defined via preperitoneal dissection, and mesh hernioplasty performed. The presentation will include selected videotape of the procedure which demonstrates the obturator canal anatomy, as well as slides outlining the surgical history and clinical features of obturator hernia. A slide reproduction of the CT image revealing the obturator hernia will be utilized.

Results:

The procedure was performed expeditiously with no postoperative complications encountered.

Conclusions:

The laparoscopic management of complicated obturator herniation is a natural extension of techniques already employed for complicated inguinal herniation. The laparoscopic approach confers the obvious benefits of a minimally invasive technique, avoiding a major laparotomy incision in patients afflicted by complicated obturator herniation, most of whom are elderly with multiple concurrent illnesses.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Repair of Pediatric Femoral Hernias

Jeffery J DuBois, Joseph G Doyle, J Craig Egan

Abstract

Introduction:

Femoral hernias represent less than one percent of all pediatric groin hernias. Likewise, recurrence of an indirect hernia occurs in less that one percent of pediatric inguinal hernia repairs. Laparoscopic technique was employed in two children with reported recurrent inguinal hernias. Laparoscopy provided the correct diagnosis of missed bilateral femoral hernias and permitted a simplified laparoscopic repair of both sides.

Methods and Procedures:

One boy and one girl, both two years of age, underwent diagnostic laparoscopy with a 4 mm pediatric laparoscope for unilateral recurrent inguinal hernias. Bilateral femoral defects were visualized in both patients. In neither patient were the contralateral femoral defects suspected clinically. Of the four femoral defects, one patulous defect was repaired with a laparoscopic iliopubic tract repair with a protecting Teflon felt patch overlay in the extraperitoneal position. The remaining three femoral defects were repaired with a Teflon felt plug and extraperitoneal overlay felt patch. The peritoneum was reconstructed with either absorbable sutures utilizing intracorporeal knots or ligaclips applied via a 5 mm port. All port sites were closed.

Conclusion:

Laparoscopy is a valuable aid in the evaluation of recurrent pediatric inguinal hernias. First, not only does laparoscopy provide the correct anatomic diagnosis but does so without the need to traverse an intact inguinal floor (as would otherwise be required in an open approach to femoral hernias). Second, the use of laparoscopy provides significant information regarding the contralateral groin. Third, the use of laparoscopic technique permits simultaneous bilateral tension-free repairs. Laparoscopy should be considered in the evaluation, if not repair, of all children with recurrent inguinal hernia.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Colon Surgery for Benign Conditions

Michael Fenoglio, John T Moore, Robert Reed, William Haun

Abstract

There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will help answer this question in the near future.

All four patients had a quick and uneventful recovery. Follow-up ranges from six and 24 months. There were no complications or recurrence of the pneumothorax.

Conclusions:

Video assisted thoracoscopy is a safe technique in recurrent spontaneous pneumothorax. It allows for an accurate identification and removal of bullae, with quick recovery, minimal discomfort and good cosmetic result.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Subfascial Ligation of Perforators

Muhammad A Jawad

Abstract

As described by Linton, subfascial ligation of lower extremity perforators prevents reflux from the deep venous system to the superficial venous system in the patient with stasis ulceration and stasis changes secondary to either post phlebitic syndrome (with either outflow obstruction or valvular defect) or congenital valvular deficiency with secondary venous hypertension.

Subfascial ligation of perforators accomplishes a high healing rate of stasis ulcers and also relieves the symptoms of venous hypertension. Wound healing problems are associated with this procedure, because it requires a long incision extending from the knee to the ankle at the medial aspect of the leg.

Performing this procedure laparoscopically has achieved the same result with minimal wound morbidity. Since December, 1996, 12 laparoscopic subfascial ligations have been performed on nine patients. This surgery resulted in the complete healing of venous ulcers in six patients and reduction in the size of the ulcers in two other patients. There was one patient who had no improvement from the surgery. Over all, the results were gratifying. This video demonstrates the technique of this procedure.

JSLS. 1997 Oct-Dec;1(4):363–394.

Utility of Office-Based Ultrasonography

Raymond P Onders

Abstract

Background:

There is little data analyzing the utility of ultrasonography in a surgical practice, yet there has been a plethora of recent courses for surgeons. The goal of this study was to assess the overall utilization and to categorize the indications of office-based ultrasonography when patients are referred prior to diagnostic tests.

Methods:

One hundred fifty consecutive new patients who had not had previous radiographic studies presenting to a surgical practice were prospectively analyzed in terms of whether the results of ultrasonography would change their management or whether it would only be used as an adjunct to a physical exam. The types of diagnostic ultrasounds that were performed were also classified.

Results:

An ultrasound was performed on 51 (34%) of the presenting patients in the categories outlined in the following table. Since there was no additional charge by the surgeon in this practice setting, there was a total cost savings to the 29 patients when the ultrasound ($3190) was medically necessary.

Categories	Results Change Management	Adjunct To Physical Exam
Breast	10	15
Biliary Tract	11	0
Abdominal Aneurysm	3	0
Thyroid	0	7
Metastatic Liver Exam	3	0
Hernia	2	0

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Conclusion:

Ultrasonography has a utility in a surgical practice if patients are referred prior to diagnostic tests being ordered. This allows the patients to be evaluated at the same time as their diagnostic procedure by a surgical provider, which is more convenient to patients and can decrease the cost and utilization of diagnostic procedures.

Objective:

The purpose of this experiment was the testing of the monopolar electrocautery under special conditions.

Methods and Procedures:

In order to minimize the risk of undesirable side effects of monopolar electrocautery, experiments were undertaken testing the effects of monopolar electrocautery on the small intestine of the rat. The supply artery of the intestine was subject to electrocautery at various distances from the intestine wall. We evaluated the resulting adhesions in the peritoneal cavity and the effect of monopolar electrocautery on the serosa, muscle and mucosa layers of the small intestine.

Results:

A total of 103 experimental animals were operated on and included in the experiment. For statistical evaluation and computer processing we used statistical software.

Conclusions:

The number of adhesions increases with time after monopolar electrocautery application. After electrocautery at large distances from the intestine, injury to the muscle layer is significantly lower. Injury to the mucosa decreases with decreasing distance of the cautery parameter from the intestine.

JSLS. 1997 Oct-Dec;1(4):363–394.

Unsuspected Foreign Body Aspiration and Asthma

Gustavo Stringel, Nikhil Amin, Hossein Sadeghi, Allen Dozor

Abstract

Purpose:

The objective of our report is to raise awareness of unsuspected foreign body aspiration in children who develop new-onset asthma and have a suboptimal response to medical treatment, and to emphasize the important role of rigid bronchoscopy in the management of these patients.

Methods:

An eight-year-old boy had a three month history of asthma. There was no history of choking. A four-year-old girl was treated for asthma for two and one half months. The initial episode was traced back to coughing while eating a cookie. A 23-month-old male had a one month history of asthma. There was no history of choking or aspiration. An 18-month-old boy presented with a six month history of wheezing and was treated for asthma; there was no episode of choking. Physical examination revealed wheezing in both lungs with moderately decreased air entry in the affected side. In two cases, lateral decubitus chest roentgenograms demonstrated mild hyperinflation and air trapping in the affected lung. Rigid bronchoscopy confirmed the presence of foreign bodies in all four patients.

Results:

After removal of foreign bodies, symptom resolution occurred in all four patients.

Conclusion:

Foreign body aspiration can mimic the clinical picture of asthma. In one case, a history of aspiration was elicited retrospectively. In the other three cases there was no history of aspiration at all. A high index of suspicion, physical examination and appropriate radiological investigations are essential to make the diagnosis. In these cases, the surgeon should not hesitate to recommend rigid bronchoscopy as a definite diagnostic and therapeutic modality.

JSLS. 1997 Oct-Dec;1(4):363–394.

Carter-Thomason Uterine Suspension and Positioning by Ligament Investment, Fixation, and Truncation (UPLIFT)

James E Carter

Abstract

Objective:

To describe a technique and results of uterine suspension and positioning by ligament investment, fixation and truncation (UPLIFT).

Subjects:

Seventy-five women, age 19-48 years, with chronic pelvic pain, dyspareunia and dysmenorrhea seeking treatment were evaluated and treated over a two year period.

Methods:

Laparoscopic uterine suspension was performed using the Carter-Thomason 2 mm needle point suture passer to pass suture percutaneously and transfascially into the extraperitoneal space and then within the round ligament. The suture was exited from the ligament near the uterus and then was retrieved by a second pass of the instrument through the fascia and within the ligament. This created a fascial bridge at the natural exiting point of the ligament out through the inguinal canal. The ligament folds within itself as it is pulled up by the suture. This moderately antiverts the Uterine Position by Ligament Investment, Fixation, and Truncation (UPLIFT). This procedure creates a thickened and strengthened ligament, suspending the uterine fundus securely at the level of the exit point of the round ligaments through the inguinal canal. This procedure was performed without complications in 75 patients over a two-year span. Each patient was evaluated for degree of retroversion and by ultrasound to identify any uterine or ovarian abnormalities. Pelvic pain and dyspareunia were reproduced by palpation of the retroverted uterus.

Results:

The procedure took an average of 12 minutes to perform. All procedures were performed as outpatient with same day discharge, and there were no intraoperative complications. Delayed postoperative pain at the suspension site, significant enough to require oral analgesia or injection with local anesthesia, occurred in five patients (7%): four for one week and one for one month. Significant relief from chronic pain symptoms of dysmenorrhea and dyspareunia was reported in 85% of patients at up to a two-year follow up. Pain with periods decreased from an initial 8.4 to 1.7 (p<0.1, Wilcoxon Signed Rank Test) (with 10 being the worst pain). Pain with intercourse was from 8.1 to 1.5 (p<0.01).

Conclusion:

When dyspareunia, dysmenorrhea and pelvic pain are associated with retroverted uterus, the uterus can be repositioned to a slightly antiverted position by Uterine Positioning using Ligament Investment, Fixation, and Truncation (UPLIFT) with the Carter-Thomason needle point suture passer. Results with this anatomically correct technique are consistent with reports previously given for other uterine suspension procedures. The advantages of this procedure are ease of performance, strengthening of the ligaments by shortening and investment procedure, and a repair that maintains normal anatomic relationships.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Burch Procedure: An Alternative Approach

E D Riza, A S Deshmukh

Abstract

We describe an alternative simple method to do the Burch procedure via a laparoscopic approach.

Stress incontinence has been treated with a multitude of procedures. The Burch procedure has been performed by open methods and now also by laparoscopic means.

The main challenges of a laparoscopic Burch procedure are development of the space of Retzius and anchoring of the paraurethral suspending sutures to Cooper's Ligaments.

The laparoscopic method utilizes difficult suturing and tying of intracorporeal or extracorporeal knots. The expertise to perform these tasks is difficult to acquire.

An alternative method of doing a Burch procedure by the extraperitoneal method is described. The ease of suturing the paraurethral portion of pubocervical fascia to the Cooper's ligament is evident.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Superior-Lateral Paravaginal Reconstruction for SUI

Adam Ostrzenski

Abstract

Objective:

To develop and evaluate translaparoscopic technique of superior lateral paravaginal and pelvic side-wall reconstruction for genuine stress urinary incontinence.

Methods and Procedures:

From January 1992 to July 1996, 28 patients in a consecutive, prospective clinical case study were subjected to laparoscopic reconstruction of the tendinous arch of the levator muscle-obturator internus muscle fascia and superiorlateral paravagina.

A clinical diagnosis of genuine stress urinary incontinence was established and documented by cystometry following a positive cough stress test. When indicated, a multichannel urodynamics study was performed.

Results:

In 16 patients (57%) out of 28, the right pelvic side-wall defect was documented, and in 43% the damage was identified and reconstructed bilaterally. The average operative time was 2 hours, 45 minutes; average blood loss was 1.2g hemoglobin. No intraoperative, immediate postoperative, delayed postoperative, nor anesthesia-related complication was observed. Patients were discharged from surgical units in an average time of 5 hours, 15 minutes. There was no postoperative hospital readmission.

Conclusion:

Laparoscopic superior-lateral paravaginal and pelvic side-wall reconstruction is simple, safe, and has a 93% cure rate; this operation presents an alternative to laparotomy approach.

JSLS. 1997 Oct-Dec;1(4):363–394.

Randomized Trial of the Veress Needle Parallel Technique Insertion

Adam Ostrzenski

Abstract

Objective:

To evaluate the safety and effectiveness of the new parallel technique of Veress needle insertion, and to compare this method with the conventional closed approach in a randomized, prospective, single-blind clinical trial.

Methods and Procedures:

Patients (n=200) were assigned randomly to the conventional closed method (Group I; n=100) and parallel technique (Group II; n=100) of Veress needle insertion. A randomized, prospective, single-blind clinical trial was conducted on women undergoing elective diagnostic and/or operative laparoscopy. Randomization of the patients was done in the operating room.

Results:

There were no significant demographic differences between the groups or between the duration of the Veress needle insertion needed to accomplish pneumoperitoneum. No non-lethal major or minor intraoperative complications occurred with either laparoscopic approach method.

Conclusion:

1) There is no significant disadvantage between those two methods. 2) Parallel technique avoids, during insertion, the anatomical location of large vessels; therefore, it may serve as a safeguard that decreases the potential of lethal major vessels laceration.

JSLS. 1997 Oct-Dec;1(4):363–394.

Classic Intrafascial Semm Hysterectomy (C.I.S.H.): 5 Years Experience in a Community Hospital

John E Morrison, Volker R Jacobs

Abstract

Objective:

Laparoscopic C.I.S.H. procedure was introduced by Gynecologist Kurt Semm from Kiel, Germany, on September 7th, 1991 and started at Fayette Medical Center in November, 1992. With 263 cases up to now, this is the largest number of cases done and reported by one surgeon in the United States. We reported about the long-term experience in a local community hospital.

Procedure:

Indications for C.I.S.H. are similar to open or vaginal hysterectomy. Contraindications - besides for standard laparoscopy - are malignancy and obesity (> 350 lb.). The C.I.S.H. procedure is described in detail. In a retrospective study we found the following:

Results:
Period of Report	11/92 - until now
Cases	263 patients / 1 surgeon
Age	Avg. 44 years (22 - 92 years)
Length of Operation	Avg. 1 hr 15 min (50 min - 6 hr 10 min)
Blood Loss	Avg. 125 cc (55 cc - 765 cc)
Hospital Stay	Avg. <24 hr (max. 5 days)
Return to Work	Avg. 2 weeks (1-4 weeks)
Complications	3 cervical bleedings (1 return to OR)
	1 internal bleeding (return to OR)
	1 ileus (conservative treatment with insertion of NG tube)
Conversions	1 (technical reason: instruments too short because weight-- 406 lb.)

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Advantages of C.I.S.H.: leaving pelvic floor intact, cost effective, short hospital stay, short recuperation, high patient satisfaction. Disadvantages: advanced laparoscopic procedure, technically challenging, learning curve.

Conclusions:

C.I.S.H. is the procedure of choice for hysterectomy because it keeps the normal anatomy of the pelvic floor intact. It has been proven to be a safe and cost-effective technique which can be done in a community hospital.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Vaginal-Sacral-Culpo Suspension: Alternative Technique for Cystocele, Vaginal and Uterine Prolapse and Incontinence

John E Morrison, Volker R Jacobs

Abstract

Objective:

Prolapse of vagina or pelvic organs, a common problem especially in elderly women, causes increasing bladder infections, is socially stigmatizing and leads to a decreasing quality of life. Increasing number of pregnancies and previous gynecological operations (e.g. hysterectomies) lead to damage of pelvic floor and support structures which results in different degrees of cystocele and vaginal or uterus prolapse often combined with incontinence. Mechanical therapy is necessary to return organs to normal position. The number of different techniques published so far shows that there is still no optimal solution. Therefore, we introduced laparoscopic vaginal-sacral-culpo suspension (LVSCS) as a new technique in December 1993 because this procedure supports the idea of mechanical pull up of prolapsed organs into their right anatomical position.

Procedure:

After standard pneumoperitoneum and exploration of abdominal and pelvic organs, both ends of a double layer Prolene mesh - approx. 1.5 x 6 in. - are sutured, not stapled, to the cervical stump or vaginal cuff. The sacrum is exposed, the uterus or vaginal cuff pulled up, and the mesh is longitudinally stapled to the sacrum. The mesh is finally reperitonealized by closure of peritoneum over mesh. In a retrospective study we found the following:

Results:
Period of Report	12/93 - until now
Cases	101 patients / 1 surgeon
Age	Avg. 56 years (35-79 years)
Length of Operation	Avg. 1 hr 4 min (52 min - 2 hr 18 min)
Length of Hospital Stay	Avg. 1.24 days (<24 hr - 3 days)
Outcome	Prolapse (100% no recurrence)
	Incontinence 88% very, 10% somehow, 2% not improved
Complications	No severe complication, 2 wound infections.

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Advantage of LVSCS: It supports the vagina which is hooked to bony structure. It is superior to the conventional Burch procedure because of true bladder support, not just a changed angulation of the urethra. It improves incontinence problems significantly. Disadvantage: a lack of long-term experience with mesh as foreign body material.

Conclusion:

Regained bladder control as well as short operation time and hospital stay, efficient cost and early return to work are a benefit for the patients who demand and prefer this new technique.

JSLS. 1997 Oct-Dec;1(4):363–394.

Benefit of Preoperative Uterine Ultrasonography to Predict Outcome of Endometrectomy in the Treatment of Bleeding Due to Severe Adenomyosis

Judlin Philippe, Burlet Gilles, Koebele Antoine, P Bassnagel

Abstract

Objective:

Our purpose was to determine whether severe adenomyosis was correlated with frequent failure after treatment by hysteroscopic endometrectomy. The severity of adenomyosis was preoperatively defined by transvaginal ultrasonographic evaluation of uterine.

Method:

Forty-two consecutive women with abnormal bleedings due to histologically confirmed adenomyosis (uterine cavity without gross polyps or submucous fibroids) were treated by hysteroscopic endometrectomy. They were subsequently followed up to 24 months (6-24). All patients underwent preoperatively a transvaginal ultrasonography of the uterus that indicated the presence of adenomyosis. Based on the extension and localization of myometrial lesions, adenomyosis was tentatively classified into two groups: mild adenomyosis (few superficial lesions)--M group N=26; severe adenomyosis (many and/or deep lesions)--S group N=l6. Patients received no subsequent hormonal therapy.

Results:

Patients of the S group had poor outcome compared with ones in the M group: recurrent abnormal bleeding occurred in 14 cases (85.5%) in S group vs. 1 (3.8%) in M group.

Conclusions:

This study confirmed hysteroscopic endometrectomy is not effective in the treatment of severe and deep adenomyosis. We have tried to determine preoperatively which cases were severe with the help of transvaginal sonography. Few studies proposing ultrasonographic criteria for adenomyosis exist, and fewer data have studied correlation between sonographic lesions and outcome of treatments. Our method to evaluate severity of adenomyosis was rough and imperfect but it proved to be accurate to predict outcome of the endometrectomy. In the future, studies (with ultrasound or MR imaging) have to be undertaken to improve preoperative evaluation of the severity of adenomyosis so that the best treatment (endometrectomy or hysterectomy) should accurately be selected.

JSLS. 1997 Oct-Dec;1(4):363–394.

A Comparison of Laparoscopy and Laparotomy in the Management of Endometrial Cancer

Guy M Boike, James E Graham Jr

Abstract

The management of endometrial cancer has changed dramatically over the past 15 years with a shift to primary surgical staging including hysterectomy, bilateral salpingo-oophorectomy, and retroperitoneal lymph node sampling. Laparoscopic staging of endometrial cancer was first reported in 1992. In July of 1992 we began offering laparoscopic management to our patients with endometrial cancer. This management consisted of laparoscopic vaginal hysterectomy with pelvic and para-aortic lymph node dissection. A retrospective chart review of all endometrial cancer patients undergoing surgery on our gynecologic oncology service from July 1992 through February 1997 was performed. A total of 204 women underwent surgery. Route of surgery included vaginal hysterectomy in 13, laparotomy in 73, and laparoscopy in 118. The average age for all patients was 62 years. Average patient weights were 150 pounds (range: 107-245) for the laparoscopy group vs. 178 (range: 103-308) for laparotomy. The average number of pelvic nodes removed was 17 (range: 7-50) by laparoscopy vs. 13.6 (range: 6-36) by laparotomy. The average number of aortic nodes removed was 8.1 (range: 2-39) by laparoscopy vs. 4.8 (range: 2-10) by laparotomy. Hospital stay was significantly shorter in the laparoscopy group (2.2 days vs. 5.9 days), and the overall complication rate was lower (8.5% vs. 28.8%).

We conclude that laparoscopic management is feasible in the majority of endometrial cancer patients. Adequacy of retroperitoneal lymph node dissection by laparoscopy appears to be as good or better than that achieved by laparotomy, with the additional benefit of shorter hospital stays. Overall complication rates are less by laparoscopy. Several ongoing national studies through Gynecologic Oncology Group will determine if laparoscopic management of endometrial cancer can be safely and efficiently performed by a large number of gynecologic oncologists.

JSLS. 1997 Oct-Dec;1(4):363–394.

The Interactive Voice-Response System: Its Use in Evaluating Resident Performance of Laparoscopy-Assisted Complicated Surgical Procedures

Michael Fung Kee Fung, Lora Temple, Karen Ash

Abstract

Objective:

The purpose of this study was to determine the feasibility and acceptability of using a telecommunication system to evaluate resident performance of laparoscopic surgery in a formative manner.

Methods and Procedures:

After completing a laparoscopic procedure, the surgeon and resident telephone a toll-free number independently and respond to three pre-recorded statements regarding the resident's performance using a Likert scale of 1 to 5. The caller is then asked to describe the resident's response to critical incidents or elements of surprise that arose during the surgery. The ratings and verbal comments are compiled, transcribed, graphed, and forwarded to the respective resident. The resident (and program director) can hear the verbal comments of the staff evaluator by entering a four-digit code.

Results:

Between May 1, 1995 and April 30, 1997, 650 cases were reported by 13 surgeon-teachers and 20 residents using the inter-active voice-response system. Two hundred and forty-four (37.5%) were entered by both the resident and surgeon. Of these, 29 were classified as laparoscopy-assisted complicated surgical procedures (i.e., vaginal hysterectomy, myomectomy) with the resident as assistant. The average combined ratings for postgraduate year (PGY) 2, PGY-5 residents are:

Combined Average Ratings

PGY	Cases (#)	(resident + surgeon ratings) / total number of ratings
PGY	Cases (#)	Statement 1	Statement 2	Statement 3
2	7	2.5	2.72	3
3	10	2.70	2.85	3.1
5	12	2.63	2.42	3.38
Total	29

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Both the PGY-2 and PGY-3 consistently rated themselves lower than their preceptors, whereas, PGY-5 residents rated their performance as higher. Graphical representation of the cases over time showed that, although the PGY-2 and PGY-3 residents' ratings were below the surgeons' ratings, their overall performance generally improved over time. Similarly, the ratings for PGY-5 residents improved over time, but were more sporadic, ranging from 1 to 5.

Conclusions:

The interactive voice-response system has been accepted by both residents and surgeons. It has also provided a novel opportunity to give semi-objective, real-time feedback and evaluation of trainee performance. The ability to graphically present this data has further enhanced the system's use and attractiveness in residency training.

JSLS. 1997 Oct-Dec;1(4):363–394.

Complications of Cholelithiasis in Pregnancy: Surgical Management Without Fetal Loss

Sonya Lee, James P Bradley, James H Barr, Matthew Kirkland

Abstract

Introduction:

To avoid fetal morbidity from premature delivery, gallbladder disease in pregnancy has been managed conservatively without surgical intervention. Recently, a few studies have suggested that surgery can be undertaken with minimal risks to the fetus or mother. It has not been shown whether operative therapy in pregnant patients with recurrent biliary colic or complications of cholelithiasis is warranted. To determine whether an aggressive surgical approach is superior to conservative medical management in these patients, the clinical courses of all pregnant patients with biliary disease at a single institution were reviewed over a selected time period.

Methods:

A review of all pregnant patients at Pennsylvania Hospital from 1988-1997 who were hospitalized with symptoms of biliary disease was performed. Data was collected by record review and interviews to determine: 1) fetal and maternal status throughout the episodes of biliary disease or course of treatment; 2) complications: relapses of disease, premature labor; and 3) fetal outcome: fetal stress, Apgar score, birth weight.

Results:

From 38,200 pregnancies during the 8 years study period, 38 patients were identified with biliary disease (23 biliary colic, 7 acute cholecystitis, 3 gallstone pancreatitis, 5 choledocholithiasis, 1 cholangitis). Patients managed medically had 1) frequent symptom relapses (avg. ER visits=3.0; avg. hospital days=11); 2) poor nutrition (three patients required long term TPN); 3) one maternal mortality (secondary to vomiting, severe hypokalemia and arrhythmia); and 4) increase fetal stress (4 premature deliveries, 80% meconium, 60% ICN). In contrast, surgical intervention lead to 1) few complications, 2) better per os intake, 3) no premature deliveries, and 4) no fetal loss. Laparoscopic procedures were done between 14-34 weeks.

Conclusion:

From these data, we conclude 1) pregnant patients with biliary disease managed nonoperatively have a high rate of relapse, and 2) no significant perioperative morbidity resulted from surgery during pregnancy. We recommend that all pregnant patients who are hospitalized with symptomatic biliary disease undergo cholecystectomy and a definitive surgical procedure.

JSLS. 1997 Oct-Dec;1(4):363–394.

Bilateral Ureterocele (Stenotic Ureterocele): Cystoscopy and Endoscopic Resection

Jose M M Ferreira Coelho, Ricardo Matos, Manuel X Ferreira Coelho

Abstract

This case involves a 42-year-old healthy, white woman, who had chronic symptoms of urinary frequency associated with urethral, pelvic, and bladder pain and often dyspareunia with no identifiable cause. Physical examination, laboratory investigation, sonogram of the urinary bladder and kidneys were within normal limits. The symptoms did not respond to antibiotic therapy; routine cultures of the urine were negative.

Endoscopic examination of the urinary bladder revealed a bilateral Ureterocele of the “simple orthotopic” variety. All cystoscopic findings are those seen on the surgeon's external monitor. The left ureterocele, a large cystic dilatation of 17 cm3, rather the right of 12 cm3, was explored with “Fogarty catheter.” Transurethral resection (TUR) was made under balanced anesthesia with knife and loop, with distal incision and resection of all dome ureteroceles. Cystogram, with visualization on the monitor, revealed no vesico-ureteral reflux bilaterally after TUR. Histologically, the wall of the ureterocele contained varying degrees of fibrous tissue, collagen and attenuated smooth muscle bundles.

Follow-up after 6 and 12 months with cystourethroscopy was normal with good ejection from the left and right ureteral orifices.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Orchiopexy: The Treatment of Choice for the Impalpable Undescended Testis

Ashraf Bakr

Abstract

Objective:

Management of impalpable testis often represents a diagnostic and therapeutic challenge for the surgeon. The aim of this work is to present the superior value of laparoscopy as a single tool in the diagnosis and treatment of impalpable testis.

Methods and Procedures:

Twenty-nine patients with 38 impalpable testes are included in this study. One patient had a negative inguinal exploration previously. For each patient, magnetic resonance imaging (MRI) was performed to localize the impalpable testes. Laparoscopy was then performed for each patient. Either the testis or blind-ending cord structures was searched for. The testis was either brought down to the scrotum (in single or multiple stages) or removed, depending on the condition of each patient.

Results:

MRI detected 14 out of 38 impalpable testes (37%); nine intra-abdominal, four inguinal and one in the peritoneum. MRI failed to localize the remaining 24 testes raising the possibility of either absent or atrophic testes. Laparoscopy, on the other hand, detected 18 intra-abdominal testes, four inguinal and 16 blind-ending cord structures either above or below the internal inguinal ring. Blind-ending cord structures suggested a vanished testis. Orchiopexy was performed for 19 cases. Orchiopexy was performed in 17 cases and in two cases only laparoscopy was done. There was no morbidity and no mortality in this series.

Conclusion:

Laparoscopy seems to offer a safe, reliable, diagnostic and therapeutic option to patients with impalpable testes. Intra-abdominal dissection allows more testes to be brought down to the scrotum. The procedure is best viewed as laparoscopy-assisted because Orchiopexy has to be done in a conventional manner.

JSLS. 1997 Oct-Dec;1(4):363–394.

Suction Curettage for Removal of Retained Intrathoracic Blood Clots and Benign Pleural Lesions

Jay A Redan, Meade T Palmer, Frank Tylutki

Abstract

Objective:

To develop a thoracoscopic technique for correcting and/or removing an intrathoracic disease process using our existing operating room equipment, and without a “small thoracotomy.”

Methods and Procedures:

Ten patients, from January 1996 to December 96, were prospectively studied. All were undergoing procedures involving the removal of a suspected (benign or infectious) pleural process or a retained blood clot. Three or four thoracic ports were used in all cases. Straight and curved suction curettage cannulae (with finger valve attachment) ranging from 8 to 16 French were available for use. Intermittent variable suction (between zero and 60 mm Hg) was used in all cases. Dependent upon the size and adherence of the lesion to be removed, the pressure was determined by the surgeon and regulated by the circulating nurse in the room. In each case, a trap system was used for retrieval of the specimen. One lung ventilation was used in every case and, when suction was used, one of the ports was kept “open” to allow room to enter the chest cavity.

Results:

All patients in our series had their procedures completed without the need for any kind of open thoracotomy. Pre and postoperative diagnosis concurred in all ten patients, and no complications occurred (specifically no injury to the lung tissue or chest wall structures). Operative time ranged from 45 minutes to 180 minutes, with a mean of 60 minutes. In all cases of a hemothorax, a cell saver system was used for an average of one unit of blood auto-transfused per case.

Conclusion:

New techniques don't always require the purchase of new equipment. Tight hospital budgets are forcing surgeons to rely on redefining uses of instrumentation already available in solving surgical problems. My colleagues and I feel that the use of this instrumentation will provide another avenue for surgeons to successfully complete a procedure thoracoscopically without the need for a thoracotomy. It is through multidisciplinary conferences, such as those presented by the Society of Laparoendoscopic Surgeons, that ideas such as this are propagated.

JSLS. 1997 Oct-Dec;1(4):363–394.

Minimally Invasive In-Situ Femoral-Distal Bypass

Gregory K Patterson, Jose Mena

Abstract

Distal bypass from the femoral artery to the vessels below the popliteal trifurcation has become a common procedure secondary to refined techniques and improvements in instrumentation. Femoral-distal bypasses to the dorsalis pedis, posterior tibial and the anterior tibial vessels are indicated for limb salvage, impending tissue loss and lifestyle-altering claudications. Studies have proven that the autologous saphenous vein is the best conduit for use in below-the-knee bypasses. The current area of research surrounds which technique of harvesting and positioning of the graft has the longest patency rate. Despite improvements in conduit techniques, the largest cause of morbidity is wound complications, ranging from simple wound infections and breakdown to tissue lose, gangrene and amputation. The high incident rate of wound complications stems from the long incisions needed to harvest, in most cases, the entire saphenous vein. This is compounded by the already compromised vascular state in the affected limb or, if the vein is taken from the unaffected limb, the potential for morbidity to both lower extremities.

We describe a technique of femoral-distal bypass utilizing an insitu technique with minimal skin incisions. Using a modification of the endoscopic saphenous vein harvesting technique for coronary artery surgery, the saphenous vein is exposed from groin to the medial mallelous with skin incisions less than one-third the distance of the leg. This is accomplished with a 5 mm 15 degree endoscope and hooded dissecting sheath. The side branches are clipped during exposure of the vein, without separate counter-incisions, using a 5 mm straight endoscopic clip applier. The valves are lysed with an intra-luminal valvulotome. The proximal and distal anastomosis are performed in their usual fashion. We present three cases, all with good results, including decreased time of exposure of graft, closure of wound and overall operating time. There was only one complication, a proximal wound with an area of epidermolysis.

JSLS. 1997 Oct-Dec;1(4):363–394.

Laparoscopic Omental Transposition for Sternal Dehiscence

Joseph A Greenlee, Reed Panos, Mark Liberman

Abstract

Objective:

We report the first case of laparoscopic omental transposition to fill a large sternal wound in a patient with mediastinitis following coronary artery bypass grafting.

Methods and Procedures:

A 61 year old diabetic female suffered sternal wound dehiscence after coronary artery bypass surgery. Previous surgical debridement had left the patient with a large anterior chest wall defect. A minimally invasive technique was selected to avoid compounding the patient's tenuous clinical status. A four port technique was used. The harmonic scalpel was used to free the omentum from the transverse colon and divide the short gastric vessels. The omental flap was based on the right gastroepiploic vessels and mobilized to the upper abdomen. A feeding jejunostomy was performed. An opening in the midline fascia was made through the inferior aspect of the sternal wound. The omentum was brought through the opening and completely filled the defect. Split thickness skin grafts were applied to complete the procedure.

Results:

The patient was extubated on postoperative day two and started oral intake on day four. She had 100% viability of her omental flap.

Conclusions:

Minimally invasive surgery is safe and beneficial in the debilitated patient requiring omental transposition for an infected sternal wound. Avoiding laparotomy decreases postoperative pain, ileus, and physiologic stress. Laparoscopic mobilization should be the preferred approach when transportation of the omentum is indicated.

JSLS. 1997 Oct-Dec;1(4):363–394.

Geometric Considerations in Minimally Invasive Coronary Artery Surgery

W Peter Geis, Jeffry T Zern, Ralph J Damiano

Abstract

Introduction:

The performance of coronary artery anastomosis through thoracoscopy ports requires careful consideration of the geometric relationship between the instruments, the vessels, the anastomotic sites, and manipulation of the heart to expose each vessel. The understanding of these relationships is key to successful minimally invasive coronary surgery.

Methods:

We used the porcine model, human cadaver model, and the live human heart during standard coronary artery bypass surgery to assess the planar relationships between the anterior wall of each major coronary artery and the X, Y, and Z axis of the torso. We plotted the planar progress of each vessel during progressive elevation and rotation of the heart. The relationship between these planes and various port locations in the chest wall was determined. Lastly, the optimum relationship between instruments and the vessel planes was delineated.

Results:

Optimum versatility of thoracoscopic needle drivers occurred approximately parallel to the length of the vessel incision and with the instrument shaft 15 - 60 degrees angle anterior to the vessel plane. The most versatile dimension for a second instrument is 60 - 120 degrees. In each instance, the extension of the instrument shafts to the chest wall provided a determination for port placement.

Conclusion:

These data delineate a safe and efficient approach to fully endoscopic coronary artery bypass procedures and propose a port strategy for each major coronary vessel during rotation of the heart in order to provide access to each vessel.

JSLS. 1997 Oct-Dec;1(4):363–394.

Thoracoscopic Excision of Mediastinal Parathyroid Adenomas

Rebecca Knight, Erick R Ratzer, Michael E Fenoglio, John T Moore

Abstract

We report two cases of excision of mediastinal parathyroid adenomas via video-assisted thoracoscopy.

Primary hyperparathyroidism is the most common cause of hypercalcemia in the general population. Most abnormal parathyroid glands are removed through a cervical incision; however, 2-5% of neck explorations for primary hyperparathyroidism fail. Up to 1/3 of failures are due to ectopic mediastinal parathyroid adenomas. Rarely, a parathyroid gland may be positioned in the mediastinum such that it is inaccessible through a standard cervical incision (1-2% of cases).

Excision of such mediastinal glands have historically required a median sternotomy, thus exposing the patient to increased morbidity. Complication rates approaching 30% have been reported. Furthermore, the required hospitalization and recovery time with median sternotomy generally exceeds that of cervical exploration.

Angiographic ablation is an alternative to surgical excision with few associated major complications and minimal pain. While this technique may obviate the need for surgery, up to 40% of attempts are unsuccessful and parathyroid tissue is not preserved for pathological study of autotransplantation.

The video-assisted approach to removing mediastinal parathyroid adenoma provides direct visualization of the gland, access to the entire mediastinum, and preservation of parathyroid tissue in the event that autotransplantation is required. Furthermore, thoracoscopy has a lower associated morbidity and generally requires a shorter hospital stay. Successful preoperative localization is perhaps the most important factor in preparing for thoracoscopic excision of a mediastinal adenoma. We suggest that thoracoscopic removal of an ectopic mediastinal parathyroid adenoma is the best procedure in those instances where the exact location of the lesion can be established preoperatively.

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PERMALINK

Abstracts SLS Annual Meeting 1997

The Difficult LAVH

Andrew Brill, MD

Abstract

Objective:

Presentation Highlights:

Conclusion:

New Approaches to Stress Incontinence

James E Carter, MD, PhD

Abstract

Objective:

Presentation Highlights:

Conclusion:

References:

Interactive Multimedia Programs to Teach Diagnostic Ultrasound Skills

Mark Deutchman, MD

Abstract

Objective:

Methods:

Results:

Conclusion:

Laparoscopic Colon Resection: Tips to Improve your Technique and How to Avoid Trocar Site Implantations

Morris E Franklin, MD

Abstract

Re-Engineering Medical Education and Training for the 21st Century

Jeffrey S Levy, MD

Abstract

Use of the Robotic Arm as a Teaching Tool in Minimally Invasive Surgery

W Peter Geis, MD

Jeffry T Zern, MD

Charles H Kim, MD

Paul C McAfee, MD

Abstract

Introduction:

Methods:

Results:

Conclusion:

Training Minimal Access Surgery Skills within a Virtual Environment

Mike Kelly, MD

Nick Beagley, MD

Abstract

Objective:

Methods and Procedures:

Results:

Conclusions:

The Effects of Compression Algorithms and Changing Bandwidth of Laparoscopic Skills Performance

S Vincent Grasso, DO

Harold Brem

Ludie Rosser, BS

James Rosser, MD

Abstract

Objective:

Methods:

Results:

Conclusion:

Are Surgical Residents Being Adequately Trained During the Laparoscopic Era?

Syed Ahmad, MD

Darius Desai, MD

Peter Pastuszko, MD

Alan Schuricht, MD

Abstract

Introduction:

Methods:

Results:

Conclusions:

Training Trends of Surgical Residents During the Laparoscopic Era

Syed Ahmad, MD

Peter Pastuszko, MD

Alan Schuricht, MD

Abstract

Introduction:

Methods:

Results:

Conclusions:

The Real Intra-Abdominal Pressure During Laparoscopy. First Intraoperative Measurement Model for Insufflator Evaluation in Laparoscopy

Volker R Jacobs, MD, PhD

John E Morrison, MD

Abstract

Objective:

Aerosolization of Cancer Cells During CO₂ Insufflation

Carbon Dioxide Gas Heating in Laparoscopy: Is It Worth It? Intraoperative Evaluation of Insufflators with vs. without CO₂ Gas Heating Device