Journal of Laparoendoscopic & Advanced Surgical Techniques

: In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure.

: We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach.

: In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations.

: Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions.

: Bile duct injuries sustained during laparoscopic cholecystectomy differ from those of open cholecystectomy. The authors conducted a retrospective analysis of their experience with 124 major bile duct injuries to identify these differences.

: Biliary injury in 83 patients (67%) was sustained during open cholecystectomy, while in 41 patients (33%), it occurred during laparoscopic cholecystectomy. Intraoperative recognition was possible in 21 patients (25%) in the former group and in 14 patients (34%) in the latter (P < 0.05).

: The median time of presentation after laparoscopic cholecystectomy was 37 days v 240 days after open cholecystectomy (P < 0.001). Twenty-eight patients presented with external biliary fistulae in both groups. Spontaneous closure of these fistulae occurred in 21 patients (75%) in the open cholecystectomy group and in only 10 patients (36%) in the laparoscopic group (P < 0.01). Bismuth type III or IV injuries were the commonest type in the laparoscopic cholecystectomy group (N = 25; 61%) while Bismuth type I or II were the usual injuries in open cholecystectomy (N = 57; 69%) (P < 0.01). After hepaticojejunostomy, over a mean follow-up period of 3.4 years, stenosis of the hepaticojejunostomy was seen in two patients in both groups.

: Compared with open cholecystectomy, biliary injuries sustained during laparoscopic cholecystectomy are more likely to present earlier, are more often associated with persistent bile leaks, and are usually high injuries. However, the results of surgical repair do not appear to be different in these two groups.

: Precise localization and surgical excision is the therapeutic strategy for insulinomas. However, it is often difficult to localize the insulinomas, because of their small size. Surgeons may not localize and remove all of them together, particularly in patients with multiple insulinomas. We reviewed our experience to confirm the efficacy of blood glucose and intraoperative immunoreactive insulin (IRI) monitoring for surgical management of insulinomas.

: Thirty-nine patients with insulinoma were surgically treated in our department. Perioperative blood glucose monitoring was performed in 14 patients, intraoperative quick IRI assay of the peripheral blood in 10 patients, and assay of a portal sample in 4 patients by an IMX analyzer.

: Rebound response of blood glucose to insulinoma removal was not always noted (8/14; 57%). Seven of ten patients showed a decrease of peripheral serum IRI levels within 15 minutes after removal of the insulinoma. The other two patients showed a rebound response of peripheral blood glucose or portal IRI. All the patients who had intraoperative monitoring of peripheral blood and peripheral and portal IRI had no recurrent insulinoma syndrome after surgical removal of their insulinomas.

: Combined monitoring of peripheral blood glucose and peripheral and portal IRI are helpful in the surgical management of insulinomas, as they can indicate that no insulinoma remains.

: Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts.

: We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst.

: The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled.

: Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.

: The use of laparoscopy for the treatment of various surgical diseases has been well described, and recently, it has gained popularity in the evaluation of abdominal trauma patients. The value of diagnostic laparoscopy (DL) in avoiding unnecessary laparotomies and its effects on hospital costs was evaluated in a prospective clinical trial.

: In a 48-month period, 99 hemodynamically stable abdominal trauma patients (28 blunt and 71 penetrating injuries) among 428 patients admitted with abdominal trauma in whom the decision for surgical exploration was made were accepted for the study and underwent DL prior to laparotomy.

: The DL was negative in 60.7% of the patients with blunt abdominal trauma (BAT) and in 62.0% of the patients with penetrating abdominal trauma (PAT). Laparoscopy-positive patients (Group 1) underwent immediate laparotomy, whereas on DL-negative patients (Group 2), no laparotomies were performed. Hospitalization times and hospital costs of the two groups were recorded and compared. The difference between the hospitalization times of Group 1 and Group 2 was statistically significant (P < 0.001). The use of DL reduced the rate of unnecessary laparotomies from 60.7% to 0 in BAT and from 78.9% to 16.9% in PAT. The mean hospitalization time was 2.75 ± 1.20 days in patients with negative DL, whereas it was 7.4 ± 2.20 days and 5.2 ± 1.42 days in DL-positive patients undergoing a therapeutic and nontherapeutic laparotomy, respectively. When the hospital costs of the Group 1 patients were compared with those of Group 2 patients, there was a 4.07-fold increase in patients undergoing therapeutic laparotomy and a 1.78-fold increase in patients undergoing nontherapeutic laparotomy.

: Diagnostic laparoscopy might be used in selected patients to exclude significant intra-abdominal injuries.

: Inadvertent dissemination of latent gallbladder (GB) cancer has become a crucial issue with the widespread use of laparoscopic cholecystectomy as a standard operation for benign gallbladder diseases.

: Laparoscopic extended cholecystectomy is a new technique we have developed for the resection of GB tumors with suspicion of malignancy. The procedure is safe and minimally invasive and prevents tumor dissemination. The GB is resected laparoscopically along with a 1-cm margin of the liver using LaparoSonic Coagulating Shears without any ligation or clipping.

: We applied this technique to a patient with a GB tumor in the fundus. The tumor was not exposed on the cut surface, and there were no postoperative complications.

: Laparoscopic extended cholecystectomy for GB tumors with suspicion of malignancy is a minimally invasive technique that may decrease the risk of tumor dissemination.

: To verify the technical feasibility of laparoscopic aortorenal bypass in a porcine model and to evaluate renal pathologic findings after a short survival time.

: Laparoscopic aorta-to-left-renal artery bypass using an interposition Gore-Tex^® graft was performed in five animals. Renal function was assessed 1 week postoperatively and euthanasia performed after 14 days for histologic examination.

: The median surgical time was 210 minutes (range 160-260 minutes). The median time needed to perform the aorta-to-graft anastomosis was 65 minutes (range 50-75 minutes), and the median time required to create the graft-to-renal artery anastomosis was 50 minutes (range 45-60 minutes). No conversion to open surgery was needed. Two intraoperative complications were observed: one large-bowel perforation, which was managed laparoscopically, and one obstruction of the aorta-to-graft anastomosis caused by clots, which was managed by removal of clots with a balloon catheter. No major postoperative complications were observed. The mean preoperative and postoperative serum creatinine concentrations were 0.8 ± 1.2 and 0.7 ± 1.6 mg/dL, respectively. At autopsy, all but one of the pigs were found to have a patent aortorenal bypass. In one pig, we found a partially clotted graft. Histologic examination demonstrated an unremarkable kidney in four cases and a kidney showing aspects of coagulative necrosis with viable cells in the animal with the partially clotted graft.

: Laparoscopic aortorenal bypass is feasible. The short-term effect of the bypass on kidney vascularization seems promising, as demonstrated by pathologic findings. Laparoscopic aortorenal bypass could extend the indications for renal revascularization surgery.

: To address the feasibility and safety of laparoscopic cholecystectomy in situs inversus and highlight the necessary modifications in the surgical technique.

: We present our experience in two patients with situs inversus and symptomatic gallstones who were treated successfully by laparoscopic cholecystectomy. The surgeon stood on the right side with the video monitor above the patient's left shoulder. Two 10-mm ports were placed in the epigastric and subumbilical positions. Two 5-mm ports were placed in the left midclavicular and left anterior axillary lines. The two procedures were carried out uneventfully after reorientation of the visual-motor skills of the surgeon and cameraman to the left upper quadrant. A summary of a further similar 13 cases so far treated in the English-language medical literature is also presented.

: Skeletonizing the structures in Calot's triangle consumed extra time and was more difficult than in patients with a normally sited gallbladder. However, the hospital stay and postoperative complications were similar.

: Laparoscopic cholecystectomy in situs inversus seems to be feasible and safe provided it is performed by an expert laparoscopic surgeon who takes time in clearly demonstrating the extrahepatic mirror image anatomy of the biliary tree with its right-to-left shift.

: Splenic cysts are a rare clinical entity in the United States, and historically, management has consisted of either partial or total splenectomy via an open approach. Laparoscopic treatment of splenic cysts with preservation of splenic parenchyma offers several advantages. Compared with the open approach, a laparoscopic approach may result in less postoperative pain and a more rapid return to full activity. Compared with total splenectomy, splenic preservation eliminates the risk of overwhelming postsplenectomy infection.

: We present two patients with splenic cysts. One patient was treated with laparoscopic marsupialization of the cyst and the other with laparoscopic hemisplenectomy.

: Both patients are without further symptoms at 26 and 5 months' follow-up, respectively.

: Laparoscopic marsupialization and hemisplenectomy are appropriate treatment options for patients with splenic cysts.

: Our objective was to determine the efficacy of computer-assisted robotic laparoscopic Heller myotomy.

: A 76-year-old woman with a significant history of achalasia was evaluated for laparoscopic Heller myotomy. The daVinci^™ surgical system was used throughout the procedure.

: Computer assistance allowed scaling of hand motions from a range of 2:1 to 5:1. Successful dissection of the esophageal musculature was accomplished, and a Toupet-type fundoplication was performed. The patient was discharged from the hospital the day after surgery with five port incisions, each <1 cm.

: Telemanipulator computer-assisted surgical devices may have applications in procedures that require advanced and finely tuned motions, such as Heller myotomy. The benefits of extra magnification and three-dimensional imaging can help prevent esophageal perforation and identify residual circular muscle fibers.

: Crohn's disease confined to the appendix is rare but has been well described in the literature. It can mimic acute appendicitis clinically. After surgical treatment, recurrences of Crohn's disease are rare. We report the first case of treatment by laparoscopic appendectomy of Crohn's disease confined to the appendix.

: A healthy 32-year old man presented with a week-long history of vague lower abdominal pain. Diagnostic work-up, which included CT, enteroclysis, and routine blood work, revealed a patent appendiceal lumen with an inflammatory mass in the right lower quadrant.

: Diagnostic laparoscopy revealed an inflamed appendix, and a laparoscopic appendectomy was performed, with frozen-section examination revealing Crohn's disease of the appendix. Two years after surgery, the patient has not had a recurrence of symptoms.

: Crohn's disease of the appendix can mimic acute appendicitis, although often with a more indolent course. The disease may be treated successfully by laparoscopic appendectomy, with good long-term results.