Journal of laparoendoscopic surgery最新文献

Forty-four patients with histologically confirmed acute cholecystitis (AC) underwent attempted laparoscopic cholecystectomy (LC) from August 1990 to February 1994 and were retrospectively reviewed. During this time frame, LC was attempted in all patients with AC. Twelve of the patients were scheduled for elective LC as they were not thought to have AC preoperatively. Interestingly, eight of these unsuspected cases of acute cholecystitis had both a normal preoperative white blood cell count and were afebrile. The other 32 patients had a clinical presentation consistent with AC. The only diagnostic finding common to all cases of AC was abdominal pain and tenderness. In addition to AC, five patients also had gallstone pancreatitis, and three others were found to have concomitant choledocholithiasis. Fourteen patients required intraoperative conversion to open cholecystectomy for a laparoscopic success rate of 68%. The most common reason for conversion was difficulty in the dissection or unclear anatomy caused by dense adhesions. LC is an appropriate surgical treatment of AC, provided the surgeon abandons the laparoscopic approach if unable to safely proceed. Diagnostic and admission criteria for AC that requires elevated white blood cell count and/or fever may need revision.

Visualization of the entire biliary tree can be difficult in some patients undergoing cholangiography during laparoscopic cholecystectomy. A simple technique was developed for these patients, utilizing the laparoscope under fluoroscopic guidance, in order to visualize the proximal biliary ducts.

Thoracoscopy has been proposed as the procedure of choice for the evaluation of focal, suspected malignant pulmonary lesions in children. One drawback with this approach, however, is the concern that intraparenchymal lesions may go undetected. We prospectively evaluated the ability of an endoscopic ultrasonic probe to detect intraparenchymal nodules. The handheld probe contains a piezoelectric ultrasound emitter and receiver that operates at 7.5 MHz. The axial resolution of the probe is 1.1 cm. Two different probe tips were used. One is a forward viewing tip and the other is angled at 45 degrees relative to the axis of the probe shaft. Both probes image 90 degrees sectors. Twelve thoracoscopies on nine patients were performed using the ultrasound probe. Of seven patients with confirmed metastatic disease, six had thoracoscopy converted to open thoracotomy to assure that no lesion had been missed. The probe was able to accurately assess surrounding bronchovascular structures and the presence and location of previously placed surgical clips. Although deep structures were readily visualized with the probe, lesions within 1.5 cm of the surface of the lung were poorly visualized. No complications occurred. This ultrasound system allows for the distinction of dense lesions from the surrounding pulmonary parenchyma except for those lying near the surface of the lung, which are usually easy to see directly. Furthermore, the images define the broncho vascular structures adjacent to the lesion. This device may enhance thoracoscopy by facilitating the detection of, and ability to resect, pulmonary intraparenchymal lesions.

A 49-year-old male presented with atypical chest pain. Complete cardiac evaluation was normal except for cardiac catheterization, which revealed a myocardial bridge across the LAD (left anterior descending coronary artery) that caused a 50% systolic stenosis. Abdominal ultrasound revealed cholelithiasis. The patient became asymptomatic and was discharged only to return with biliary pancreatitis, which resolved over 2 weeks and laparoscopic cholecystectomy was attempted. Upon establishment of a pneumoperitoneum, he began to suffer cardiac ischemia, which immediately resolved upon desufflation. The procedure was converted to an uneventful open cholecystectomy. He did well without any further problems. This is the first report of myocardial bridging, a well-known cardiac anomaly, possibly preventing safe laparoscopy. This was possibly due to transmitted intraperitoneal pressure effect on the pericardium pushing closed that myocardial bridge.

Over a 2-year period 157 inguinal hernias in 151 patients were consecutively entered in this descriptive, observational study to determine any difference in outcome between a laparoscopic inguinal hernia repair versus an open inguinal hernia repair in a community hospital setting. The laparoscopic transabdominal preperitoneal technique was utilized in 50 cases. A conventional open repair was used in 107 cases. There were statistically significant differences when the laparoscopic and open groups were compared for the number of days until driving a car (p < 0.01), the number of days until getting in and out of bed comfortably (p = 0.01), the number of days until working on a limited basis (p = 0.01), and the number of days until working on a full-time basis (p < 0.05), although these differences may be due to confounding factors in this nonrandomized study. The average length of operating time was 72.2 min laparoscopic versus 51.6 min open (p < 0.001). We have shown that laparoscopic inguinal hernia repairs may have benefits over conventional hernia repairs. This may make its use more widespread than it has already become.

Advanced laparoscopic techniques can be challenging to perform because tactile sensation is limited with available laparoscopic instrumentation. Described is a technique of placing the surgeon's hand into the peritoneal cavity while maintaining pneumoperitoneum. Use of the hand allows for easy exposure, complete exploration, meticulous dissection, and immediate hemostasis. Our experience reveals patients have a short hospital stay and recuperation time.