Journal of laparoendoscopic surgery最新文献

Early definitive treatment of symptomatic posttransplant lymphoceles offers good results with fewer graft losses and reduced morbidity. If interventional therapy fails, laparoscopic internal marsupialization to the peritoneal cavity may be performed with excellent results and at low cost. In combined pancreas-kidney transplantation the transperitoneal laparoscopic access may be difficult due to adhesions caused by the intraabdominal positioning of the pancreatic graft and posttransplantation pancreatitis. Both posttransplantation lavage of the abdominal cavity as well as immunosuppression reduce formation of intraabdominal adhesions subsequent to combined pancreas-kidney transplantation. Thus, posttransplant lymphoceles may be treated safely even after combined kidney-pancreas transplantation.

Between January 1993 and November 1995 laparoscopic surgery was used in 21 patients with a variety of splenic diseases, namely idiopathic thrombocytopenic purpura, congenital spherocytosis, lymphoma, leukemic infiltrative disease, splenic infarction, trauma, or splenic cyst. Total splenectomy was carried out laparoscopically in 16 patients. Conversion to open splenectomy was necessary in two other patients because of intractable bleeding. Two patients with a splenic cyst underwent laparoscopic unroofing of the cyst. Conservative hemostasis of a spleen injury grade II was carried out in a child after blunt trauma. The total mean duration of the laparoscopic procedures was 158 min and the mean blood loss volume was 350 ml, both conversions being excluded. Postsurgical recovery was excellent and the average hospital stay was 5 days, including the patients with conversion. There were no significant postoperative complications. Our observations indicate that an increasing number of surgical diseases of the spleen can be managed adequately by a less invasive laparoscopic approach. However, the criteria for using this procedure are in an expanding phase and are still mainly dependent on the surgeon's technical experience.

The study's aim was to assess the functional results of laparoscopically performed Heller's myotomy and Dor's fundoplication in our first few cases of esophageal achalasia. Four male patients (mean age: 61 years) with long-standing symptoms of achalasia (documented on esophagogram and esophageal manometry) and not responding to several sessions of pneumatic dilatation, had laparoscopic Heller's myotomy and Dor's fundoplication. Myotomy was facilitated by distending the esophagus. The mean duration of the operation was 99 min. The third patient developed a leak from the exposed esophageal mucosa on the 5th postoperative day while at home. The leak was attributed to late desloughing of a mucosal burn, and was sealed spontaneously 15 days later after drainage. The remaining three patients were discharged after resuming diet within the first 2 postoperative days. By 1 year postoperatively, dysphagia was abolished in all cases, and there were no gastroesophageal reflux symptoms. The esophagogram showed no reflux, which was also confirmed on ambulatory 24-h esophageal pH measurement. On manometry, lower esophageal sphincter (LES) pressure dropped significantly postoperatively (preop: 56 +/- 7 SD mm Hg, postop: 5 +/- 1 SD mm Hg, p < 0.001). In conclusion, laparoscopic Heller's myotomy with Dor's fundoplication for esophageal achalasia is a feasible procedure, offering clinical and laboratory results similar to the open approach, but with better patient tolerance.

Most reports on laparoscopic fundoplication are from large, tertiary referral medical centers. Presented here is an experience by a single surgeon (M.E.F.) in community hospitals with 74 cases. All patients had esophagitis. All but two patients were Visick grade IV off medication. All patients had an incompetent lower esophageal sphicter. Four with abnormally low esophageal contractions underwent a Toupet procedure; the rest had a Nissen fundoplication. The largest estimated blood loss was 300 cc. One case (1.4%) had to be converted intraoperatively to an open procedure because of bleeding from an iatrogenic liver laceration. There were two minor complications (a urinary tract infection and a pneumothorax) and one death (massive liver necrosis with an otherwise unremarkable post mortem, thus it was felt to be due to anesthesia). The mean length of hospital stay was 2.8 +/- 0.21 days. Eighty-nine percent of the operations totally relieved reflux. Nineteen patients (26%) had mild, early postoperative dysphagia, gas bloat, and/or early satiety. Four patients did not get any improvement in their reflux, three still require chronic medication, and one underwent a redo open fundoplication. Three early patients had severe, new-onset postoperative dysphagia secondary to too tight a fundoplication. Attention must be focused on creating a loose wrap, a "floppy" Nissen by routine division of the short gastric vessels and the use of a large dilator in the esophagus when the fundoplication is constructed. Laparoscopic fundoplication is technically feasible, safe, and effective in a community hospital and does not require a large, tertiary referral medical center.

Surgical options for appendicitis have increased, just as they have with cholecystitis. The laparoscope can now be utilized in place of the standard open operation for treatment of appendicitis. Like laparoscopic cholecystectomy, laparoscopic appendectomy can be associated with increased morbidities, not usually seen with open surgery. We present a case of the unusual complication of recurrent appendicitis in a generous appendiceal remnant after laparoscopic appendectomy.

Performance of a laparoscopic posterior partial fundoplication (LPPF) for severe gastroesophageal reflux disease may have significant advantages. These include a low incidence of postop dysphagia, maintenance of the ability to belch, excellent antireflux effects, and the ease of performance of the surgery. The purpose of this study was to evaluate this antireflux procedure for these advantages to determine both its safety and effectiveness. Over 200 LPPFs have been performed by the authors in a community setting. One hundred consecutive cases are evaluated for indications, preop, and postop studies (EGD, manometry, 24 h pH), time of operation, hospital stay, complications, and conversions to an open procedure. Our technique of LPPF is presented in detail. All patients maintained the ability to belch. Postop dysphagia resolved totally in 4 patients by 7 days. Four pneumothoraces occurred; 1 patient required bilateral chest tube placement. There were no esophageal, stomach, or splenic injuries. The average hospital stay was 1.6 days. Postop 24 h pH studies revealed resolution of the esophageal reflux. Postop manometric studies show a median increase of 9.2 mm Hg for the LES pressure. No patients have resumed antireflux medication. No short gastric vessels were divided and no esophageal sutures were placed. There were no conversions to a laparotomy. Laparoscopic posterior partial fundoplication is a safe and effective antireflux procedure.

Laparoscopic cholecystectomy (LC) has become one of the options for the treatment of acute cholecystitis as surgeons gain facility with this procedure. However, acute suppurative cholecystitis is still a severe condition, because a high mortality rate still exists. In the early years (1991 to 1992), 4 patients were operated on without a preceding percutaneous transhepatic gallbladder drainage (PTGBD) at our hospital, however, one patient died of septic shock after a laparoscopic cholecystectomy. Conversion to open surgery was performed on two patients. However, in later years (1992 to 1995), 14 patients were operated on with preceding PTGBDs safely. Here, we report the safeness and significance of the combination therapy of PTGBD and LC for patients with severe acute suppurative cholecystitis.

The use of laparoscopy in general surgery has provided surgeons with a new approach to multiple procedures. New techniques are being developed daily. Laparoscopic training for surgical residents must be incorporated into their curriculum. To decrease the risks of training residents on patients and to decrease operative time, a program of videoscopic "bench" training exercises, to improve eye-hand coordination, was instituted for junior residents. Between July and September 1995, nine surgical residents participated in this proficiency videoscopic study. At the end of the study, there was a statistically significant improvement in the residents performance by an average of 37% (P = 0.0109). This program proved to be both effective and economical. It can be reproduced and easily incorporated into any surgical residency program.