Laparoscopic transperitoneal lumbar sympathectomy: a new approach.

A report of five sympathectomies for the treatment of vasospastic symptoms of coldness, rest pain and trophic lesions at the affected feet. Three patients had a right-sided sympathectomy done and the other two had left-sided done via laparoscopic surgery. This report has advocated original techniques: Under general anesthesia, a patient is put into a lateral position with the table broken between the ribs and iliac crest. The telescope port is inserted horizontally at the edge of the rectus sheath in line with the umbilicus. Two secondary ports (5 mm, 10 mm) are inserted under direct vision in the midclavicular line. The peritoneal reflection lateral to the colon is incised down to the pelvic brim. The use of the lateral position facilitates medial displacement of the colon and the kidney by virtue of gravity. The L2, L3, L4 sympathetic ganglia are then doubly clipped and divided between clips. When such a small piece of the sympathetic trunk has been removed, a laparoscopic transperitoneal lumbar sympathectomy should be a very reasonable, safe, minimally invasive alternative to the traditional operation.

Recent approach for common bile duct stone.

One hundred and thirty-nine patients underwent cholecystectomy from 1992 through 1994. Twenty-seven patients demonstrated preoperative risk factors for common bile duct (CBD) stones and underwent endoscopic retrograde cholangiopancreatography (ERCP). ERCPs were successful in 25 (92.6%) patients and there were two failures, due to pyloric obstruction and duodenal diverticulum. Of 25 patients suspected of harboring CBD stones, 48 per cent had bile duct stones on preoperative ERCP. In contrast, 3 of 112 patients (2.7%) thought not to have stones indeed had choledocholithiasis. Laparoscopic cholecystectomies (LC) were performed on 19 (76%) of 25 patients. Of these 19, 13 (68%) had negative ERCP, 5 (26.3%) had stones removed by endoscopic sphincterotomy (ES), and only one was accomplished with laparoscopic choledochoduodenostomy. Open exploration of CBD was performed on 3 patients who had complex CBD stones and bilio-enteric bypasses in 2 patients who had multiple impacted stones in the left main duct. Overall, three endoscopic failures (2 ERCPs and 1 ES) were managed by open biliary surgery. We suggest that patients with complex CBD stones who are not successful in stone extraction via ES should undergo open CBD surgery. LC following successful ES has been accepted as the gold standard for the treatment of simple CBD stones.

Totally extraperitoneal laparoscopic lumbar sympathectomy: an initial case report.

A 27-year-old man with a diagnosis of Buerger's disease presented with vasospastic symptoms of coldness and pain at rest of his right foot. Physical examination of his affected limb revealed absent popliteal pulse, cool skin hyperhidrosis and dry gangrene of the big toe. He had been operated on for a ruptured liver and liver abscess 20 years ago. He was scheduled for totally extraperitoneal laparoscopic lumbar sympathectomy on July 26, 1994. The technique was performed under general anesthesia and the patient was put in a supine position with slight extension between the rib and the iliac crest. The working space was created by digital blunt dissection and direct insufflation of carbon dioxide. The right sympathetic trunk was found between the medial edge of the psoas muscle and inferior vena cava. The L2, L3, L4 sympathetic ganglia were identified above the vertebral column and meticulously dissected cephalocaudally. Based on the concept of traditional approach, we believe that this laparoscopic technique is relatively safe and should become the procedure of choice in the future.