optimal technique for laparoscopic appendectomy: experience with a new approach

Classic approach for laparoscopic appendectomy has disadvantages regarding its cosmetic results and ergonomics, so new approaches were tried. In the current prospective study I discuss my experience with a suprapubic approach. From Dec.2002 to Oct. 2005, I used this approach in all patients operated upon for acute appendicitis. Patients evaluated regarding cosmetic results, and intraoperative or postoperative complications. 98 patients had been operated upon, age range 13 to 55 years, 24 were complicated appendicitis at the time of presentation, and 15 patients had previous pelvic operations. The main operative time was 40 mm., port bleeding occurred in 4 cases, port infection in 2 cases, pelvic or intraabdominal collection in 3 cases. All patients were satisfied with the cosmetic results. The suprapubic approach has better cosmetic outcome and is ergonomically superior to the classic approach. I recommend it to be the classic approach for laparoscopic appendectomy

Preliminary experience with laparoscopic total extraperitoneal inguinal hernia repair

Total extraperitoneal [TEP] laparoscopic inguinal hernia repair is preferred to the laparoscopic transabdominal preperitoneal [TAPP] repair since it is lacking the potential complications of damaging the peritoneal integrity. Therefore, it is increasingly adopted by many laparoscopic surgeons for treating inguinal hernias. Is to evaluate a preliminary experience with this approach for a surgeon whom already experienced in laparoscopic surgery and in Stoppa's approach. It is a retrospective study conducted during the period from Aug. 2002 to June 2005 in Dallah Hospital, Riyadh, and included all the patients treated with this approach for inguinal hernias. Preoperative, operative, and postoperative data for all patients reviewed. 47 hernias operated upon in 38 patients during the study period. There were 9 patients with bilateral hernia, and 6 with recurrent hernia. The mean operative time was 75 mm., conversion to open repair in 2 cases, no bleeding or internal organ injury occurred in any case. Hospital stay was 1 to 2 days, mean sick leave days were 15 days, and follow up ranges from 1 to 19 months, with a single case of recurrence. Laparoscopic TEP inguinal hernia repair has a steeper learning curve necessitates adequate previous laparoscopic experience. It may offer an attractive and feasible alternative for treatment of bilateral and recurrent inguinal hernia. However, using it routinely in treating unilateral new cases of inguinal hernia is still questionable

value of magnetic resonance cholangiopancreatography and selective use of endoscopic retrograde cholangiopancreatography in patient management prior to laparoscopic cholecystectomy

Different diagnostic modalities have been used to asses patients with cholelithiasis before laparoscopic cholecystectomy [LC] for the suspicion of choledocholithiasis. The aim of this study is to define predictive guidelines for patient management with selective use of magnetic resonance cholangio-pancreatography [MRCP] and endoscopic retrograde cholangiopancreatography [ERCP] before LC. ERCP is considered the gold standard for diagnosis and clearance of common bile duct [CBD] stones before LC. MRCP has recently developed as a noninvasive imaging modality for the detection of choledocholithiasis. However it needs further evaluation as regards its diagnostic accuracy in patient management before LC. Between October 2001 and December 2004, 128 patients [88 females, 40 males; mean age 48 [range 14-78 years] with cholelithiasis were prospectively evaluated before LC applying predictive guidelines that include patient information obtained from clinical assessment, blood chemistry tests, and abdominal ultrasonography. Patients were put into one of four groups according to the level of suspicion for choledocholithiasis [group 1, high; group 2, moderate; group 3, low; group 4, very low]. Group 1 patients underwent ERCP with or without endoscopic sphincterotomy for clearance of common bile duct stones; group 2 patients were subjected to MRCP; group 3 patients were operated on by LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. CBD stones were demonstrated in 15 [11.7%] of 128 patients. The incidence of choledocholithiasis in groups 1, 2, 3 and 4 was 83.3% [10/12], 27.3% [3/11], 7.1% [1/14], and 1.1% [1/91]. rescectively [P < 0.001]. ERCP was successfull in diagnosis and therapeutic clearance of CBD stones before LC in 91.7% [11/12] of patients. It showed a sensitivity, a specificity, and an overall accuracy of 92.3%, 100%, and 91.7% respectively. MRCP was utilized in 8.6% [11/128] of patients. It was unable to detect a CBD stone in one patient, with a sensitivity, a specificity, and an overall accuracy of 75%, 100%, and 91% respectively. lntraoperative cholangiography detected a CBD stone in one patient in group 2, and in another patient in group 3 which were extracted using postoperative ERCP. Only one patient in group 4 had a missed CBD stone which was manifested three months after operation and the patient underwent ERCP with stone clearance. It was concluded that initial evaluation using certain predictive guidelines in patients with cholelithiasis can accurately predict the probability of choledocholithiasis with selective use of MRCP which is an accurate non invasive diagnostic method and ERCP for therapeutic clearance of CBD stones before LC. Thereby improving patient care and resource utilization