A Clinical Review of Laparoscopic Cholecystectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: Laparoscopic cholecystectomy (LC) was performed by Mouret in 1987 and has rapidly and radically changed the surgical treatment of gallbladder (GB) disease. The purpose of this study is to clinical and historical review of LC in the Chonbuk National University Hospital. METHODS: We reviewed 1048 patients of LC between September of 1990 to April of 2000, retrospectively by clinical record. RESULTS: The age range of the patients was from 17 to 84 years(mean: 50.3). The associated diseases were hypertension and diabetes mellitus with each 56 cases, hepatitis with 22 cases, and bronchial asthma with 10 cases in order of frequency. 98 of 1048 patients had undergone previous abdominal operation. The most frequent previous abdominal opeartions were appendectomy with 56 cases, transabdominal hysterectomy with 14 cases and Cesarean section with 13 cases in order of frequency. Urinary catheters and Nasogastric tubes have not been used as a preoperative routine preparation since May 1995. Upto 1997, we preferred 4-trocar procedure to 3-trocar procedure(628/35 cases), thereafter the proportion was reversed(48/296 cases). The mean operative time was 51.6 minutes which varied between 15 minutes to 290 minutes. Up to 1996, we preferred to use a silastic drain in the Morison's pouch (465 cases of 580 cases), thereafter postoperative drains were used in selected cases(133 cases among 468 cases). The length of hospital stay ranged from 1 day to 54 days with an average of 5.2 days. The mean time gap to first oral intake was 1.1 days. Postoperative complications were occurred in 32 patients(3.1%). 12 patients among those were explored - bile leakage: 11 cases, bleeding: 1 case, the remainders were recovered by conservative treatment. A conversion to open cholecystectomy was done in 19 patiens(1.8%) during the operation and the causes of conversion were severe fibrotic adhesion due to inflammation with 8 patients, bleeding with 4 cases and previous operation with 13 cases. Pathological findings of the specimen revealed chronic cholecystitis(786 cases), cholesterolosis(52 cases), acute cholecystitis(27 cases), GB polyp(39 cases), GB cancer(26 cases), xanthogranulomatous cholecystitis(25 cases). CONCLUSION: Operative laparoscopy has advanced surprisingly in the last 10 years. LC is increasingly used in clinical surgery because of significantly faster convalescence than occurs with open surgery. These advances have been facilitated not only by optimal use of laparoscopic instruments but also by discarding unnecessary conventional procedures such as nasogastric and urinary indwelling catheterization. One of the important task in surgical education is to teach the optimal application of instruments to facilitate the conduct of an operation. In the era of minimally invasive surgery, minimal application of instruments such as less use of trocars in appropriate sites and developing more convenient instruments and measuring the technical proficiency during laparoscopic surgery are equally important issues.

Clinical Experiences of the Splanchnic Artery Aneurysms

Aneurysm of the splanchnic arteries are an uncommon form of vascular disease that have a significant potential for rupture or erosion into an adjacent viscera, resulting in life-threatening hemorrhage. Nearly 22% of these aneurysms present as surgical emergencies, including 8.5% that result in death. The major splanchnic vessels affected, in descending order of frequency, include the splenic(60%), hepatic(20%), superior mesenteric, celiac, gastric and gastroepiploic, jejunal-ileal-colic, pancreaticoduodenal and pancreatic, gastroduodenal arteries. Although in most instances these aneurysms are asymptomatic, their propensity for catastrophic exsanguinating rupture has long been recognized. Surgical and nonsurgical intervention has paralleled advances in angiography and vascular surgical technique. Currently, the increased use of percutaneous catheter-based therapy in the management of that disease. We report our experiences with surgical intervention and transcatheter arterial embolization(TAE) in 7 patients with splanchnic artery aneurysms. These consisted of 2 splenic, 3 hepatic, and 2 gastroduodenal artery aneurysms. Two splenic artery aneurysm patients were treated surgically with ligation of the proximal and distal aneurysm and splenectomy; one died of a ruptured splenic artery aneurysm before surgery was initiated and another was no further treatment. Other 5 patients were treated by TAE; no complications and no further treatments during follow-up. TAE is a safe and highly successful technique for the effective identification and treatment of splanchnic artery aneurysm.