Day-care laparoscopic appendectomies.

OBJECTIVE: To demonstrate the safety of laparoscopic appendectomy in a day-care setting and to compare patients selected for laparoscopic versus open appendectomy. DESIGN: A retrospective, nonrandomized study. SETTING: A community hospital in a small town in British Columbia. PATIENTS: Ninety-four consecutive patients with a clinical diagnosis of acute appendicitis. INTERVENTIONS: Each patient underwent laparoscopic or open appendectomy as selected by the operating surgeon. OUTCOME MEASURES: Duration of operation and of hospital stay, morbidity and mortality. RESULTS: The average operating time was 32 minutes for open appendectomy and 36 minutes for laparoscopic appendectomy. Two (4%) of the 52 patients who had a laparoscopic appendectomy had significant complications; 1 of them required reoperation for intra-abdominal abscess. Thirty-nine (75%) of the laparoscopic appendectomies were done as day-care procedures. The average length of stay for the remaining patients was 2.1 days. The overall complication rate for patients who underwent open appendectomy was 20%. The average length of stay for these patients was 3.2 days; no patient was discharged within 24 hours. CONCLUSIONS: Laparoscopic appendectomy can be safely performed as a day-care procedure, even for selected patients with gangrenous or perforated appendices. Patients typically selected for open appendectomy include children and those with more advanced infection.

Laparoscopic gastroenterostomy for duodenal obstruction.

BACKGROUND: It is not yet clear where laparoscopic procedures will fit into the armamentarium of the surgeon. Over the past decade, there has been a clear trend toward minimally invasive procedures for palliation of inoperable cancer. Traditionally, when duodenal obstruction occurs secondary to a disease process, gastric bypass through laparotomy is required. PATIENTS AND METHODS: Between November 13, 1992 and September 13, 1994, 10 patients underwent laparoscopic gastroenterostomy for duodenal obstruction. In 9 patients, the procedure was carried out for malignant obstruction; in 1 patient, duodenal obstruction was secondary to chronic scarring from benign peptic ulcer disease. Eight of these patients already had biliary decompression through radiologic or endoscopic means. One patient underwent laparoscopic cholecystenterostomy for biliary obstruction in addition to the laparoscopic gastroenterostomy. RESULTS: Laparoscopic gastroenterostomy was successfully completed in 8 of the 10 patients. In 2, conversion to open surgery was necessary. There was no mortality related to this operative approach. CONCLUSIONS: Laparoscopic gastroenterostomy is a safe procedure for treatment of duodenal obstruction. Good palliation can be expected in patients with obstruction of the duodenum secondary to advanced malignancies.

Laparoscopic Ileogastrostomy for Morbid Obesity.

This paper describes the technique of laparoscopic ileogastrostomy which we developed during the summer of 1993. The procedure is identical to that of our 'open' ileogastrostomy except that it is performed laparoscopically. The aim of the surgery is to increase ambulation of the patient, while reducing pain, morbidity, and the chance of apnea (due to impaired breathing in the first 24 h following conventional surgery), by carrying out surgery for the morbidly obese person through a laparoscope. This form of laparoscopic surgery may be completed within 4 h and, as our staff gains more experience with laparoscopic ileogastrostomy, we expect patient stays to be 2-3 days in length. Pulmonary function tests at 24 h show a great advantage in favor of the laparoscopic approach. Response of the medical team to this procedure was that it was more time-consuming and demanding than open surgery.

Liver Biopsies Following Ileogastrostomy.

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. One concern in patients undergoing any form of intestinal bypass surgery is that of possible liver damage. To assess for possible liver damage in morbidly obese patients undergoing ileogastrostomy, we undertook a prospective study of liver biopsies in 12 consecutive patients. Preoperative and 2-year postoperative biopsies of the liver were planned. There were six liver biopsies available for comparison both pre- and post-operatively. The biopsies showed changes of fatty infiltration both pro- and post-operatively. There were no differences in the degree of fatty infiltration, or of other histological parameters which we measured. There were no cases of cirrhosis of the liver recorded.

Sartorius myoplasty in the treatment of exposed arterial grafts.

The long-term success of sartorius myoplasty in 14 of 16 patients who presented with an exposed vascular graft in an infected groin is described. The presenting complications were wound dehiscence (ten patients), hemorrhage (two), skin erosion (two), late bilateral fistulas (one) and false aneurysm (one). Ten grafts were prosthetic and six autogenous. Positive cultures were obtained from 15 wounds; four grew Staphylococcus epidermidis, the remainder mixed or Gram-negative bacteria. Each groin was radically debrided, including the surface of the arterial graft, and, if possible, closed immediately with a sartorius myoplasty applied directly to the graft. Twist, fan and loop myoplasties were equally effective. Grossly infected wounds were debrided initially and obviously infected grafts were replaced in situ before myoplasty. Sartorius myoplasty is recommended as an elegant solution for the infected groin in which there is an exposed arterial graft.