The advantages of preview cholangiography during laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: Despite the numerous and often cited benefits of routine cholangiography during laparoscopic cholecystectomy, universal application of this technique has not been realized. Surgeons who advocate selective cholangiography cite the extra cost, the low yield of unanticipated findings, and the marked increase in the duration of the operation when cholangiography is added to laparoscopic cholecystectomy. We present our experience with preview cholangiography and compare it with the transcystic-duct approach. METHODS: We attempted preview cholangiograms on 11 consecutive patients undergoing laparoscopic cholecystectomy. Successful cholangiography was determined by using established radiologic criteria. RESULTS: Preview cholangiogram was successful in all 11 patients. No complications occurred. The average time required was 110 seconds. The mean operating time was 52 minutes. These times are far better than our best accomplishments using the cystic duct cannulation method for cholangiography (mean cholangiogram time, 22 minutes, and mean operative time, 75 minutes) following the first 100 cases. CONCLUSIONS: Preview cholangiography is a safe, relatively easy, quick method for outlining the anatomy of the extrahepatic biliary tree prior to dissection necessary to remove the gallbladder with laparoscopic techniques. The ease of this approach should result in more widespread use of cholangiography during laparoscopic cholecystectomy.

Laparoscopic-assisted abdominal aortic aneurysmectomy.

PURPOSE: The technical elements and early results of laparoscopic-assisted abdominal aortic aneurysmectomy are described. METHODS: From February 1997 to May 1999, 60 patients underwent elective laparoscopic surgery for infrarenal abdominal aortic aneurysm. Patients ranged in age from 53 to 87 years (mean age, 70.6 years). The mean aneurysm size was 5.7 cm (range, 4.4-8.0 cm). All patients underwent aortography and computed tomography scanning preoperatively. Patients were not deemed candidates for the procedure when visceral arterial abnormalities requiring surgical treatment were present or an aortic aneurysm neck shorter than 0.5 cm was found. A risk-stratification system was used as a means of quantitating risk factors and excluding high-risk patients. Aortic reconstruction was performed with retroperitoneal laparoscopy, with the patient in a modified right lateral decubitus position. An Endo TA 30 and an Endo TA 60 laparoscopic staplers (US Surgical, Norwalk, Conn) were used in occluding the common iliac arteries and aneurysm sac. Laparoscopic hemoclips were used as a means of occluding the lumbar arteries and other branches of the aneurysm sac. An aortobifemoral or aortobi-iliac bypass grafting procedure was performed by means of the laparoscope to position the graft and visualize the end-to-end aorta-to-graft anastomosis, with distal anastomoses performed through counter incisions. RESULTS: Three patients died within 30 days of surgery (mortality rate, 5.0%). Complications included left ureteral injury (1), postoperative myocardial infarction (1), ileofemoral deep venous thrombosis (1), acute renal failure (2), colon ischemia (1), and infected graft limb requiring revision (1). The mean operative time was 7.7 hours, and the mean aortic cross-clamping time was 112 minutes. Compared with a contemporary consecutive series of 100 patients undergoing open transabdominal or retroperitoneal aneurysmectomy performed by the same group of surgeons, the laparoscopic patients had decreased length of stays in the intensive care unit and the hospital, with less need for ventilator support, earlier resumption of a regular diet, and an earlier return to normal activity. At the follow-up examinations, all bypass grafts were patent. CONCLUSION: Laparoscopic-assisted aneurysmectomy is safe and effective and can be performed with good results. The longer operation time required is well tolerated in patients who are at good and moderate risk. Prior training in laparoscopic aortic surgery is necessary for surgeons to obtain the required level of expertise needed to perform these procedures. With these caveats, the results of our study suggest that laparoscopic-assisted aortic aneurysmectomy is appropriate for moderate-to-good risk (American Society of Anesthesiologists class of III or lower) operative candidates meeting standard criteria for aneurysm resection in whom preoperative computed tomography scan and biplane arteriography demonstrate a proximal aneurysm neck of 0.5 cm or larger and no need for visceral or internal iliac artery reconstruction. A randomized trial would be required to confirm the benefits of this procedure over open aneurysmectomy.

Laparoscopic aortic aneurysm resection.

PURPOSE: To describe a laparoscopic technique for resection of infrarenal abdominal aortic aneurysms (AAAs). METHODS: The operation is based on the principle of retroperitoneal reinforced staple exclusion of the aneurysm sac with aortobifemoral or aortoiliac bypass using gas and gasless laparoscopic techniques. Patients were eligible for this procedure if their infrarenal AAAs (with or without iliac artery involvement) were considered appropriate for surgical resection; however, renal or other visceral arterial stenoses, aneurysmal disease requiring surgical treatment, and/or aneurysms of the hypogastric arteries excluded patients from laparoscopic AAA resection. RESULTS: Of 31 candidates for this procedure, 9 were excluded owing to high surgical risk. Twenty-two patients (16 males; age range 62 to 88 years) were deemed appropriate for the laparoscopic procedure. Maximum aneurysm diameter ranged from 4.0 to 8.0 cm. The operation was completed successfully in 20 (91%) patients. Two (9%) deaths in high-risk patients admitted early to the study occurred within 30 days of surgery. The only major complication was an injured ureter, for which a nephrectomy was performed. Comparison to a historical cohort of conventionally treated patients showed that the study group needed less ventilator support, had shorter intensive care and hospital stays, and resumed diet earlier despite relatively prolonged anesthesia and aortic clamping times. CONCLUSIONS: The laparoscopic approach to infrarenal AAAs appears feasible, with several potential advantages in low- and moderate-risk patients. Once the technique is optimized, randomized prospective studies will be needed to verify the apparent benefits demonstrated by these initial patients.

Laparoscopic surgery for abdominal aortic aneurysms. Technical elements of the procedure and a preliminary report of the first 22 patients.

BACKGROUND: Laparoscopic surgery for infrarenal aortic aneurysms is based on the principle of retropertoneal exclusion of the aneurysms sac with aortofemoral or aortoiliac bypass. METHODS: Of 22 patients who met the selection criteria, 20 successfully underwent laparoscopic aortic surgery at Morristown Memorial Hospital between February and October 1997. Technical elements and steps of this operation are described and illustrated. RESULTS: Within 30 days of surgery, 2 patients died and 9 had various major and minor perioperative complications. As a group, the laparoscopic patients had less postoperative pain, needed fewer hours of ventilator support, had shorter intensive care unit (ICU) and hospital lengths of stay, and resumed diet and normal activity earlier than the historical norms of patients undergoing transabdominal or retroperitoneal aortic resections at the same institution. CONCLUSIONS: These early observations suggest that the laparoscopic treatment of infrarenal abdominal aneurysms may have several significant potential benefits. Long-term results and randomized prospective studies with patients matched by risk stratification will be needed to confirm these impressions.

Laparoscopic fundoplication and the aberrant left hepatic artery.

The aberrant left hepatic artery is a frequently encountered anomaly found during laparoscopic fundoplication. The incidence of this anomaly in textbooks of surgery and anatomy is often cited as 25%. However, in our experience it occurs in only 6.5% of patients; preponderantly in females. The presence of an aberrant left hepatic artery complicates the dissection at the esophageal hiatus. This artery should be identified and isolated without being injured or divided. As documented in our series, the operation can be safely completed leaving this artery intact.

Laparoscopic repair of paraesophageal hernia.

OBJECTIVE: The purpose of this report is to describe the authors' technique for the laparoscopic repair of paraesophageal hernias and the outcome in their series of patients. METHODS: Thirty patients underwent elective laparoscopic repair of paraesophageal hernias. All were pure type II paraesophageal hernias as defined by upper gastrointestinal contrast studies. All operations were performed by a single surgeon (JKE) assisted by five different chief surgical residents. The authors have used various prototypes of a laparoscopic utility belt to reduce the physician requirement to the surgeon and a first assistant. The operative setup and specific techniques of the repair are described and illustrated. A concomitant anti-reflux procedure was performed in the last 23 patients. RESULTS: Satisfactory repair using video-laparoscopic techniques was achieved in all cases. There were no deaths. Complications occurred in 8 of 30 patients. Postoperative gastroesophageal reflux developed in three of the first seven patients in whom fundoplication was not performed. Three consecutive patients had left lower lobe atelectasis believed to be related to endotracheal tube displacement during the passage of the bougie. One patient had postoperative dysphagia. There was one case of major deep venous thrombosis with pulmonary embolism. Twenty-eight of 30 patients were discharged home by postoperative day 3. Twenty-four of 30 patients had returned to normal activity by the time of their first postoperative office visit 1 week after surgery.

Technical elements of successful laparoscopic cholangiography as defined by radiographic criteria.

OBJECTIVE: To define the elements of successful laparoscopic cholangiography. DESIGN: Retrospective review of 130 consecutive patients who underwent laparoscopic cholangiography. SETTING: Community hospital with a surgical residency. PATIENTS: Thirty-four males and 96 females, aged 16 to 86 years, with acute and chronic cholecystitis. INTERVENTION: Laparoscopic cholecystectomy during intraoperative cholangiography. MAIN OUTCOME MEASURE: A cholangiogram that satisfactorily delineates biliary anatomy as defined by accepted radiologic criteria. RESULTS: A successful laparoscopic cholangiogram was obtained in 98.5% of the study group. CONCLUSION: A safe and reliable technique to obtain a laparoscopic cholangiogram is described and validated using accepted radiologic criteria.

Ventilatory impairment during laparoscopic cholecystectomy in a patient with a ventriculoperitoneal shunt.

A patient with a recently placed ventriculoperitoneal shunt suffered ventilatory impairment due to decreased thoracic compliance related to massive subcutaneous emphysema during laparoscopic cholecystectomy. The patient recovered uneventfully; however, recently established closed communication between the peritoneal cavity and the subcutaneous space may be a relative contraindication to laparoscopic surgery.

Failure of conservative management of splenic rupture in a patient with mononucleosis.

"Conservative" management of splenic rupture in patients with mononucleosis has not been adequately evaluated because of its infrequent occurrence. Splenic rupture can be lethal in this setting and is the most common cause of death from mononucleosis. We report a case of spontaneous splenic rupture in a young girl with mononucleosis. The initial management was nonoperative but because of recurrent pain and rebleeding, a splenectomy was later performed. We do not recommend observation of splenic rupture in patients with mononucleosis because of the danger of delayed hemorrhage.

An improved double-lumen biliary catheter for cholangiography.

A double-lumen biliary catheter was developed to aid in the performance of cholangiography and bile duct stone extraction. A prototype catheter was used in four cadavers. Excellent cholangiograms were obtained and a cryoprecipitate coagulum easily formed in the bile ducts without waste. Extraction of the coagulum from the bile ducts was aided by use of the catheter. The catheter also can aid in routine balloon catheter bile duct stone extraction, and thus is useful for both diagnosis and treatment of bile duct stones.

Paradoxical embolism to the superior mesenteric artery.

Paradoxical embolism occurs when venous thrombi embolize into the systemic arterial circulation by passage of clots through an intracardiac septal defect. This paper describes a case of paradoxical embolism to the superior mesenteric artery in a patient with recent myocardial infarction and pulmonary embolism. This phenomenon was first described in 1877 (Cohnheim, 1877) and many case reports have followed but most of these have been autopsy findings. We emphasize that this diagnosis should be suspected in all patients who suffer systemic arterial emboli without any evidence of left heart origin and/or in association with pulmonary emboli. One author has reviewed 19 cases since 1930, most of which were reported in the past 15 years (Johnson, 1951). This probably reflects an increased awareness of the diagnosis and more sophisticated diagnostic modalities. It also raises the possibility that paradoxical embolism may be more common than originally believed.

Peripheral migration of pacemaker electrodes.

A 55-year-old male was admitted with right ileo-femoral phlebitis caused by an unused pacemaker electrode fragment which had migrated from the right subclavian vein to the right iliac vein. Vena cava plication was followed by removal of the electrode fragment and complete resolution of the phlebitis. The exposed metal coil may have contributed to the severe inflammatory reaction.

Inhibition of programmable demand pacemaker by pacemaker-induced myopotentials.

Pacemaker-induced myopotentials caused inhibition of a demand pacemaker in two cases in which the unipolar partially encapsulated pacemaker flipped over in its pocket and directly stimulated the muscles of the chest wall. This pacemaker-induced muscular stimulation, possibly combined with afterpotential sensing or T-wave sensing (or both), caused the rate of the demand pacemaker to fall when the output of the programmable pacemaker was set to deliver high energy charges. By programming the unit to deliver a lower charge (shorter width of pulse), the rate rose appropriately to the programmed rate. Likewise, manual rotation of the unipolar pacemaker into proper orientation with the active uninsulated surface directed towards the skin also solved the problem temporarily.

Avoiding renal vein entry when implanting the Mobin-Uddin vena cava umbrella filter.

Transvenous placement of a Mobin-Uddin vena cava umbrella filter is a safe and effective method of vena cava interruption in high-risk patients who cannot undergo laparotomy. When the renal veins enter the vena cava acutely, there may be preferential passage of the filter insertion device into the aberrant renal veins. If the usual maneuvers of changing the patient's position do not correct this aberrant passage, then a venous thrombectomy catheter may be used to temporarily occlude the vein orifice. This technique avoids the problems of incorrect placement and abandonment of the transvenous approach to vena cava interruption.

Pitfalls in measuring R waves in pacemaker-dependent patients.

Determination of adequate R wave sensing is an important step in pacemaker electrode implantation and pacemaker replacement operations. In patients who are completely pacemaker dependent, these operations are usually performed with a functional temporary pacemaker in place throughout the testing period. In such patients, there is the special problem of determining whether the test system is sensing the temporary pacemaker spike rather than the resultant QRS voltage. Patients were studied and a laboratory model was created to evaluate the response characteristics of a standard R wave test device. Patients showed two general types of curves as R waves were measured at various output voltages of the temporary pacemaker. Type A responses showed direct correlation between output voltage and measured R waves. Type B responses showed an initial high plateau of R waves followed by an abrupt fall below acceptable values, and then a direct correlation between R waves and output voltage. Laboratory testing revealed that the temporary pacemaker spike, and not the R wave, was being "sensed" in Type A curves, and that the R wave was sensed only in the initial plateau of the Type B curves. This pitfall can lead to acceptance of an unsatisfactory electode position in some patients and to futile electrode repositioning in others.