Geometry and reproducibility in 360 degrees fundoplication.

BACKGROUND: In this study, we set out to precisely define two symmetrical points-a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or "floppy") 360 degrees fundoplication (FP). METHODS: For the terms of this study, circumference = c; diameter = d; c/d = pi; pi = 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n = 5) and intraoperatively (n = 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. RESULTS: The smallest measured value for c was 7.5 cm (d = 2.39 cm); the largest value for c was 10.0 cm (d = 3.18 cm). The mean value was 8.35 cm (d = 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d = 2.66 cm. This technique creates a correctly oriented, symmetrical, "floppy," true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. CONCLUSIONS: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a "floppy" 360 degrees fundoplication.

Mini-laparoscopic cholecystectomy: validating a new approach.

Advances in instrumentation have led to the development of 2-mm laparoscopic equipment. The purpose of our investigation was to validate the safety and efficacy of laparoscopic cholecystectomy (LC) using one 10-mm and three 2-mm ports (mini-LC). Mini-LC was performed using a 2-mm fiberoptic videolaparoscope inserted via a midepigastric port, 2-mm graspers inserted via right upper quadrant ports, and standard dissection, clipping, and cautery instruments inserted via the umbilical port. Data from 100 sequential patients were acquired between July 1996 and August 1997 and compared with those of 100 sequential patients who had undergone conventional LC (C-LC). The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group, with means of 89 and 82 minutes, respectively (P > 0.05). Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group, with means of 1.5 and 1.9 days, respectively (P > 0.05). There were no conversions to open cholecystectomy. These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively.

Thoracoscopic repair of a recurrent diaphragmatic hernia four years after initial trauma, laparotomy, and repair.

Traumatic diaphragmatic hernia is not an uncommon problem and has been noted after either penetrating or blunt trauma. A high index of suspicion must be maintained in order to identify patients with this injury, as delay in identification may result in significant morbidity and death. It is essential that a thorough evaluation be performed, and if a diaphragmatic hernia is found, surgical repair is necessary. We present a case of thoracoscopic repair of an incarcerated recurrent diaphragmatic hernia appearing several years after successful open (via laparotomy) repair of an acute blunt traumatic hernia. A brief review of the surgical literature is also presented. With the broadening use of minimally invasive surgical techniques, we feel that their application to the repair of chronic diaphragmatic hernia is safe and effective, reduces morbidity, and results in a faster recovery.

Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases.

A new technique utilizing miniaturized (2 mm) instrumentation to perform laparoscopic cholecystectomy (LC) is introduced. The safety and efficacy of this mini-LC were assessed. Fifty consecutive mini-LCs were performed using one 10-mm port and three 2-mm ports (cumulative port size 16 mm). A 2-mm fiberoptic video-laparoscope was placed in the mid-epigastrium through a 2-mm port. A 10-mm umbilical port was then placed under direct visualization, allowing access for standard laparoscopic instruments. Two additional 2-mm ports were placed in the right upper quadrant allowing insertion of grasping instruments. Parameters reviewed included total operative time (OT), postoperative length of stay (LOS), anatomic pathology, complications, and rate of conversion to conventional LC and open cholecystectomy. Results were compared to those of 50 consecutive conventional LCs using two 10-mm and two 5-mm ports (cumulative port size 30 mm). The OT for the mini-LC and conventional LC were 88 +/- 5.9 and 78 +/- 5 minutes (mean +/- SD), respectively, (p = NS), and postoperative LOS for the mini-LC and conventional LC were 1.5 +/- 0. 2 and 1.8 +/- 0.4 days (mean +/- SD), respectively, (p = NS). Of the 50 mini-LC cases, 5 required conversion to conventional LC. One cystic duct leak was detected and successfully treated conservatively; no common bile duct injuries occurred; and no patients required conversion to open cholecystectomy. This study demonstrates the safety and efficacy of minilaparoscopic instruments for the performance of cholecystectomy. The data reveal that this new technique is comparable to conventional LC.