Effectiveness and long-term results of laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is a cost-effective, efficient, and minimally invasive method of treating choledocholithiasis. We reviewed the long-term results and efficacy of LCBDE for the common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Medical charts were reviewed for all patients undergoing LCBDE at St. Vincent Hospital over 11 years (1990-2001). Demographic data, clinical features, laboratory data, radiologic and operative findings, and postoperative follow-up evaluation were analyzed. RESULTS: A total of 346 LCBDE were performed during the study period. The mean operative time was 127 +/- 3 min, and the length of hospital stay averaged 2.8 +/- 0.1 days. In 8 patients (2.3%), LCBDE was converted to an open procedure. Complications were noted in 33 patients (9.5%), including patients (2.7%) with retained stones. No postoperative mortalities were recorded. No long-term strictures or biliary complications were noted over a mean follow-up period of 43 months (follow-up data available for 96%). CONCLUSION: A policy of routine cholangiography and LCBDE for CBD stones was effective in clearing the bile duct and avoiding further hepatobiliary instrumentation. The findings show that LCBDE can be performed successfully with low morbidity and mortality.

Laparoscopic adrenal surgery.

Laparoscopic adrenalectomy (LA) was performed in 6 patients (4 right and 2 left). A transperitoneal approach in a lateral position was used. Pheochromocytoma was present in two patients and Conn's syndrome, with a solitary functioning adenoma, was the diagnosis in four. Early vascular control was obtained in the two patients with pheochromocytoma, resulting in very stable intraoperative blood pressure. Operative time for LA was 152 +/- 26 min and was associated with a short length of stay (2.0 +/- 0.6 days) and minimal intraoperative blood loss (82 +/- 30 ml). There were no conversions to laparotomy and one complication was noted. LA is a safe and effective operation for patients requiring adrenalectomy for hormone-secreting tumors.

Common bile duct exploration in the era of laparoscopic surgery.

OBJECTIVE: To review the treatment and outcome of patients with common bile duct (CBD) stones who underwent cholecystectomy. DESIGN: Prospective series of 700 consecutive laparoscopic cholecystectomies, with a mean follow-up of 22 months. SETTING: University-affiliated community hospital. PATIENTS: Eighty patients with documented CBD stones during a 42-month period (July 1990 to January 1994). INTERVENTIONS: Laparoscopic CBD exploration (LCBDE) was performed with either choledochotomy and T tube (n = 27) or transcystic duct choledochoscopy (n = 33). Open CBDE (OCBDE) (n = 16) and endoscopic sphincterotomy (n = 16) were also employed. MAIN OUTCOME MEASURES: Documented removal of CBD stones and procedure-related complications. RESULTS: Laparoscopic CBDE was successful in 60 (94%) of 64 attempted cases. Mean operating time was 149 +/- 40 minutes and length of hospital stay was 2.8 +/- 2.1 days. Six complications (10%) were recorded, including three retained stones (5%). In 11 of 16 patients undergoing OCBDE, CBD stones were discovered with intraoperative cholangiography after conversion to laparotomy was needed for completion of the cholecystectomy. One OCBDE was planned in a patient with suppurative cholangitis. Preoperative endoscopic sphincterotomy (n = 11) was successful in four patients. Postoperative endoscopic sphincterotomy (n = 5) was successful in four patients. CONCLUSION: With a protocol of routine cholangiography, LCBDE, and selective use of OCBDE (when LCBDE is not possible), the reliance on a second procedure (endoscopic sphincterotomy) can be minimized. Laparoscopic CBDE, a technically demanding operation, is possible at the time of laparoscopic cholecystectomy in the majority of cases, with a low complication rate and a short length of hospital stay.

Laparoscopic cholecystectomy. A clinical and financial analysis of 280 operations.

Two hundred eighty patients underwent laparoscopic cholecystectomy (LC) and were compared with 304 patients who underwent traditional "open" cholecystectomy (OC). Laparoscopic cholecystectomy was performed electively in 72.5% of cases and urgently in 27.5% of cases. Conversion from LC to OC was required in 14 patients (5%), six of whom required common bile duct exploration. Common bile duct stones were managed with video-laparoscopic techniques in 11 patients, with percutaneous transhepatic laser lithotripsy in three patients, and with laparotomy in six patients. Hospital stay was significantly shorter and complications were significantly fewer for LC compared with OC. Hospital expenses for LC were significantly higher than for OC because of longer duration of operation and higher operating room expenses. Patients who underwent elective LC returned to work an average of 31 days earlier than patients who underwent OC (10 days vs 41 days). These data indicate that LC can be performed safely although at a higher cost than OC, and that patients as well as employers benefit from a short length of hospital stay.

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.

Regional differences in capillary density and myocyte size in the normal human heart.

Significant regional morphometric differences are reported for the normal human left ventricle. Epimyocardial capillary density (2,439 capillaries/mm2) is 21% greater than endomyocardial capillary density (2,014 capillaries/mm2). The minimum intercapillary distance is, therefore, increased in the inner region. Endocardial myocytes (617 micron2) have a 53% greater cross-sectional area than epicardial myocytes (403 micron2).