Technique and early results of videoscopic lumbar sympathectomy.

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

Comparative study of the holding strength of slipknots using absorbable and nonabsorbable ligature materials.

The holding and tensile characteristics of five extracorporeal slipknots in relation to absorbable and nonabsorbable ligature materials have been evaluated in a standardized in vitro test rig. The knots studied: Tayside, Roeder, Melzer (modified Roeder), Cross square, and Blood knots were tied with the following materials: silk, polyamide, Dacron, polydioxanone (PDS), and lactomer (Polysorb). Following construction and slippage (run down) to a fixed-diameter loop around a cylinder, the knots were locked (tightened) using a standardized force after which they were removed from the test rig and subjected to holding strength (force required to induce reverse slippage) and other tensile characteristics (stress, strain, elasticity) by a tensiometer. Analysis of the data has demonstrated the following: (1) The safest slip knots (resist slippage) are the Tayside, Melzer, and Roeder knots tied with lactomer and Dacron. (2) The holding strengths of the Cross square and Blood knots are weak with all ligature materials tested. (3) Polydioxanone is a safe ligature material for the Melzer and Tayside but not the Roeder knot. (4) Extracorporeal slipknots tied with silk and polyamide are less secure than the equivalent knots tied with Dacron, lactomer, and polydioxanone.

Diagnostic yield and management benefit of laparoscopy: a prospective audit.

A prospective audit of the diagnostic yield and management benefit of laparoscopy was undertaken in 220 consecutive patients. The procedure was performed electively in 180 patients and as an emergency in 40. The indications for laparoscopy in the elective group were suspected hepatic disease, staging of intra-abdominal malignancy, diagnostic problems, and chronic abdominal pain. Emergency laparoscopy was performed in patients admitted with acute abdominal pain. Diagnostic benefit varied with the indication for the procedure: liver disease 71%, tumour staging 87%, uncertain diagnosis 74%, acute abdominal pain 100%, and chronic abdominal pain 41%. Clinical management was significantly influenced by laparoscopy in 15 of 21 (71%) patients with liver disease, 10 of 30 (33%) with intra-abdominal malignancy, 5 of 19 (26%) with uncertain diagnosis, 32 of 40 (80%) with acute abdominal pain, and 15 of 110 (23%) patients with chronic abdominal pain. A wrong assessment of the nature or stage of the disease was made by laparoscopy in 3 of 220 (1.0%). There was no morbidity or mortality attributed to laparoscopy in the study.

Interleukin-6 and coagulation-fibrinolysis fluctuations after laparoscopic and conventional cholecystectomy.

This study assesses quantitatively the fluctuations of interleukin-6 (IL-6) and coagulation-fibrinolysis proteins in patients undergoing elective laparoscopic (n = 14) and conventional (n = 10) cholecystectomy. The patients in both groups were comparable in age and sex. Serum levels of interleukin-6, and plasma levels of fibrinogen, von Willebrand factor-antigen, tissue-type plasminogen activator-antigen, and plasminogen activator inhibitor-1 were determined for up to 48 h postoperatively. The postoperative changes of all parameters tested were comparable in both patient groups with a trend toward a higher interleukin-6 response at 8 h postincision (NS) and a trend toward a higher fibrinolysis inhibition (NS) after conventional cholecystectomy.

Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse.

Five women aged 64-81 years with complete rectal prolapse and incontinence were treated by laparoscopic mobilization of the rectum and posterior fixation to the presacral fascia using Marlex mesh. Mobilization was carried out with standard straight laparoscopic instruments in the first two patients (operating times 3.5 and 4.5 h) and with coaxial curved instruments and ultrasonic dissection in the succeeding three (operating times 2.5, 2.0 and 2.5 h). Restoration to full continence (grade 1) was observed in two patients and to grade 2 in a further two. No recurrence of the prolapse occurred during follow-up of 4-27 months.

Outcome after cholecystectomy for symptomatic gall stone disease and effect of surgical access: laparoscopic v open approach.

The pre and postoperative symptoms and outcome after surgery in patients with symptomatic gall stone disease were evaluated by a detailed self administered postal questionnaire. The survey was conducted in two groups: 80 patients treated by laparoscopic cholecystectomy and an age matched cohort of patients who had conventional open cholecystectomy. The overall response rate on which the data were calculated was 76%. Symptomatic benefit ratios accruing from the surgical removal of the gall bladder were calculated. The symptoms that were relieved by cholecystectomy were nausea (0.98), vomiting (0.91), colicky abdominal pain (0.81), and backpain (0.76). Flatulence, fat intolerance, and nagging abdominal pain were unaffected as shown by a benefit ratio of 0.5 or less. Relief of heartburn (39/49) outweighed the de novo development of this symptom after cholecystectomy (7/49), resulting in a benefit ratio of 0.65. Postcholecystectomy diarrhoea occurred in 21/118 patients (18%): 10 after open cholecystectomy and 11 after laparoscopic cholecystectomy. The type of surgical access did not influence the symptomatic outcome but had a significant bearing on the time to return to work or full activity after surgery (laparoscopic cholecystectomy two weeks, open cholecystectomy eight weeks, p = 0.00001). In the elderly age group (> 60 years), significantly more patients (29/30) regained full activity after laparoscopic cholecystectomy when compared with the open cholecystectomy group (16/22), p = 0.001. The patient appreciation of a satisfactory cosmetic result was 72% in the open group compared with 100% of patients who were treated by laparoscopic cholecystectomy (p = 0.0017). Despite the persistence or de novo occurrence of symptoms, 111/117 patients (95%) considered that they had obtained overall symptomatic improvement by their surgical treatment and 110/118 (93%) were pleased with the end result regardless of the access used.

Endoscopic ultrasonic dissection for thoracoscopic and laparoscopic surgery.

A specifically designed handpiece has been developed for ultrasonic dissection of tissues and organs during minimal-access surgery. The experimental prototype has been evaluated in major endoscopic operations on the esophagus, colon, and rectum (n = 19). The benefits documented by this initial experience include increased dissection efficiency of extensive fibroareolar attachments, safe exposure of major vascular pedicles (especially those located in mesocolic fat), greatly reduced risk of major hemorrhage, and decreased operating time.

Localization of insulinoma by laparoscopic infragastric inspection of the pancreas and contact ultrasonography.

A new technique for localizing pancreatic insulinoma is described. This consists of a laparoscopic examination of the body and tail of the pancreas through an infragastric approach combined with contact ultrasonography of the gland. Accurate localization of an occult insulinoma in the body of the pancreas was achieved in one patient with the technique described. Laparoscopic contact ultrasonography of the pancreas by the infragastric approach should be as reliable as open intraoperative ultrasonography and constitutes the first step in the laparoscopic treatment of insulinoma.

Abdominal wall lift. Low-pressure pneumoperitoneum laparoscopic surgery.

A method of abdominal wall lift has been developed and evaluated clinically in this unit during the past 18 months. It permits the conduct of laparoscopic procedures at an intraabdominal pressure of 6-8 mm Hg. The technique was introduced for laparoscopic surgery in patients with preexisting cardiac disease and chronic bronchitis. The procedure, by lifting both the abdominal wall and the falciform ligament together, also elevates the central portion of the liver (segments 3-5), thereby improving the surgical exposure. For this reason it is now also used in fit patients with ptotic livers or hypertrophied quadrate lobes undergoing laparoscopic cholecystectomy and common bile duct exploration, and to facilitate left subhepatic exposure in patients during laparoscopic antireflux surgery and vagotomy.

Carcinoid tumours of the appendix. Case-report and review of the literature.

The authors describe two cases of carcinoid of the appendix. The review of the literature showed there is still discussion about the pathogenesis of this rare condition. About the treatment there is less controversy.