Laparoscopic adrenalectomy - a review of initial 24 consecutive patients.

AIM: To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department. METHODS: Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25-68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The clinical and intraoperative characteristics, complications and outcomes of all patients were analyzed. RESULTS: The mean operative time for laparoscopic adrenalectomy was 136 minutes. Intraoperative hypertension occurred in 8 patients. Intraoperative hypotension occurred in 2 patients. One patient required conversion due to dense adhesions and hemorrhage. Postoperative complications were seen in six patients - immediate postoperative hypotension (2 patients), features of steroid withdrawal (2 patients) and postoperative pyrexia (2 patients). Five patients with pheochromocytoma required antihypertensive drugs in the postoperative period. There was no mortality in our series. CONCLUSIONS: Laparoscopic adrenalectomy is a safe operation that incorporates all the benefits of minimal access surgery and is associated with a satisfactory postoperative outcome. A careful preoperative preparation in functioning adrenal tumours aids in the faster recovery of these patients.

Laparoscopic repair of diaphragmatic hernias: experience of six cases.

OBJECTIVE: Laparoscopic diaphragmatic hernia repair is increasingly performed in adults for congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias. This study reviewed our experience with laparoscopic diaphragmatic hernia repair to evaluate its safety, efficacy and outcomes. METHODS: Between January 1999 and December 2002, four male and two female patients presented to us with diaphragmatic hernias, three with traumatic and three with congenital hernias. The mean age of patients was 58.6 years (range, 42-83 years). Five patients presented with main complaints of postprandial retrosternal/chest discomfort and one patient had an acute gastric outlet obstruction. Dissection was performed laparoscopically to reduce the contents of the sac and the hernial defect was repaired using prolene sutures and a polypropylene mesh. RESULTS: Laparoscopic repair of diaphragmatic hernias was completed successfully in all patients. The mean size of the defect was 6.8 cm (range, 3-12 cm) and the mean operative time was 100 minutes (range, 60-150 minutes). There were no major intraoperative complications. One patient required placement of a chest tube due to inadvertent opening of the pleura with the hernial sac and one patient had prolonged postoperative gastric ileus. The mean hospital stay was 2.3 days (range, 1-4 days) and the mean pain score was 4 (range, 2-6). All patients remained asymptomatic over a mean follow-up of 2.9 years. CONCLUSION: Adult congenital and chronic traumatic diaphragmatic hernias are amenable to laparoscopic repair. Laparoscopic repair is safe and feasible and confers all the advantages of minimal access surgery.

Endoscopic management of a retroperitoneal hydatid cyst.

Hydatid cyst is a significant health problem in endemic regions. Although progress has been made in medical treatment and interventional radiology techniques, surgery is currently the treatment of choice. The hydatid cysts are known to occur at several unusual sites in the body. With increasing experience in laparoscopy and retroperitoneoscopy, attempts have been made to offer the advantages of minimal access procedures to hydatid disease patients. We present a case report of such a patient whose retroperitoneal hydatid cyst was removed endoscopically.

Ectopic gallbladder: laparoscopic cholecystectomy.

An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.

Endoscopic totally extraperitoneal repair for occult bilateral obturator hernias and multiple groin hernias.

INTRODUCTION: An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. METHODS: A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. RESULTS: The patient was discharged the next day and is symptom-free on followup at eight months. CONCLUSION: Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.

Combined procedures in laparoscopic surgery.

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30-280 minutes). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1-21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.