Laparolithic cholecystectomy: laboratory data and first clinical case.

A method of laparoscopic cholecystectomy is described. After control of the cystic duct and artery, gallstones are emulsified with a laparoscopic lithotriptor and the debris aspirated from the gallbladder. The free wall of the gallbladder is excised and the remaining gallbladder mucosa ablated with holmium:yttrium-aluminum-garnet (Ho:YAG) laser. This technique eliminates the need for dissection of the gallbladder from the liver, thereby reducing the possibility of hemorrhage from the gallbladder fossa. At the same time stones and bile are aspirated so that the excised portion of gallbladder can be easily removed through an access port without spillage of contaminated bilious debris into the abdominal cavity or puncture wound that could cause infection. Acute and chronic animal studies confirm the feasibility of this technique. A clinical case is described.

An experimental technique of laparoscopic bowel resection and reanastomosis.

With the development of laparoscopic cholecystectomy, surgeons have been stimulated to develop techniques that allow many open surgical procedures to be performed laparoscopically. Appendectomy, hernia repair, and vagotomy have already been introduced clinically. Laparoscopic bowel resection, however, is somewhat more complicated. Bowel transection, mass tissue removal, and reanastomosis in the proper geometric fashion are critical to the success of this type of operation. The introduction of the Endo-GIA stapler (United States Surgical Corp., Norwalk, CT) will make this procedure feasible on a large-scale basis. The major problem with bowel resection is not transection or tissue removal, but, rather, reanastomosis. With intracorporeal anastomosis, manipulation of the bowel with proper orientation becomes difficult. This is less of a problem when performing low-anterior resection, however, because one of the bowel limbs is fixed. The purpose of this study was to develop a technique in the laboratory that would ensure proper orientation of the two bowel limbs, with minimal manipulation prior to performance of the anastomosis. The technique that we developed and describe herein does not require manual orientation during anastomosis. Improper bowel alignment with kinking and twisting is thereby avoided. The technique appears to be useful for small- and large-bowel resections, but not for low-anterior resection. For this technique to become a reality clinically, longer endoscopic staplers with taller staple height will be required.

Experimental transperitoneal laparoscopic pyloroplasty.

Interest in laparoscopic abdominal surgery continues to grow, which has persuaded a number of centers to pursue actively laparoscopic techniques that will allow surgeons to perform additional operative procedures in a less invasive manner. Peptic ulcer surgery, because of the morbidity associated with gastric surgery as well as the pain and discomfort associated with any major abdominal operation, has been largely replaced by pharmacologic therapy. As a result, patients are often advised to continue drug therapy indefinitely. This form of therapy, however, often only partially relieves the symptoms associated with peptic ulcer disease and leaves the patient at risk to develop life-threatening complications such as bleeding and perforation. Therefore, the rapid advances occurring in the field of laparoscopic surgery provide a fertile area for the development of simple, safe, and effective procedures to treat peptic ulcer disease in selected patients. A variety of different peptic ulcer operations have already been successfully performed under laparoscopic guidance. This report describes an experimental technique of transperitoneal stapled laparoscopic pyloroplasty using a modified end-to-end anastomotic stapling device (EEA Stapler; United States Surgical Corporation, Norwalk, CT, U.S.A.). The feasibility of this procedure was documented by detailed histologic evaluation of the pyloroplasty and revealed that the pyloric musculature had been excised, resulting in a true gastroduodenostomy. Pyloroplasty, coupled with either transabdominal or transthoracic vagotomy, could be a simple alternative to more extensive open abdominal surgery. This procedure represents one additional step in providing the practicing surgeon with the ability to perform a variety of different ulcer operations in a minimally invasive (laparoscopic) fashion.

Complications of laparoscopic cholecystectomy: a prospective review of an initial 100 consecutive cases.

In order to identify problems in concept or technique with laparoscopic cholecystectomy, a prospective analysis of the initial consecutive 100 procedures was accomplished. Ongoing review of the results led to modifications in order to improve operative outcome. Minor complications such as nausea for more than 12 h (20%) and right shoulder pain (29%) were self-limiting. There were no deaths, two bile duct injuries, two abscesses, two retained common duct stones, and one case requiring transfusion, totaling a 7% major complication rate. In the subsequent 200 laparoscopic cholecystectomies, there was a 1.5% rate of major complications. Specific measures and modifications in technique that account for this improvement are detailed. Complications of laparoscopic cholecystectomy are more frequent in initial cases but can be minimized by observing specific intraoperative principles.

Cholecystcholangiography during laparoscopic cholecystectomy: cholecystcholangiography or cystic duct cholangiography.

Laparoscopic cholecystectomy is being used more frequently in the treatment of symptomatic cholelithiasis. The procedure as originally described was performed with cystic duct cholangiography. An alternate technique of performing cholangiography is cholecystcholangiography. Because of the objections that have been voiced concerning direct gallbladder injections namely, reliability of the technique, quality of the studies, and the risk of forcing stones into the common bile duct this study was performed. Subjects were 25 consecutive patients who underwent cholecystcholangiography during laparoscopic cholecystectomy. A standard technique was developed and used. Studies were graded from 0 to 5 depending upon quality with 5 being the best and 0 the worst. A 5 consisted of visualization of all of the biliary tract structures and the duodenum and a 0 consisted of visualization of only the gallbladder. Acceptable studies (graded 3, 4, or 5) were obtained in 20 patients (80%). An inability to obtain an acceptable study could usually be determined prior to contrast injection. Accordingly there would be no time delay in proceeding directly to cystic duct cholangiography. In our patients, 48% had stones in the gallbladder smaller than the caliber of the cystic duct. Based upon the results of this study we believe that cholecystcholangiography is the technique of choice for intraoperative cholangiography during laparoscopic cholecystectomy. In patients in whom this technique is not feasible the surgeon should proceed directly to cystic duct cholangiography. There was no added risk to the patient when cholecystcholangiography was performed. There was a benefit in terms of the ease of the procedure and the performance of the procedure over cystic duct cholangiography. The determination of ductal anatomy prior to cystic duct dissection may be important in minimizing the risk of ductal injury during laparoscopic cholecystectomy.

Laser laparoscopic vagotomy and pyloromyotomy.

We performed bilateral truncal vagotomy and gastric drainage procedure using standard laparoscopic instruments in five mongrel dogs. The procedure consisted of a transthoracic thoracoscopic bilateral truncal vagotomy and transperitoneal laparoscopic pyloromyotomy. A contact Nd:YAG laser fiber was used. There was no mortality, minimal morbidity, and post-operative gastric emptying was satisfactory. Pathologic studies indicated vagotomy was complete. We believe that this may be the initial step in the development of a simple, safe, and effective endoscopic procedure for the treatment of peptic ulcer disease.

The use of spinal cord stimulation for severe limb-threatening ischemia: a preliminary report.

Spinal cord stimulation has been shown to control ischemic pain. We have applied spinal cord stimulation to nine patients with rest pain, non-healing ulceration, or digital gangrene to evaluate its effect on limb salvage. The patients had a mean age of 69 years. Six were diabetic, and all had previous major complications of their atherosclerotic disease. Stimulation was obtained by placing an electrode on the spinal cord under local anesthesia. Seven patients experienced marked reduction in their ischemic pain immediately after stimulation. These patients also had improved healing of ulcers documented by direct measurement. No significant change in ankle/brachial Doppler indices could be measured in any patient. One patient became suddenly worse and required amputation after one year of good pain relief and ulcer improvement. Two patients were not helped and went on to amputation within one month of stimulation. We conclude from these preliminary data that spinal cord stimulation effectively relieves ischemic pain and is associated with improved ulcer healing.

Stroke after carotid endarterectomy: risk as predicted by preoperative computerized tomography.

In patients undergoing carotid endarterectomy, the role of preoperative computerized tomographic head scanning in predicting the risk of postoperative neurologic deficit was determined by a retrospective evaluation of a select group of 107 consecutive patients with preoperative scans. Patients with infarction determined preoperatively by computerized tomography were found to be at a significantly higher risk for postoperative neurologic deficit than patients with a normal preoperative computerized tomographic scan. History and physical examination alone detected only 66 percent of the infarctions found with preoperative computerized tomographic scanning in these patients. Because the incidence of infarction revealed computerized tomography in patients with symptoms of a reversible ischemic neurologic deficit was 22 percent, we have proposed a new definition of reversible ischemic neurologic deficit to include the necessary finding of a normal computerized tomographic scan. Patients who presented with transient ischemic attack and the unexpected finding of a subclinical infarction on the preoperative scan were at the same significantly higher risk for postoperative stroke and a permanent neurologic deficit. Computerized tomographic scanning of potential carotid endarterectomy patients is of benefit not only to rule out other sources of neurologic symptoms, but also to predict more accurately the risk of postoperative neurologic deficit.

Favorable balance of prostacyclin and thromboxane A2 improves early patency of human in situ vein grafts.

Graft thrombosis soon after reconstruction remains a major obstacle to the use of reversed vein grafts in infrapopliteal reconstruction. Our clinical experience with in situ vein grafts corroborates Leather's results by demonstrating an overall graft patency of 95% below the knee at 1 year and 94% in the infrapopliteal group. It has been postulated that this improved early patency rate of in situ vein grafts is the result of more optimal preservation of the endothelium of the vein graft. To investigate this hypothesis, human saphenous veins were handled by an in situ and a reversed technique. The intact vein segments were then tested for luminal production of prostacyclin and thromboxane A2 and fixed for scanning electron microscopic analysis of the surface morphology. This study demonstrated that endothelial cell prostacyclin release is enhanced in human in situ vein segments but not in reversed vein segments. In addition, luminal production of thromboxane A2 is significantly greater in the reversed than in the in situ vein segments. These findings are associated with marked endothelial structural damage in the reversed veins and minimal endothelial disruption in the in situ veins. Therefore the ratio of the antiaggregatory vasodilator prostacyclin to the proaggregatory vasoconstrictor thromboxane A2 is significantly more favorable for the in situ vein segment than for the reversed vein segment. The observed excellent early patency of the in situ vein grafts in our poor-risk patient population may in part be the result of this favorable balance of prostacyclin and thromboxane A2 and the more optimally preserved endothelial morphology.

Relationship of duration of postoperative ileus to extent and site of operative dissection.

Postoperative ileus has been thought to be related to intraoperative manipulation of the intestines and to the duration of operative procedures. In order to study the effect of these variables on the postoperative myoelectrical activity of the intestine, six stumptailed monkeys had strain-gauge force transducers and bipolar electrodes placed on gastric antrum, mid-small bowel, right colon, and sigmoid colon. The animals were then subjected to three operations in random order varying in extent and site of dissection: (1) midline incisions, mobilization of right colon and kidney, clamping of renal pedicle, and extensive blunt dissection of right retroperitoneum; (2) the same operation but done on the left side; and (3) midline incision and gentle digital manipulation of the intestines. The first two procedures involved much more intestinal handling and dissection and took five to six times longer than the minimal laparotomy procedure. Postoperative inhibition of bowel motility was most profound and persistent in the colon. The duration and pattern of postoperative ileus in these experiments were independent of the extent, site, and duration of the operative procedure.