Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation.

BACKGROUND: Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes. METHODS: A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized. RESULTS: The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were "round." Remaining nodes were "oblong." All nodes had a hyperechoic center with a hypoechoic rim. CONCLUSION: In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.

Ultrasound of the inguinal floor for evaluation of hernias.

BACKGROUND: This study aimed to evaluate the utility of ultrasound in the diagnosis of inguinal hernias and obscure groin pain. METHODS: A series of 65 consecutive groin explorations performed subsequently to percutaneous ultrasound examination were prospectively evaluated. Patients were examined in an office setting. The examination included a history and a physical. Then an ultrasound of the inguinal region was performed. Ultrasound was performed by the staff surgeon and fellows. Patients then were taken to surgery for either a laparoscopic or open hernia repair. The preoperative and operative findings were compared to determine the utility of groin ultrasound. RESULTS: A series of 41 patients presenting with symptoms of groin pain or palpable groin bulge were evaluated with ultrasound of the groin. Of these patients, 24 went on to have bilateral repairs, bringing the study total to 65 groins. Surgery involved 50 laparoscopic and 15 open hernia repairs. This included 20 groins without hernia, as determined by physical examination, and 45 groins with a palpable hernia. Overall, ultrasound was used to identify the type of hernia correctly (direct vs indirect) with 85% success. In the 20 patients who had no palpable bulge, ultrasound identified a protrusion (hernia or lipoma) in 17. Two of these were false positives, and the three negative ultrasound examinations were false negatives. Thus ultrasound identified the pathology in a groin without a palpable bulge at an accuracy of 75%. The overall accuracy in finding a hernia of any kind by ultrasound was 92%. CONCLUSION: Ultrasound is a useful adjunct in evaluating the groin for hernia, and can be performed by surgeons.

A balanced approach to choledocholithiasis.

BACKGROUND: We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS: We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. RESULTS: A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). CONCLUSIONS: Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.

Ultrasound-guided laparoscopic resection of pancreatic islet cell tumors.

Pancreatic islet cell tumors represent a diverse group of neuroendocrine lesions. These tumors may be singular or multiple, benign or malignant, sporadic, or part of the constellation of multiple endocrine neoplasia type 1. Tumors such as insulinomas and gastrinomas produce gastrointestinal peptides that lead to diagnosis. Nonfunctioning lesions may be found incidentally or by screening patients at high risk for such tumors. Successful management of patients with pancreatic islet cell tumors relies on accurate localization and sound operative technique. With proper preoperative localization, advanced laparoscopic methods can be used to manage patients with these pancreatic neoplasms. Preoperative localization of pancreatic islet cell tumors was difficult in the past. Standard imaging and localizing modalities, such as computed tomography scanning, magnetic resonance imaging, angiography, transabdominal sonography, and portal venous sampling, yield only 24% to 75% accuracy. Consequently, many biochemically suspected lesions cannot be imaged with current techniques. Decreased tactile sensation of laparoscopy adds complexity to intraoperative identification. Endoscopic sonography and laparoscopic sonography provide accurate preoperative and intraoperative localization to enhance laparoscopic and open resection. The authors treated two patients with islet cell neoplasms using endoscopic sonography to preoperatively visualize the tumors and laparoscopic sonography to guide laparoscopic enucleation. Their approach and difficulties are discussed.