Laparoscopic antireflux surgery at an outpatient surgery center.

BACKGROUND: Laparoscopic fundoplication (LF) procedures have been shown to be safe and effective for the control of gastroesophageal reflux disease (GERD). Preliminary reports suggest that LF can be performed safely in an ambulatory surgery center. We report on our extensive experience with outpatient LF. METHODS: Since May 1995, we have performed laparoscopic antireflux procedures in 557 consecutive patients at a freestanding outpatient surgery center. All patients had esophageal manometrics and esophagogastroduodenoscopy (EGD) within 1 year of their surgical procedure. This series included 16 patients with large paraesophageal hernias (mostly type III) and 22 patients with prior antireflux procedures. Most patients (n = 494) underwent Nissen fundoplication. RESULTS: Patients were typically given clear liquids 6 hs postoperatively and discharged home in

Minimally invasive antireflux surgery.

BACKGROUND: Previous reports of minimally invasive antireflux surgery for gastroesophageal reflux disease (GERD) have been small, short-term series utilizing only a laparoscopic approach. We conducted a retrospective review and report our 66-month experience with more than 1,000 laparoscopic and thoracoscopic antireflux procedures. METHODS: Between September 1991 and October 1997, 968 adults underwent 1,003 minimally invasive antireflux procedures on a tailored basis, based on their preoperative evaluation. Procedures performed were laparoscopic Nissen (626), Toupet (348), paraesophageal (33), and thoracoscopic Belsey (22). A total of 23% (233) of patients underwent an ancillary procedure (esophageal myotomy 85, vagotomy 67, pyloromyotomy 13, and cholecystectomy 66). RESULTS: Follow-up averaged 33 months (range 1 to 66), operative mortality was 0.1%. Complications occurred in 2.7% with a 1% long-term dysphagia rate. Demonstrated recurrence rate was 3.8% to date, with an associated 3.4% reporting symptoms of GERD. CONCLUSION: Minimally invasive antireflux procedures provide sustained relief of GERD symptoms with low morbidity and rapid recovery.

Bilateral thoracoscopic stapled volume reduction for bullous vs diffuse emphysema.

BACKGROUND: We compared our results with bullous vs diffuse emphysema by performing a bilateral thoracoscopic stapled volume reduction technique in 15 patients (age 45-80, 10 males, five females). METHODS: Eight patients demonstrated bullous emphysema and seven patients diffuse emphysema. Lung reduction was performed with a bilateral thoracoscopic stapled technique utilizing bovine pericardium in the supine position. RESULTS: Comparison of the bullous versus diffuse groups revealed no significant differences in means for the following variables: length of air leak (7.5 vs 3.3 days); length of stay (8.1 vs 6.5 days); pre-op FEV1, (23% vs 22%); pre-op dyspnea index (3.4 vs 3.6). At 3 months the bullous subset had a highly significant improvement (p < 0.007) in FEV1 (88%) compared with the diffuse subset FEV1 (59%). CONCLUSIONS: These early results suggest that patients with bullous emphysema are at no greater risk and demonstrate a significantly greater improvement in FEV1 than patients with diffuse emphysema.

New application of bipolar coagulation in laparoscopic surgery.

Bipolar electrocautery is associated with a lower risk of tissue injury from an inadvertent energy transfer compared with monopolar diathermy, and bipolar coagulation has been effectively employed in obstetric and gynecologic procedures. The present report describes the successful use of bipolar diathermy during general laparoscopic surgery. Hemostasis and closure of even large vessels was possible with the use of bipolar forceps during laparoscopic cholecystectomy, fundoplication, appendectomy, and highly selective vagotomy procedures. No intraoperative complications resulting from bleeding were apparent in this series of 296 laparoscopic operations, nor were any postoperative complications suggestive of inadvertent tissue damage, such as peritonitis, apparent. Thus, these results suggest that bipolar coagulation can be used safely and without difficulty in laparoscopic surgical procedures.

Comparison of minimally invasive thoracoscopy versus open thoracotomy for staging lung cancer.

Minimally invasive thoracoscopic staging for lung cancer was compared with re-staging by open thoracotomy in seventeen patients to evaluate whether videoimaged thoracoscopic staging was accurate. Seventeen patients underwent thoracoscopic staging initially with a closed videoimaged technique. These same patients then underwent an open thoracotomy and re-staging with a therapeutic resection for lung cancer. All patients underwent pleural evaluation and biopsy if indicated, thoracic hilar and mediastinal lymph node sampling, and then resection of the parenchymal lesion via a wedge resection, lobectomy or pneumonectomy. There was complete TMN stage correlation between the closed videoimaged thoracoscopic and open thoracotomy techniques. This preliminary study suggests minimally invasive videoimaged thoracoscopic staging is an accurate method to assess the stage of lung cancer to guide rational management.

Laparoscopic antireflux surgery.

Laparoscopic techniques have facilitated dissection of the esophageal hiatus by providing clearer visualization and access to this region, thus enabling successful antireflux surgery. We have performed laparoscopic antireflux surgery in 283 patients with symptomatic gastroesophageal reflux disease (GERD) refractory to medical management, including 16 patients with large paraesophageal hernias and six patients who had undergone previous antireflux surgery. Eighty-one per cent (n = 230) underwent a laparoscopic Toupet fundoplication procedure, and 37 had a laparoscopic Nissen fundoplication. Of the 16 surgical repairs for paraesophageal hernias, 10 were accomplished with the Nissen procedure. Regardless of the laparoscopic technique, oral feedings were resumed on the first postoperative day and patients were typically discharged within 24 to 48 hours after surgery. All of our patients reported symptomatic improvement following the laparoscopic antireflux operation, with 89 per cent of the patients undergoing the Toupet fundoplication and 79 per cent of those having the Nissen repair rating their postoperative results "excellent." Only one patient had to be converted to an open procedure (< 0.5 per cent). None of the patients in this series died and the complication rate was only 3.5 per cent. Six patients required reoperation (2.1 per cent), including three of whom originally presented with difficult paraesophageal hernias and did not undergo an initial fundoplication procedure. Thus, laparoscopic fundoplication procedures appear to provide sustained symptomatic relief for patients with refractory gastroesophageal reflux disease, with a rapid recovery and a low incidence of complications.

Access techniques: Veress needle--initial blind trocar insertion versus open laparoscopy with the Hasson trocar.

The two most common techniques used to gain entry into the peritoneal cavity during laparoscopic general surgery are the blind Veress needle/trocar insertion and open trocar placement under direct visualisation. Once entry to the peritoneal cavity has been achieved, gas insufflation is used to establish pneumoperitoneum and enable visualisation of abdominal structures. Many of the complications associated with operative laparoscopy arise from creation of the pneumoperitoneum, such as subcutaneous emphysema and gas embolism, or from injury to internal structures during abdominal entry. Because of the relative infancy of laparoscopic general surgery, much of the information relating to these types of complications are associated with minimally invasive gynaecologic procedures. Compared to gynaecologic laparoscopy, general surgical interventions are typically more complicated, require longer operative times and a greater number of access sites, and are more likely to be performed in older patients. Therefore, complication rates associated with pneumoperitoneum or abdominal entry may actually turn out to be higher for laparoscopic general surgery, making selection of a blind versus open access technique more important. Two direct comparisons of these access approaches in laparoscopic cholecystectomy indicated that an open technique employing a peritoneal cut-down and trocar insertion under direct visualisation was safer than blind insertion of the Veress needle and primary trocar. We also favour the open access technique, believing that the risk for serious visceral or vascular complications is less than that with a blind approach.

Extraperitoneal prosthetic inguinal hernia repair using an endoscopic approach.

OBJECTIVE: To describe a laparoscopic extraperitoneal prosthetic repair technique to treat inguinal hernia defects. SURGICAL TECHNIQUE: Operating laparoscopically in the preperitoneal plane, a piece of polypropylene mesh, placed behind the cord structures, is used to reinforce or replace the transversalis fascia. It is secured with staples placed in the fascia adjacent to Cooper's ligament and in the iliopubic tract. PATIENTS: Our laparoscopic extraperitoneal prosthetic technique was used successfully to repair 107 direct, 142 indirect and one femoral hernia; 67% of these defects were bilateral and 30% were recurrent. RESULTS: Operative time averaged 66 minutes and almost all patients were discharged on the day of surgery. All returned to normal activities within seven days. There were few complications and during the average follow-up period of 18 months, only one patient had a recurrent herniation that was due to a retained indirect defect. ADVANTAGES OF TECHNIQUE: The laparoscopic extraperitoneal procedure shares the same benefits attributed to traditional preperitoneal prosthetic hernia repairs: direct access to the posterior inguinal structures, clear visibility of all possible hernia defects; ability to circumvent scar tissue and intraabdominal adhesions; ease in effecting difficult repairs; avoidance of side effects associated with severance of superficial inguinal nerves; and fortification of the defect via an inlay prosthetic buttress. Moreover, the laparoscopic technique offers clear advantages to open surgery in terms of reduced pain, quicker recovery, and improved cosmesis. CONCLUSIONS: We consider the laparoscopic extraperitoneal prosthetic repair the procedure of choice for patients with recurrent as well as bilateral inguinal defects.

Technical aspects for laparoscopic nissen fundoplication.

Laparoscopic Nissen fundoplication is indicated in patients with documented gastroesophageal reflux disease who are refractory to maximal medical therapy or who develop a complication of reflux. The laparoscopic approach is a technically demanding procedure which requires extensive two handed tissue dissection and advanced suturing and knotting skills. Our experience with over 400 laparoscopic antireflux procedures over the last three years has highlighted several technical aspects which facilitate the procedure.

Complications and recurrences associated with laparoscopic repair of groin hernias. A multi-institutional retrospective analysis.

Although the laparoscopic technique is a new approach to groin hernia, it is becoming more widely accepted as an alternative to traditional open techniques. This study is a preliminary review of complications and recurrences. A questionnaire specific for complications was sent to each investigator. From 12/89 to 4/93, 1,514 hernias were repaired; 119 (7.8%) were bilateral and 192 (12.7%) recurrent. There were 860 indirect, 560 direct, 43 pantaloon, 37 femoral, and 6 obturator hernias, and 8 were not specified; 553 were repaired using a transabdominal preperitoneal mesh technique (TAPP), 457 with a total extraperitoneal technique (TEP), 320 with intraperitoneal onlay mesh (IPOM), 102 by ring closure, and 82 involved plug and patch technique. Eighteen intraoperative and 188 postoperative complications were seen. The total complication rate was 13.6%, of which 1.2% were intraoperative. Of the intraoperative complications, 12 were related to the laparoscopic technique, three were related to the hernia repair, and one was related to anesthesia. The rate of conversion to open was 0.8%. Of the postoperative complications, there were 95 local, 25 neurologic, 23 testicular, 23 urinary, 10 mesh, and 12 miscellaneous. There were 34 recurrences after the 1,514 hernia repairs (2.2%). The follow-up was reported in 825 patients for an average of 13 months. The recurrence rate varied drastically with the technique: A 22% recurrence rate after the plug and patch vs 3%, 2.2%, 0.7%, and 0.4% with the ring closure, IPOM, TAPP, and TEP, respectively. Laparoscopic repair of groin hernia can be safely performed. Complications, mostly minor, diminish with experience. The recurrence rate is less with large mesh which is anchored.

Laparoscopic repair of gastroesophageal reflux disease. Toupet partial fundoplication versus Nissen fundoplication.

This report describes our preliminary experience with two surgical laparoscopic fundoplication procedures, the Nissen technique and the Toupet operation, in which the fundal wrap is reduced from 360 degrees to 180-200 degrees. Fourteen patients with symptomatic gastroesophageal reflux disease who were refractory to pharmacologic and medical therapy underwent a laparoscopic Nissen fundoplication; in an additional 14 patients, we performed a laparoscopic Toupet partial fundoplication. Our laparoscopic approach to the two procedures does not differ significantly from the traditional open methods and the effectiveness of the laparoscopic fundoplication procedures appears similar to that of the same conventional techniques. Oral feedings can be resumed on the first postoperative day and patients typically are discharged on the second day after surgery. Operative time for performing the Toupet procedure averaged just approximately 1.6 h and was shorter than that for the Nissen fundoplication, due to the use of a stapler to secure the fundal wrap. Confirming earlier observations, the laparoscopic Toupet 180-200 degrees fundoplication was associated with a lower incidence of postoperative digestive complications, such as dysphagia, than was the laparoscopic Nissen operation. The laparoscopic fundoplication approach offers the advantages of clear visualization, adequate dissection and precise repair, along with the benefits associated with endoscopic surgery: diminished postoperative pain and discomfort, reduced hospitalization, and quicker return to normal activities. Our experience indicates that the Toupet fundoplication may be preferable to the Nissen technique for many patients requiring surgical treatment of their reflux disease.

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease.

The Nissen fundoplication is the most common operative approach to the correction of gastroesophageal reflux disease (GERD) in the United States. This report describes our success in performing this anti-reflux procedure laparoscopically in 28 patients with symptomatic GERD refractory to conventional medical therapy. Our laparoscopic technique does not differ significantly from the traditional, open Nissen fundoplication. After surgery, all patients reported symptomatic relief, and none required medication for the control of reflux symptoms. Oral feedings were begun on the first postoperative day, and patients were typically discharged on the second day after surgery. All but two patients resumed normal eating within an average of 26 days. Two patients experienced longer term postoperative dysphagia, including one who had undergone a highly selective vagotomy concurrent with the antireflux surgery.

Duodenal ulcer disease and gastric cancer: vagotomy, drainage and resection.

Laparoscopic adaptation of highly selective vagotomy procedures associated with no mortality, low morbidity and no reports of diarrhoea and dumping syndrome has been reported. Although experience to date with these procedures is limited, they hold the promise of being a viable alternative for patients refractory to medical therapy or for those non-complaint with long-term maintenance pharmacologic treatment. Simple closure of an acute perforated ulcer has also been accomplished laparoscopically. In performing laparoscopic surgical procedures for duodenal ulcer disease, the relief of symptoms appears similar to that reported following comparable open procedures but with the advantages of diminished postoperative pain and disability. Moreover, the use of angled endoscopes and the magnification afforded by laparoscopy greatly facilitate the identification and transection of small vagal fibres adjacent to the oesophagus.

Improved visibility of black surgical needles in laparoscopic surgery.

Black needles were compared to silver needles for quantity of reflected light and ease of laparoscopic visualization. The black needles reflected less light and were thus more easily visualized during laparoscopic surgical procedures. The silver needles resembled a mirror in that they reflected incident light from both the light source and light from the surrounding tissue.

Laparoscopic extraperitoneal repair of inguinofemoral herniation.

This report describes my group's experience with repairing 100 direct and indirect inguinal hernias using a solely extraperitoneal, laparoscopic prosthetic procedure. No unusual complications were noted and all patients were discharged on the day of or the day following surgery and resumed normal activities within one week. The surgical technique is outlined, with attention given to general guidelines performing this minimally invasive repair procedure.

Complications of laparoscopic herniorrhaphy.

Anterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Cooper's ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Endoscopic management of peptic ulcer disease.

OBJECTIVE: This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure. SUMMARY BACKGROUND DATA: Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage. METHODS: The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown. RESULTS: There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days. CONCLUSIONS: Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.