Laparoscopic pancreaticoduodenectomy: technique and outcomes.

BACKGROUND: We describe our experience with laparoscopic pancreaticoduodenectomy, including 5-year actuarial survival rates. STUDY DESIGN: This is a retrospective study of selected patients who underwent laparoscopic pancreaticoduodenectomy at a single center between 1998 and 2006. We have described the salient features of our technique and followup protocol. Patient characteristics, histologic variety of the tumor, resection margins, morbidity, mortality, and actuarial survival rates were studied. RESULTS: The procedure could be completed laparoscopically with tumor-free margins in all patients, including patients with ampullary carcinoma (n = 24), pancreatic cystadenocarcinoma (n = 4), pancreatic head adenocarcinoma (n = 9), low common bile duct cancer (n = 3), and two patients with chronic pancreatitis with a suspicious mass lesion in the head of pancreas. Mean age of patients was 61 years (range 28 to 70 years). There was a single perioperative mortality. Overall followup rate was 95.1%, with two patients lost to followup at 22 and 36 months. Among the survivors, two patients have metastatic disease and local recurrence developed in one patient. Five-year actuarial survival rates for all patients with malignancy, ampullary adenocarcinoma, pancreatic cystadenocarcinoma, pancreatic head adenocarcinoma, and common bile duct adenocarcinoma are 32%, 30.7%, 33.3%, 19.1%, and 50%, respectively. Presence of microscopic lymph node involvement is associated with poor survival, although operations in the setting of chronic pancreatitis resulted in increased morbidity. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy can be performed with safety and good results in properly selected patients. Localized malignant lesions, irrespective of histopathology, are particularly amenable to this approach.

Laparoscopic repair of a paracolostomy hernia: secure reinforced closure of the defect prevents recurrence.

High incidence rates have been reported for parastomal hernias after colostomies, particularly end colostomies. In addition to cosmetic disfigurement, parastomal hernias also cause several functional problems in stoma management, and their repair becomes essential. While a variety of open techniques have been described for their management, including the extreme step of stoma relocation, laparoscopic techniques offer a viable and possibly better option. We present a case of parastomal hernia and describe our technique of repair.

Laparoscopic management of acid peptic disease.

BACKGROUND: Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. Almost all types of conventional operations available for ulcer disease have been successfully performed by the laparoscopic approach and this has become the preferred approach in tertiary centers for operative management of acid peptic disease. METHOD: Between 1995 and 2004, laparoscopic management was offered to refractory or obstructive acid peptic disease patients. For intractable disease, we performed either posterior truncal vagotomy with anterior fundal seromyotomy or posterior truncal vagotomy with anterior proximal gastric vagotomy. For peptic ulcer disease complicated with gastric outlet obstruction, we carried out bilateral truncal vagotomy with gastrojejunostomy. RESULTS: Two hundred sixty three patients were operated of whom 236 (89.7%) were men and the average age of the patients was 48.4 years. Thirty-two (12.2%) patients underwent posterior truncal vagotomy with anterior seromyotomy, 89 (33.8%) underwent posterior truncal vagotomy with anterior proximal gastric vagotomy, 120 (45.6%) underwent bilateral truncal vagotomy with stapled gastrojejunostomy whereas 22 (8.4%) underwent bilateral truncal vagotomy with hand-sewn gastrojejunostomy. The average operating times were 142, 110, 98, and 72 minutes, respectively. The average postoperative stay was 5.4 days. CONCLUSIONS: Laparoscopic posterior truncal vagotomy with anterior proximal gastric vagotomy for refractory disease and laparoscopic bilateral truncal vagotomy with stapled gastrojejunotstomy for obstructive disease have become the standard at our institution. Regardless of the preference of individual surgeon, our results have shown that laparoscopic surgery may become the gold standard for surgical management of peptic ulcer disease.

Early ligation of the splenic artery in the leaning spleen approach to laparoscopic splenectomy.

BACKGROUND: A variety of approaches have been proposed for laparoscopic splenectomy, including the anterior approach, the lateral approach (hanging spleen technique), and the semilateral approach (leaning spleen technique). We advocate a leaning spleen approach with early ligation of the splenic artery. MATERIALS AND METHODS: Since 1997, we have performed 120 laparoscopic splenectomies using the leaning spleen approach along with early ligation of the splenic artery. The patient is placed in a 70-degree semi-right lateral position. The operative steps are: exposure of the lesser sac, control of the splenic artery, mobilization of the splenic flexure, division of the splenocolic ligament, division of the splenophrenic ligament, hilar mobilization, mobilization of the upper pole of the spleen, and removal of the specimen. RESULTS: The most common indication for surgery was autoimmune hemolytic anemia (35.8%). One patient had severe perisplenitis with extensively vascularized adhesions, which led to oozing during surgery obscuring the laparoscopic view, requiring conversion to open surgery. The mean spleen diameter was 22.8 cm (range, 12.5-37.0 cm) on imaging. The mean operative time was 85 minutes (range, 54-124 minutes). Concomitant laparoscopic cholecystectomy for pigment stone cholelithiasis was performed in 8.3% of the patients. Accessory splenic tissue was found in 4.2%. The average hospital stay was 3 days (range, 1-6 days). There were no significant postoperative complications. The average follow-up has been 5.4 years (range, 1 month-9 years). CONCLUSION: In adopting the modification of early ligation of the splenic artery in the leaning spleen approach, we believe we have helped to advance laparoscopic splenectomy.

Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants.

BACKGROUND: Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients. STUDY DESIGN: Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy. RESULTS: Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered. CONCLUSIONS: Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.