Laparoscopic Nissen fundoplication at a teaching center: prospective analysis of 103 consecutive patients.

The Nissen fundoplication is the most extensively studied and successfully employed surgical solution to gastroesophageal reflux disease (GERD). Early success with the application of minimally invasive techniques to this procedure has been reported by several authors. One hundred three consecutive patients were operated on for the symptoms and complications of GERD. Preoperative evaluation consisted of esophagogastroduodenoscopy and esophageal manometry. Twenty-four-hour esophageal pH was obtained selectively. All cases were performed in a traditional training environment, adhering to techniques previously described in the open literature. Clinical data consisted of operative time, postoperative hospital days, days to resumption of normal activities, and morbidity. Patients were followed clinically for the incidence of dysphagia, bloating, and recurrent reflux symptoms. These were graded using a modified Visick score prior to discharge, at 1, 3, and 6 months, and then annually. All patients underwent completion of their procedure; however, four required conversion to open technique and were excluded from analysis. Mean operative time for the 99 laparoscopic procedures was 180 min. Mean operative time was significantly longer for the first 50 cases (202.1 min) than the last 49 (164.2 min). Mean postoperative hospital stay was 2.3 days with 10 days to resumption of normal activities. Mean follow-up was 15 months (range 3-39 months). Three of the four treatment failures underwent open revision with good subsequent results. Patient satisfaction as reflected by the modified Visick score reveals 96% good to excellent results (Visick 1 or 2) with no persistent dysphagia. The Nissen fundoplication can be safely performed using minimally invasive techniques with the benefit of postoperative recovery typical of other laparoscopic procedures. By strictly adhering to the primary technical principles previously described in the open approach, early results are comparable. The procedure can be safely performed in a traditional training environment. The modified Visick system is a simple and effective method to quantify postoperative patient satisfaction.

Pelvic congestion syndrome: a new approach to an unusual problem.

Pelvic congestion syndrome (PCS) is an uncommon and frequently overlooked cause of debilitating pelvic pain. The well-described clinical presentation is that of pain and fullness exacerbated by prolonged standing, coitus, and in the premenstrual period in multiparus women. Physical signs include vulvar varices that can communicate with the saphenous vein in the groin, causing thigh or buttock varices. The diagnosis is usually confirmed by ovarian vein venography demonstrating reflux to the ovaries and often into the thigh with erect positioning and valsalva. Standard surgical treatment is bilateral ovarian vein ligation and excision or ligation of as many collaterals as possible. The traditional approach is bilateral retroperitoneal incisions, with medial rotation of the viscera. We report the first patient managed transperitoneally using minimally invasive techniques. Our case suggests that this approach can easily and safely be performed by surgeons experienced in laparoscopic surgery with the advantages of improved cosmesis, less postoperative pain, and rapid convalescence typical of other minimally invasive procedures. Additionally, it provides the opportunity to perform diagnostic laparoscopy as well.

Traction injury to the liver during laparoscopic cholecystectomy.

We describe an intraoperative complication of laparoscopic cholecystectomy and make recommendations to avoid its occurrence. We describe a case in which the liver was lacerated during a routine laparoscopic cholecystectomy. The laceration occurred when the gallbladder was retracted into the suprahepatic space, causing a traction injury of the quadrate lobe, 2 cm lateral to the falciform ligament. The placement of the epigastric trocar through the falciform ligament fixed the liver to the abdominal wall, facilitating the injury. When placing the epigastric trocar, care should be taken to avoid placement through the falciform ligament. If this is not possible, retraction of the gallbladder into the suprahepatic space should be accomplished while observing the liver edge. If the liver edge seems to be under tension, division of the falciform ligament to allow for easy retraction of the liver is recommended.

Nephrogenic diabetes insipidus secondary to lithium therapy in the postoperative patient: a case report.

Nephrogenic diabetes insipidus (NDI) presents a rarely encountered but challenging fluid management problem in the perioperative period. This case is that of a patient with a perforated duodenal ulcer and previously undiagnosed NDI who received standard preoperative and postoperative hydration with normal saline, causing hypernatremia and an inappropriate diuresis. The resulting hypernatremia and hyperosmolality required aggressive hypotonic fluid replacement to return to preoperative values. Though refractory to 1-desamino-8-D-argenine-vasopressin (dDAVP), thiazide diuretics and nonsteroidal anti-inflammatory agents have a role in managing selected patients. Early diagnosis with careful fluid and electrolyte management are critical in successful management of these patients in the perioperative period.

Laparoscopic treatment of appendicovesical fistula: a case report.

Appendicovesical fistula is an uncommon type of enterovesical fistula and a rare complication of unrecognized appendicitis. Only 100 cases have been reported previously in the literature, the vast majority being in young male patients. Our case is that of a middle-aged woman and is the first in which the diagnosis is made and surgical treatment rendered using a laparoscopic approach. Familiarity with diagnostic laparoscopy adds a powerful tool to the evaluation of patients with difficult or unusual surgical problems. Subsequent implementation of minimally invasive techniques for surgical therapy when appropriate can significantly decrease hospitalization and convalescence.

Abdominal wall recurrence after laparoscopic-assisted colectomy for adenocarcinoma of the colon. Report of a case.

PURPOSE: To report an unusual mode of colorectal carcinoma recurrence after laparoscopic-assisted right hemicolectomy. METHODS: Retrospective case review. RESULTS: Laparoscopic-assisted colectomy has been shown in a variety of settings to be safe and technically feasible. The question of its efficacy in treating colorectal carcinoma remains uncertain. We report a case of a 71-year-old male who presented with a trocar site abdominal wall recurrence 10 months after a laparoscopic-assisted right hemicolectomy. To our knowledge, this represents the first such reported case in the literature. CONCLUSION: Questions surrounding the efficacy of laparoscopic colectomy in eradicating colorectal carcinoma support the need for rigorous prospective study of this new technique.