Pneumothorax as a complication of laparoscopic inguinal hernia repair.

Pneumothorax was identified as a complication of endoscopic hernia repair in two patients with insufflation pressures of 15 mmHg and operating times exceeding 2 h. These patients also showed intraoperative perturbations in both oxygen saturation and end-tidal CO2 production. A prospective study was undertaken to determine whether similar complications would arise if preperitoneal insufflation pressures were limited to 10 mmHg. Postoperative chest x-rays were obtained on all patients to check for pneumothoraces, even clinically occult ones. Fifty patients were studied, with average operating times of 67 min. No patient demonstrated any hemodynamic or ventilatory changes, and none had any evidence of pneumothorax on x-ray. We conclude that these complications were not present when insufflation pressure was maintained at 10 mmHg and that routine x-ray is not warranted. Larger randomized trials of insufflation pressures are needed.

Laparoscopic common bile duct exploration: a review.

The use of laparoscopic methods to explore the common bile duct is now well-established, although they continue to undergo continuous evolution and improvement. In experienced hands laparoscopic management of choledocholithiasis may be undertaken with morbidity and mortality at least as good as that of open surgery. The use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy before or after laparoscopic intervention must be evaluated. The degree of acceptance that laparoscopic techniques for common bile duct exploration (CBDE) will achieve within the surgical community remains to be determined, but will likely increase as more practicing surgeons familiarize themselves with them.

Changing experiences with 1848 cholecystectomies at a single institution.

A retrospective review of all cholecystectomies performed at a single institution since the advent of laparoscopic cholecystectomy at that institution was undertaken. Of the 1848 cases analyzed, 1372 were completed laparoscopically. There was an increase in utilization of ERCP prior to cholecystectomy, and an increase in the number of cases being done laparoscopically for acute and gangrenous cholecystitis over the 48 months of the study. Of the 1442 cases started laparoscopically, eight technical complications were recognized, and conversion was required in five of these. Only two bile duct injuries were identified in the laparoscopic group. Data analyzed over the past 2 years of the study, when the number of surgeons performing laparoscopy remained stable, showed a decrease in both complication and conversion rates. There are no strong data to support the practice of routine intraoperative cholangiography.