Analysis of a structured training programme in laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is an established treatment for almost all gallbladder diseases with bile duct injury rates similar to open cholecystectomy. These laparoscopic skills must be passed on to junior surgeons without compromising patient safety. MATERIALS AND METHODS: We analysed our structured training programme over 6years (May 2000 to May 2006) by following three trainee surgeons during their training and beyond. During this period, 1,000 laparoscopic cholecystectomies were carried out with five consultant surgeons supervising and three new trainees who completed their accreditation in laparoscopic cholecystectomy. RESULTS: There were 694 patients operated on by consultant surgeons (Group 1), 202 by trainee surgeons (Group 2) and 104 by newly trained surgeons (Group 3). There were no differences between the groups in terms of age and gender. However, there was a significant difference in gallbladder disease among the three groups; Group 2 had more gallstone pancreatitis patients (P < 0.019). There were no differences among the three groups in conversion rates, bile duct injury rates, general complication rates or length of stay. However, the duration of operation in Group 2 was significantly longer compared to the other two groups (P < 0.0001). CONCLUSION: This programme is effective in training junior surgeons and does not compromise patient safety.

Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder diseases. Conversion to open cholecystectomy is necessary in some patients for any of a number of factors. Identifying these factors will help the patient, the surgeon, and the hospital. METHODS: One thousand laparoscopic cholecystectomies were performed from May 1998 to May 2004 in Changi General Hospital, Singapore; 103 patients (10.3%) required conversion to open cholecystectomy. All data were kept prospectively and analyzed retrospectively. RESULTS: The patients who had conversion were mostly men (P < 0.0001), were heavier (P < 0.05), had acute cholecystitis (P < 0.0001), and had a history of upper abdominal surgery (P < 0.001). There were no differences in terms of race (P = 0.315) and presence of diabetes mellitus (P = 0.126). Diabetic patients who had conversion had a significantly higher glycosylated hemoglobin (Hba1c) (8.9% +/- 0.6%; P < 0.038). Patients who had conversion had a higher total white count (P < 0.05), but liver function tests were similar between the two groups. There was a higher conversion rate among the junior surgeons than the more experience surgeons (P < 0.032). CONCLUSIONS: The significant risk factors for conversion were male gender, advanced age (> 60 years), higher body weight > 65 kg, acute cholecystitis, previous upper abdominal surgery, junior surgeons, and diabetes associated with Hba1c > 6. Chronic liver disease was not found to be a risk factor (P = 0.345), and performing laparoscopic cholecystectomy in cirrhotic patients is safe. Identifying risk factors will help the surgeon to plan and counsel the patient and introduce new policies to the unit. Some of the risk factors are similar to those reported from international centers, but others may be unique to our department.

Treatment of obesity with laparoscopic adjustable gastric banding in Singapore: an initial experience.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) has been used for the treatment of obesity, being shown in western populations to be a safe and effective option. We present the results of our experience in the use of LAGB in the treatment of obesity. METHODS: A retrospective review of all patients who underwent LAGB from February 1999 to June 2004 was made from a prospectively collected database. Pre-operative comorbidities, height, weight and body mass index (BMI) were recorded and compared with post-operative results. Operative times, length of stay and complications were also noted. RESULTS: 38 consecutive patients underwent LAGB. The 16 male and 22 female patients had a mean age of 37.6 years (range 19 to 62 years) and a mean BMI of 42.7 kg per square metre (range 28.8 to 78.4 kg per square metre). Nine were done utilising the perigastric approach, and the other 29 with the pars flaccida approach. There were no open conversions. Overall peri-operative morbidity was encountered in two (5.3 percent) patients, with a minor liver laceration and a capsular splenic laceration in separate patients. There were no post-operative complications. One (2.7 percent) patient had the band removed at 29 months post-operatively on request. There were no mortalities. Mean follow-up period was 13 months (range one to 56 months). Mean BMI decreased to 40.7, 38.7, 37.4, 34.1 and 32.9 kg per square metre, respectively, at one week, one, six, 12 and 18 months post-operatively. CONCLUSION: LAGB is a feasible modality in the multifaceted approach to treatment of morbid obesity. The results from our follow-up are comparable to larger series in western populations, with a similar safety profile.

Laparoscopic ventral hernia repair: local experience.

INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) is a recent development that has been shown to be an effective way of treating ventral hernias. We present the first local series of LVHR with a review of the literature on laparoscopic ventral herniorrhaphy. METHODS: We retrospectively reviewed all our patients who underwent laparoscopic surgery for ventral hernias from December 1998 to May 2002. Results of LVHR such as operative time, length of hospital stay, complications and recurrence rates were evaluated. RESULTS: Twenty patients underwent LVHR. There were 16 female and four male patients. The average age was 54 years. The mean fascial defect was 46 square cm. An ePTFE Mesh was used in all the patients except for one patient who had a prolene mesh. The mean operative time was 117 minutes and the hospital stay was two days. There were two minor complications and no major complications. With a mean follow-up period of 14.9 months, the recurrence rate was 5.0 percent with a single recurrence at four months. CONCLUSION: Our initial experience with this modality shows that LVHR a feasible option with great potential in both treatment success and reduction of surgical morbidity.

Remifentanil in the management of laparoscopic resection of phaeochromocytoma--case reports.

INTRODUCTION: The laparoscopic adrenalectomy approach to phaeochromocytoma surgery offers the opportunity to use new short-acting drugs to facilitate rapid recovery. CLINICAL PICTURE: We report on 2 cases who underwent laparoscopic resection of phaeochromocytoma. The first was a 40-year-old lady who had been started on phenoxybenzamine 20 mg bd, but developed a recurrence of bronchial asthma after starting atenolol which was subsequently stopped. The second was a 51-year-old lady with neurofibromatosis who was taking phenoxybenzamine 20 mg bd and propanolol 20 mg tds. TREATMENT: The intraoperative management was facilitated by the stress suppressive effects of remifentanil infusion combined with nitroprusside as a vasodilator, and desflurane as an anaesthetic. OUTCOME: Both patients were extubated at the end of surgery and made uneventful recovery. CONCLUSION: Remifentanil possesses several useful properties, which deserve serious consideration in phaeochromocytoma surgery, particularly in the instance where beta-blockade is contraindicated. In combination with other titratable short-acting agents, it potentially facilitates rapid recovery especially following the laparoscopic approach to adrenalectomy.

Laparoscopic drainage of liver abscesses.

BACKGROUND: The mainstay of the management of liver abscesses has been intravenous antibiotics and radiologically guided percutaneous drainage. However, not all abscesses are treated successfully in this way, and some require surgical drainage. Laparoscopic drainage of liver abscesses may be an alternative to open surgical drainage. METHODS: Twenty consecutive patients with liver abscesses treated by laparoscopic drainage in combination with intravenous antibiotics were studied prospectively. Fifteen had had failed percutaneous drainage previously. RESULTS: There were 13 right lobe and seven left lobe abscesses ranging from 6 to 25 cm in diameter. Mean operating time was 38 min. Seventeen patients were drained successfully. Three patients developed recurrent symptoms of which two resolved with conservative measures, but one required a second laparoscopic procedure. There were no intraoperative or other postoperative complications in the 20 patients. Follow-up ranged from 5 to 12 months. CONCLUSIONS: Laparoscopic drainage of liver abscesses, in combination with systemic antibiotics, is a safe and viable alternative in all patients who require surgical drainage following failed medical or percutaneous treatment, and in those with large abscesses.

Emergency laparoscopic procedures.

Emergency laparoscopic procedures (ELPs) have been performed since the 1960s. It never caught on due to limitations inherent in the actual procedure. Technological innovations notably in camera, electronic insufflators and light systems were key to the rebirth of laparoscopy in the late 1980s. This was mostly confined to elective indications where its benefits were most obvious. With increasing experience, the benefits of minimally access surgery (MAS) are being applied to emergency indications such as evaluation of peritonitis and abdominal pain, appendectomy, repair of perforated ulcers and other acute conditions. ELP offers good training for surgeons but requires a trained laparoscopist to perform more complicated procedures. As there is not much time for thorough patient evaluation, patient selection and resuscitation are key to safe ELP. It should be done the same way as in open surgery; the difference is in the access. Visibility and technical difficulties are more likely and where further progress is limited or patient's condition changes, then early conversion is wise. Conversion rate in ELP is higher and the tolerance level for this should be much lower than in elective circumstances. However, the benefits of ELPs can be seen in decreased wound and other complications, and earlier mobilisation. Hospitalisation is not very much shorter in most instances as managing the disease process itself requires this. With time, more emergency procedures will be done laparoscopically for demand and knowledge will increase as patients and surgeons become familiar with MAS.

Laparoscopic bladder-neck suspension for urinary stress incontinence in women: our first twenty patients.

BACKGROUND: Laparoscopic bladder-neck suspension for women with urinary stress incontinence avoids the problems associated with a large abdominal incision. This study reviews the short-term outcome of this minimally invasive operation. METHODS: Between September 1993 and February 1995, 20 female patients with type II urinary stress incontinence underwent laparoscopic bladder-neck suspension at our institution (mean age, 46.6 years; mean weight, 59.5 kg; mean duration of symptoms, 3.75 years; mean follow-up, 7 months). The extraperitoneal space was created with a preperitoneal distention balloon system; dissection of the bladder and bladder neck was done via 3 working ports. In 16 patients, the paraurethral vagina on either side of the bladder neck was hitched up to the iliopectineal ligament by 2-0 sutures. In the remaining 4 patients, the bladder-neck suspension was performed using hernia mesh and staples. Four patients had intraperitoneal suspension. RESULTS: The operative time ranged from 75 to 205 minutes, with a mean of 111.5 minutes. The period of urethral catheterization ranged from 2 to 7 days, with a mean of 3.1 days. The hospitalization stay ranged from 5 to 15 days, with a mean of 6.35 days. Thirteen patients (65%) had complete resolution of symptoms, 5 patients (25%) reported significant improvement, and 2 patients (10%) did not benefit from the operation. CONCLUSION: Long-term follow-up is necessary to determine the efficacy of this laparoscopic technique. The success rate for any incontinence procedure is usually inversely proportional to the duration of follow-up.

Laparoscopic varicocelectomy: technique and results.

OBJECTIVE: To determine the safety and efficacy of laparoscopic varicocelectomy in the treatment of symptomatic varicocele. PATIENTS AND METHODS: Indications for surgery were subfertility in 98 patients and pain in nine. All varicoceles were confirmed on Doppler ultrasound. Seventy-two per cent of the patients had left-sided varicoceles and bilateral varicoceles were seen in 27%. A three-puncture technique was used with carbon dioxide insufflation. The spermatic vessels were individually identified and clips were used to ligate the veins. The spermatic artery was preserved in all cases. The operation was performed on a day surgery basis with an average operative time of 61.4 min (56.6 min for unilateral and 75.8 min for bilateral varicocelectomy). RESULTS: Morbidity was low, with pneumoscrotum in two patients and wound infection in two others. Sixty-one patients for whom pre- and post-operative seminal analyses were available showed improvement in sperm count and motility, with a concomitant fall in the percentage of abnormal sperm forms. CONCLUSION: Laparoscopic varicocelectomy is safe and effective, causing minimal discomfort and allowing patients an early return to activity.

Nodular skin tuberculosis with lymphatic spread--a case report.

An unusual case of tuberculosis paronychia with skin infection of the big toe was recently seen in a patient returning from Kalimantan. This was complicated by inguinal lymphadenitis and tuberculosis abscess formation. The diagnosis was made on culture of the pus from the abscess and upon biopsy and histological examination of the skin lesion from the toe. The patient responded to surgical treatment and chemotherapy with ethambutol, rifampicin and isoniazid.

Gastric ulceration with acute bleeding from tuberculosis of the stomach--a case report.

Tuberculosis of the stomach is a rarity. Its diagnosis is difficult as it is often unsuspected or unrecognised. This is a case report of an elderly man who presented with active upper gastrointestinal tract bleeding. The diagnosis was made postoperatively following gastrectomy for bleeding gastric ulcers. The histological specimens showed caseating epithelioid granulomas with Langerhan's giant cells centrally. The authors reviewed the recent literature on tuberculosis of the stomach, and suggest ways to identify the patients at risk.

Ureterorenoscopy: factors influencing success.

The first 100 patients with ureteric calculi to undergo planned ureteroscopy and lithotripsy were retrospectively studied to evaluate the factors which influenced the success of the procedure. All 75 males and 25 females who underwent this procedure had surgical indications to treat the stones. The factors influencing a successful outcome were studied over four different time frames. It was found that the procedure was more successful in females, and lower ureteric stones. The stone size did not affect the outcome as expected. The learning curve was very evident as increased experience produced higher success rates for ureteric access and lithotripsy, less morbidity, shorter operating time and lower open surgery rates. The introduction of the miniscope and laser lithotripsy was however the most significant factor in ensuring a successful outcome.