Laparoscopic management of failed antireflux surgery.

Whether performed open or laparoscopically, antireflux procedures for gastroesophageal reflux disease sometimes fail and may require reoperation for optimal results. Between June 1992 and May 1995 eight patients presented with a failed antireflux procedure. Four patients had previously had a Belsey operation performed through the chest, two had had open Nissen fundoplications, and two had Nissen fundoplications performed via laparoscopy. Preoperative workup included cardiac, hematologic, and pulmonary evaluation as well as Esophagogastroduodenscopy (EGD), esophageal manometry, and 24-h pH studies to document reflux as a cause of recurrent symptoms. Two patients had aspiration symptoms even on medication. All patients had severe esophagitis on biopsy. Six reoperations (75%) were completed laparoscopically. In two patients we converted to open procedures due to an inability to expose the esophageal hiatus secondary to adhesions between the left lobe of the liver and the stomach. Of the six patients completed laparoscopically, one had a Nissen fundoplication and the others had a 200 degrees partial wrap. Two patients developed left pneumothorax, one patient required a single postoperative dilation, and one patient treated with open surgery developed pneumonia. The average hospitalization for laparoscopy was 2.2 days (range, 1-4 days), while those two who underwent open surgery stayed in the hospital 5 and 6 days. All patients were followed from 12 to 42 months and all are currently off medication and free of symptoms. Laparoscopic re-exploration for esophageal reflux disease can be safely performed with excellent results.

Avoiding laparoscopic complications.

Two years after laparoscopic cholecystectomy was introduced, and new horizons in laparoscopic surgery were being developed, a noted academic surgeon told me that although he had initially doubted the viability of laparoscopic 'cholecystectomy, he had become an avid supporter. He cautioned, however, that many surgeons would perform the operation with minimal training and marginal laparoscopic skills and that the injury rate would be devastating. Unfortunately, that prophecy has come to pass. In this dissertation, I would like to discuss some of those complications and how to avoid them. I choose not to dwell on minor or peripheral complications such as wound infection, pneumonia, deep venous thrombosis, urinary tract infection and the like, but rather, concentrate on complications related directly to laparoscopy and Iaparoscopic surgery. Laparoscopic complications are either a direct result of poor laparoscopic technique or related to anatomic misidentification. Technical complications include major vascular or intestinal injury or insufflation injury. Anatomic injuries usually involve the bile ducts, ureter or sensory nerves due to poor dissection and identification.

Laparoscopic cholecystectomy in freestanding outpatient centers.

Laparoscopic cholecystectomy has been shown to effectively reduce the hospitalization and postoperative recovery of patients undergoing cholecystectomy and has now become the most common method of cholecystectomy across the United States. Although previous reports document that this procedure can be performed safely on an outpatient basis, there is still some concern about discharging patients immediately after surgery. This study was undertaken by a cross section of general surgeons to determine whether laparoscopic cholecystectomy could be performed safely in an outpatient center.

Credentialing in laparoscopic surgery: a survey of physicians.

Laparoscopic surgery is now established as a major advance in modern surgery. Assurance of adequate training and credentialing is still a significant problem. Using laparoscopic cholecystectomy as an example, a survey was conducted to assess what criteria surgeons deem necessary for training and credentialing in a laparoscopic procedure. One hundred and forty-nine questionnaires were completed by surgeons from academic and private practice. A total of 110 (74%) surgeons consider that a course involving a hands-on animal lab should be required. Ninety-two (84%) of them answered that a preceptorship also should be required (average of 6.42 as surgeon and 5.86 as assistant). Ninety-nine (66%) responders believe that a surgeon should serve a probationary period (average of 11.6 cases) with review of morbidity, prior to being given full privileges. No statistical difference was found when comparing the answers of academic surgeons with private practitioners or between surgeons who had performed laparoscopic cholecystectomy and those who had not.

Laparoscopic cholecystectomy: cost analysis.

Recently laparoscopic cholecystectomy (LC) has become an accepted alternative to the traditional open cholecystectomy (OP). The purpose of this study was to compare laparoscopic cholecystectomy to open cholecystectomy with respect to four variables: (a) operative time, (b) length of hospital stay, (c) total hospital cost, and (d) morbidity and mortality rates. The most recent 200 LCs performed at HCA West Side Hospital were selected for comparison in the study. Demographic data, including age and sex were collected for all patients. The medical record for each patient was then reviewed to obtain the study variables. A control group of 200 patients undergoing elective open cholecystectomy over the same period was selected. Complications occurred in 12 patients (6.0%) in the LC group with one postoperative mortality. Nineteen patients (9.5%) suffered complications in the OC group with no operative mortality. The difference between the two groups was not statistically significant. The average length of operation (recorded in minutes) in the OC group was 87.79 (SD +/- 20.69) as compared to 103.78 (SD +/- 29.01) in the LC group. This difference proved to be slight, but significantly greater (p < 0.0001). The average length of stay (recorded in days) in the OC group was 4.43 (SD +/- 1.29) versus 1.13 (SD +/- .93) in the LC group. Again, the difference proved to be statistically significant (p < 0.0001). The corrected average total hospital charge from OC was $3,006 (SD +/- 755) versus $2,312 (SD +/- 484) for LC, a difference that was statistically significant (p < 0.0001). Laparoscopic cholecystectomy is a safe, effective, and cost-efficient alternative to open cholecystectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic laser cholecystectomy: analysis of 500 procedures.

Laparoscopic laser cholecystectomy (LLC) is a less morbid alternative to open cholecystectomy. The advantages of laparoscopic techniques associated with advances in laser technology have heralded a dramatic advancement in the surgical treatment of biliary disease. Earlier return to work, lower morbidity, and lower medical expense are known advantages of laparoscopic surgery. We present the findings of our initial 500 procedures. The outcome of the first 200 procedures is compared to the following 300 procedures. Operating time averaged 88 min, and cholangiograms were achieved in 79%. Thirty-two percent were performed as outpatients and average hospital stay was 0.98 days. Conversion to open cholecystectomy occurred in 1.8% of cases and there were 5 major complications related to the procedure. No wound infections and no respiratory complications were encountered. There were no mortalities. Management of common bile duct stones with combined surgical and endoscopic modalities are discussed.

Safe performance of difficult laparoscopic cholecystectomies.

Laparoscopic cholecystectomy has been advocated for the treatment of uncomplicated symptomatic gallstone disease, but has not been widely advocated for the management of more complicated gallbladder disease such as acute cholecystitis, previous surgery, or common duct stones. During the last 9 months, 360 patients underwent laparoscopic removal of their gallbladder. A total of 138 had a complicated presentation, making surgery more difficult. This article discusses the management of these patients with acute cholecystitis, previous surgery, or common duct disease. Using the described techniques, there were no complications or mortality. Laparoscopic management of difficult gallbladder problems is safe and effective.

Outpatient laparoscopic laser cholecystectomy.

Laparoscopic laser cholecystectomy has been performed clinically in the United States since 1988. After refinement of the technique, the procedure was offered on an outpatient basis. Eighty-three patients underwent laparoscopic laser cholecystectomy during the study period. Thirty-seven (45%) had the procedure as an outpatient. Younger patients were more suited for the outpatient procedure and those without previous surgery were more likely to have the procedure done as an outpatient. Weight, operating time, and gallbladder pathology were similar, although patients with acute inflammation of the gallbladder were more likely to require hospitalization. The primary reason for patient admission was patient preference.

Laparoscopic laser cholecystectomy and choledocholithiasis.

The management of common bile duct stones during laparoscopic laser cholecystectomy (LLC) is uncertain. Open common bile duct exploration is the least desirable option since it defeats the purpose of LLC. Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy has become the procedure of choice since it has a high rate of success and results in minimal morbidity. Intraoperative techniques using balloon catheters and the flexible choledochoscope via the cystic duct may obviate the need for ERCP in selected cases.

Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy.

The standard treatment of cholelithiasis in the United States is surgical removal of the gallbladder, but this treatment often has a major economic impact on the patient: major surgery, lengthy hospitalization, and several weeks' absence from work. Because of this economic factor, there has been a movement toward non-invasive methods, but they, too, have their drawbacks: long-term medical therapy; a high risk of stone recurrence because the diseased gallbladder is still in place. We therefore developed a means of performing a cholecystectomy through a laparoscope using laser technology, the results of which are compared here with the results in a series of "mini-lap" cholecystectomies that we also performed during the same time period.

Air gun injuries in children.

Air gun injuries occur frequently in children and are potentially lethal. Three cases of air gun injuries in children are described. Two children sustained air gun injuries to the neck that penetrated the platysma. Each had exploration of the wound. One had injury to the esophagus that was treated with external drainage; the other sustained no major injury to vital cervical structures. A third child received a penetrating injury to her right flank that did not appear to enter the peritoneal cavity. She was observed for 24 hours and released. After a six-month followup, all patients have remained free of complications. The emergency physician should be aware of the penetrating capabilities of these weapons, and they should be managed as would any other low-velocity gunshot wound.

Sepsis from sinusitis in nasotracheally intubated patients. A diagnostic dilemma.

The cause of sepsis in the intensive care unit patient can be a perplexing diagnostic problem. We have recently encountered seven patients who had sepsis associated with sinusitis of the paranasal sinuses. They represented 26 percent of all patients who had nasotracheal intubation for 5 days or more. Sinusitis as a complication of nasotracheal intubation has been previously reported, but its frequency has not been appreciated. Three case reports are presented to emphasize the importance of making this diagnosis. Standard x-ray studies will not adequately demonstrate all the paranasal sinuses. We have utilized computerized tomography to study these patients and found it to clearly demonstrate all the paranasal sinuses. We suggest a plan to help prevent sinusitis from nasotracheal intubation. Should this complication occur, however, the nasotracheal tube should be removed and the sinuses surgically drained or treated aggressively with topical agents.

Hemoperitoneum secondary to umbilical artery catheterization in the newborn.

A case of neonatal hemoperitoneum secondary to umbilical artery catheterization is presented. The only sign of arterial laceration was a rapid accumulation of intraperitoneal fluid following placement of the catheter.

Evaluation of the helicopter in aeromedical transfers.

Since the end of the Vietnam conflict, the technology of moving patients by helicopter has been applied to peacetime uses. There is doubt, however, that the helicopter has much to offer the patient when used as a routine and semi-emergency ambulance. This study reviewed 52 consecutive aeromedical evacuation requests which included both civilian and military patients. By comparing the patient's condition at both pickup, delivery and his subsequent course, it was determined that most patients would not have been unduly harmed by the slower methods of ground transfer. Only 33% of the patients were benefitted by rapid aeromedical transfer. Those patients benefitted can roughly be grouped as true surgical and medical emergencies. The use of the helicopter for routine transfers is to be discouraged.