Short-term outcomes in open vs. laparoscopic herniorrhaphy: confounding impact of worker's compensation on convalescence.

Over a 28-month period, 123 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open herniorrhaphy (OH) to laparoscopic inguinal herniorrhaphy (LH). The primary end point was duration of convalescence. Sixty-five patients underwent OH and 58 underwent LH. Both groups were well matched for all baseline parameters, although LH patients anticipated a shorter convalescence than OH patients (14.3 +/- 9.4 days vs. 18.5 +/- 10.8 days; P = 0.021). The median duration of hospital stay was one day in both groups. No difference was observed in the duration of convalescence (LH 9.8 +/- 7.4 days; OH 11.6 +/- 7. 7 days) across groups. However, when the data were analyzed after removing patients receiving disability ("worker's") compensation (21 patients), patients undergoing LH recovered on average 3 days faster (LH 7.8 +/- 5.6 days; OH 10.9 +/- 7.5 days; P = 0.02). Patients not receiving worker's compensation appear to have a shorter convalescence after LH compared to OH. Disability compensation is a major confounding variable in determining convalescence and needs to be controlled for in any future trial design.

Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial.

BACKGROUND: Benefits of laparoscopic herniorrhaphy (LH) over open hernia repair (OH) remain unproved. METHODS: Interim analysis of a prospective randomized controlled trial compared OH with LH where study outcomes were measured by third-party evaluators through patient interviews. RESULTS: Both groups were well matched for all baseline parameters, although LH patients anticipated a quicker postoperative recovery than OH (p = 0.014). No significant difference was noted in operating time or surgeon operative satisfaction. The median duration of hospital stay was 1 day in both groups; LH patients made use of significantly less postoperative narcotics than OH (p = 0.02). No difference was observed in the durations of convalescence (LH, 9.6 +/- 7.6 days; OH, 10.9 +/- 7.4 days). Greater improvements in quality of life were exhibited in LH patients than OH patients 1 month after operation (p = 0.035), with one of the two measures used. A greater percentage of LH patients seemed "very satisfied with their operation" (p = 0.07). Complication rates were similar, and a single recurrence, in a patient in the OH group, has been observed after a median follow-up of 14 months. CONCLUSIONS: Direct cost measurements showed LH to be 40% more expensive than OH in the context of a Canadian-type health care system. To date, benefits in postoperative pain and possibly quality of life have been detected in the LH group.

The general surgeon through the looking glass: bright reflections from a tarnished image.

The image of the general surgeon is suffering in the eyes of trainees, peers, the public and even general surgeons themselves. The magnitude and importance of this to the future of the specialty is reviewed. A diminishing number of graduates are entering general surgical training, and only one-quarter ultimately complete their training and remain in general surgery practice. A lack of suitable academic role models and the dichotomy that exists between traditional insistence on uniform broad-based training for all and the realities of clinical practice are important parts of the image problem. This is particularly evident in small communities where the general surgeon may be ill prepared for the surgical needs of the community, or conversely where the present generation of general practitioners fails to recognize the capabilities of the general surgeon. The public does not know the meaning of the term general surgeon and fails fails to recognize and reward its highly specialist nature. Solutions to this image problem include the following: acceptance of and emphasis on the generalist nature of the specialty of general surgery; innovation and emulation of technologic advances but with careful evaluation; and reorganization of training programs with emphasis on core training in "surgery in general," flexibility tailored to ultimate career goals and preservation of in-depth general surgical experience for those who ultimately intend to serve its practice.

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

OBJECTIVE: This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. SUMMARY BACKGROUND DATA: There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. METHODS: Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. RESULTS: A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. CONCLUSIONS: LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.

Risks of blind versus open approach to celiotomy for laparoscopic surgery.

Patients undergoing laparoscopic cholecystectomy had celiotomy either by a blind (Veress needle) approach (n = 781) or by fascial and peritoneal incision with insertion of a 10-mm sheath under direct vision (n = 247). The blind approach was associated with three small bowel injuries and one tear of the left common iliac artery. No intestinal or vascular injuries occurred in the open insertion group. The difference was not statistically significant. The mean duration of surgery was 81.4 +/- 1.3 min in the blind group compared with 72.6 +/- 2.0 min in the open group (p < 0.001). There was no significant difference in postoperative stay or in return to normal activity between the two groups. It is recommended that blind access to the peritoneal cavity for laparoscopy be abandoned in favor of an open approach because the blind approach confers no advantages and places the patient at risk for unrecognized visceral or vascular injury even though these injuries may not occur at a statistically significant frequency.

Canadian laparoscopic surgery survey.

OBJECTIVE: To assess the status of laparoscopic general surgery in Canada and the training experience and educational needs of Canadian surgeons, particularly with laparoscopic cholecystectomy (LC). DESIGN: All of Canada's practising general surgeons were surveyed by mail approximately 15 months after the general availability of laparoscopic video equipment. Questionnaires completed by 736 surgeons form the basis of the analysis. SETTING: The respondent profile produced a good sample distribution to assess differences related to age, experience, location and type of practice; 30% practised in communities of 50,000 or less; 38% in hospitals with 250 or fewer beds and 57% in community hospitals. RESULTS: Eighty-four percent had already learned LC, and 51% of them had performed more than 25 LCs. The number performed correlated directly with the number of cholecystectomies usually performed yearly before laparoscopy. Age and lack of relevance to practice were reasons for not learning. Ninety-one percent took formal training courses, usually university sponsored and in Canada. Complications were experienced by 44% of respondents. Bile leak (26%), hemorrhage (15%) and bile-duct injury (9%) were the most common and increased as the number of cholecystectomies usually performed prior to LC increased. Age, sex, type and location of hospital and size of city were not significant factors. The data show a consistent (p < 0.001) increase in the proportion of surgeons who encountered a complication as the number of LCs performed increased. CONCLUSIONS: LC has been introduced in Canada in an unpredicted, rapid and seemingly orderly and responsible fashion in all areas, types and sizes of communities. It has been equally well applied by surgeons of all ages and size of practice whether practising in the smaller community or in the university centre. The dogma of complications related to a "learning curve" is not supported by the author's data, and experience with complications is not restricted to the occasional biliary surgeon. Continued vigilance is necessary.

Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group.

Laparoscopic cholecystectomy (LC) has gained wide acceptance for treatment of cholelithiasis in preference to open cholecystectomy, though it has not been formally compared with mini cholecystectomy (MC). We have compared these two techniques in a randomised trial. 70 patients with ultrasound-proven cholelithiasis were randomly allocated LC (38) or MC (32); 37 and 25, respectively, underwent the assigned procedure. The mean hospital stay (including 1 preoperative day) was significantly shorter in the LC than the MC group (median 3 [interquartile range 2-3] vs 4 [3-5], p = 0.001) as was duration of convalescence (mean 11.9 [SD 9.1] vs 20.2 [16.5] days, p = 0.04). The rate of return to normal activities was 1.77 times greater in the LC group than in the MC group (95% confidence interval 1.01-3.11, p = 0.03). In regression analysis, the type of cholecystectomy done was the only variable significantly associated with the duration of convalescence. Although there was significant postoperative improvement in all of three quality of life scores in both groups, LC patients improved more quickly than did MC patients. This randomised trial shows the superior effectiveness of LC over MC in treating cholelithiasis.

Role of the teaching hospital in the development of a laparoscopic cholecystectomy program.

Laparoscopic cholecystectomy was introduced at McGill University-affiliated hospitals in a planned manner to evaluate the safety and results of this new procedure while training attending and resident surgeons. Laparoscopy was performed with the intent of carrying out cholecystectomy in 500 consecutive patients (70% female, 30% male), whose age averaged 48 years (range from 7 to 93 years). Thirty-seven percent had undergone intra-abdominal surgery previously, and 9.1% had had acute cholecystitis. There were two common-bile-duct injuries and one major small-bowel injury. The procedure had to be converted to open cholecystectomy in 25 (5%) patients. There were no deaths. The mean duration of surgery was 88 minutes. Fifty-five percent of patients were discharged home in 24 hours or less after surgery, and 75% were back to normal activity within 1 week of discharge. Fourteen attending staff and 8 senior residents achieved competence to carry out laparoscopic cholecystectomy independently.

Preoperative parathyroid localization: a prospective evaluation of ultrasonography and thallium-technetium scintigraphy in hyperparathyroidism.

To assess the ability of ultrasonography (US) and dual tracer thallium-technetium subtraction scanning (NS) to localize abnormal parathyroid glands, these two investigations were carried out preoperatively in 27 consecutive patients who underwent surgery for hyperparathyroidism. Nineteen patients had adenomas and 8 hyperplasia. Of 23 US procedures 2 were inadequate, and of 26 NS procedures 1 was inadequate. Ultrasonography was found to be superior to NS for preoperative localization of abnormal parathyroid glands (sensitivity per gland 53% versus 36%); detection rates for hyperplasia were poor for both techniques (sensitivity per gland 36% and 25%). However, when positive, both techniques were extremely accurate (positive predictive value of 100% for both). There was no correlation between the weight of the gland or degree of physiological hyperfunction (parathyroid hormone level) and detection rates for the two techniques. False-positive results were rare for both, so a positive result was highly predictive of an abnormality at that location. Ultrasonography had sufficient accuracy to suggest its routine use when adenoma is suspected, particularly to detect the side of the lesion (sensitivity 78% and positive predictive value 100%). The addition of subtraction scintigraphy does not appear to be warranted.

Nonshunting operations for variceal hemorrhage.

To evaluate the various nonshunting treatment modalities currently being used, it is difficult to make comparative assessments by reviewing the literature. There is varied composition in the groups studied; numerous major modifications, but more often subtle but poorly described differences in surgical techniques; and lack of uniform definitions and methods of reporting even the most basic of results, be it recurrent hemorrhage, encephalopathy, or survival. Series often lump together patients with cirrhosis, both alcoholic and nonalcoholic, noncirrhotic intrahepatic block, and extrahepatic block, each of which has a different natural history, prognosis, and physiologic and hemodynamic response to interventions. Classification of severity of cirrhosis, although commonly referred to as Child's class A, B, or C, may be based on time of assessment, worst criteria present, or a point scoring system. The operations are described as "emergency," "urgent," "emergent," or "elective," and the definition of each varies with investigator. Clearly, the ability of the patient to stop bleeding and survive the hazards and high mortality of the early hours of the acute event places him in a better risk group irrespective of whether the surgical intervention is performed "urgently" within 24 hours or electively in 24 days. Expressions of long-term survival frequently do not always take into account the operative deaths or the mean follow-up time. However, some general remarks can be made. The Sugiura procedure can be performed with an extremely low mortality in selected elective patients, particularly the nonalcoholic, with virtually no postoperative encephalopathy and negligible variceal rebleeding. Postoperative major hepatic decompensation does not appear to occur with time, and long-term survival would appear superior to DSR shunt. In the class A or B alcoholic cirrhotic, results are certainly as good as and perhaps better than DSR shunt, and it is a reasonable alternative, particularly when technical and other considerations make the performance of such a shunt difficult. Surgeons who routinely perform the Warren shunt should have this operation available in their repertoire as an alternative. Attempts to compromise and reduce the extent of devascularization utilizing only a thoracic or abdominal venue or to violate Sugiura's principle of leaving intact the coronary-periesophageal-azygos venous pathway generally result in a progressively higher incidence of recurrent hemorrhage with time. The early success reported by Perecchia, Abouna, and Franco, with a transabdominal approach and lesser thoracic devascularization, which avoids "entry" into the chest, is noted with interest for the future and suggests such an approach for the more critically bleeding patients rather than the initial thoracic approach of others.(ABSTRACT TRUNCATED AT 400 WORDS)

The open abdomen. The Marlex mesh and zipper technique: a method of managing intraperitoneal infection.

In conclusion, a zipper technique has been outlined that allows effective continuing drainage of the septic abdomen, permits early diagnosis of organ damage, is rapid and cost effective, minimizes ventilator dependency and gastrointestinal complications, is well tolerated by the patients, and has produced a modest 65 per cent survival rate in the first 34 critically ill patients in whom it was used. Selection of patients is critical. It is a technique that must not be undertaken lightly but that appears to have life-saving potential.

Euvolemic cirrhotic dogs in sodium balance maintain normal systemic hemodynamics.

Dogs with chronic biliary cirrhosis and portal hypertension commonly develop plasma volume expansion, urinary sodium retention, ascites, and perturbed systemic hemodynamics, i.e., a rise in cardiac output and a fall in peripheral vascular resistance. Our laboratory has previously demonstrated that creating a side-side portacaval anastomosis in such animals, and so venting hepatoportal pressure, will prevent sodium retention and ascites formation and will maintain the animals euvolemic. In the present study, in four cirrhotic dogs with such an anastomosis, observations made at 12 weeks postbiliary duct ligation, and in the presence of grossly disturbed liver function and morphology, failed to demonstrate any change from control conditions in arterial blood pressure, cardiac output, or peripheral vascular resistance. We conclude that venting hepatoportal pressure in cirrhotic dogs with markedly disturbed liver function prevents the advent of a hyperdynamic circulation, possibly by preventing volume expansion.

Hepatic denervation alters first-phase urinary sodium excretion in dogs with cirrhosis.

Cirrhotic dogs without intrahepatic hypertension (IHH) never retain sodium or expand plasma volume. To test the hypothesis that IHH may cause urinary sodium retention early in cirrhosis, we prepared cirrhotic dogs (chronic biliary obstruction) who underwent simultaneous hepatic denervation with end-side portacaval anastomoses. Such animals, along with appropriate controls and unanesthetized were studied by balance techniques. In the experimental group, plasma volume never increased, and sodium retention did not occur until 2 days prior to the appearance of detectable ascites. In a sham-denervated group, plasma volume increased by 10% and sodium retention occurred on the average 8.4 days prior to ascites. When the portal veins were left intact, the sham-denervated group showed the usual magnitude of plasma volume expansion observed in cirrhotic dogs (18.3%) with a 7-day delay between sodium retention and ascites appearance. Those dogs with hepatic denervation demonstrated a 9.2-day delay with 12.6% expansion of plasma volume. When ascites was mobilized with a peritoneovenous valve, and dogs were subjected to a high salt diet (130 meq/day), denervated dogs excreted the load normally, whereas sham-denervated dogs retained sodium and developed anasarca. We conclude that in cirrhotic dogs with IHH, liver denervation prevents early non-volume-related sodium retention.

Sodium excretion in dogs with low-grade caval constriction: role of hepatic nerves.

Low-grade thoracic caval constriction will raise intrahepatic pressure without driving fluid from the vascular space as ascites. In eight such dogs where venous pressure was increased by 6.6 cmH2O, sodium balance studies showed a positive cumulative balance of 85 meq and a weight gain of 480 g over a 6-day period in the absence of any change in renal perfusion, glomerular filtration rate, central venous pressure, blood pressure, cardiac output peripheral vascular resistance, or plasma levels of aldosterone. Liver function tests, including bromosulfophthalein disappearance curves, were also normal. In dogs with either sham surgery, or subjected to equivalent venous hypertension of the abdominal vena cava or portal veins, there was a cumulative positive sodium balance of only 21-28 meq over a 2-day period. When the liver was completely denervated prior to performing the thoracic caval constriction, the sodium handling profile reverted to the same pattern as observed in sham controls, i.e., 22 meq cumulative sodium over a 3-day period. When the thoracic caval constriction was tightened to produce ascites, a LeVeen valve was inserted and the ascites mobilized. In response to 130 meq/day sodium diet, denervated dogs excreted the sodium load normally, whereas dogs with intact hepatic nerves retained sodium and developed anasarca. We conclude that intrahepatic baroreceptors may modulate sodium excretion in the presence of intrahepatic hypertension.