Percutaneous laparoscopic cholecystectomy: indications, contraindications and complications.

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.

Laparoscopic management of small bowel obstruction caused by a retrocaecal hernia.

Laparoscopy is not commonly used in the management of small bowel obstruction (SBO). We report the first documented case of laparoscopic diagnosis and treatment of a retrocaecal hernia, a type of internal abdominal hernia. An 86-year-old woman with a chest infection was referred with features of a well-established SBO. At laparoscopy, the hernia was quickly diagnosed and easily reduced, the bowel assessed for viability, and the sac treated by widely laying open its neck, thereby marsupializing the defect. A laparotomy was avoided, and she recovered promptly and without complication. We conclude that laparoscopy can play a useful role in the management of SBO and that its use should be considered in patients with no obvious external hernia and a virgin abdomen in whom an unusual cause is suspected.

Percutaneous laparoscopic cholecystectomy: the first fifty.

A series of 50 percutaneous laparoscopic cholecystectomies was performed by one surgeon between 7 June and 25 October 1990 using a modified technique as described by Dubois. There were 42 females and 8 males, the average age being 44 years with a range of 14-76 years. The average operating time was 80 min, ranging from 35 to 210 min. Postoperative stay averaged 2.9 days and there was an average of 11 days to return to work. Complications consisted of a subhepatic bile collection requiring open drainage, one minor wound infection and one minor abdominal wall haematoma. Laparoscopic cholecystectomy is a safe technique for removing the gall-bladder resulting in a rapid convalescence and early return to work. The initial learning curve is long and careful case selection should be carried out in this phase.

Laparoscopic management of blunt diaphragmatic injury.

BACKGROUND: Diaphragmatic injury is difficult to diagnose using current radiological modalities, and missed diagnosis has been associated with a mortality of 20-36%. Laparotomy is the most sensitive of the standard diagnostic tools, but its unnecessary use can be up to 25% and carries a morbidity of 20%. METHODS: The use of the laparoscope in three cases of blunt diaphragmatic injury is reported here. Two cases were non-acute. The diagnosis of diaphragmatic injury could not be confirmed pre-operatively in any of the cases. RESULTS: One, a left-sided injury, was easily diagnosed and repaired laparoscopically. The second, right-sided, was confirmed laparoscopically but had to be repaired by open due to difficulty with liver retraction. The third case, an acute injury, was not diagnosed at laparoscopy. Findings of free blood and distended small bowel warranted laparotomy and prevented the establishment of a safe, satisfactory pneumoperitoneum. Repair was performed open. None of the cases was complicated by pneumothorax. CONCLUSIONS: Laparoscopy is a useful tool for diagnosis of non-acute blunt diaphragmatic injury but has limitations in the acute setting. Left-sided injuries can be repaired laparoscopically but right-sided injuries proved difficult and may be better dealt with thoracoscopically.

Preoperative screening for common bile duct stones with infusion cholangiography: review of 1000 patients.

OBJECTIVE: The authors aimed to study the safety and accuracy of infusion cholangiography in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Intravenous cholangiography is a theoretically attractive method of screening the common bile duct for stones. However, there still remain serious reservations regarding its safety and accuracy, despite some reports in the literature to the contrary. METHODS: A personal series of 1000 patients undergoing routine preoperative infusion cholangiography was reviewed. RESULTS: The cholangiograms detected bile duct stones with a sensitivity of 93.3% and a specificity of 99.3%. There were no serious contrast reactions, and the minor contrast reaction rate was 0.7%. CONCLUSIONS: The authors conclude that infusion cholangiography is indeed safe and accurate and should play a substantial role in preoperative screening for incidental common bile duct stones.

Cholecystectomy without routine operative cholangiography.

A series of 1575 consecutive patients with cholelithiasis managed by cholecystectomy without operative cholangiography is presented. All operations were performed by one of our authors. Exploration of the bile ducts was performed in 185 (12%) patients. During the postoperative period there was evidence of retained calculi in three (1.6%) of the 185 patients. The incidence of remote calculi (those presenting at a time distant from cholecystectomy) was determined for patients undergoing cholecystectomy between 1963 and 1967. Follow up information was available on 258 (80%) of 321 patients. Clinical evidence of remote calculi was found in seven (2.7%) patients. The incidence of both retained and remote calculi was similar to that found in series where operative cholangiography was routine.

Synchronous carcinomas of the large intestine.

Sixty-one (3.0%) of 2029 patients managed operatively for carcinoma of the large intestine had synchronous carcinomas. In 47 (77.0%) of the 61 patients the carcinomas were in the same or adjacent segment(s) of large intestine. Adenomatous polyps were present in 18 (30%) patients compared to 269 (14%) of 1968 patients with a single cancer. A curative resection was performed in 40 of 61 patients, palliative resection in 16 and a non-resection palliative operation in five. Two patients required proctocolectomy and eight subtotal colectomy with ileorectal anastomosis. Cancer specific survival for the entire group and for those treated by curative resection did not differ significantly from that of patients with a single carcinoma. It is concluded that: (1) the presence of a second carcinoma does not significantly alter the survival prospects; (2) both pre-operative large intestinal examination and careful operative palpation of the entire large intestine should be performed, and (3) the significantly higher incidence of adenomatous polyps in patients with synchronous carcinomas is consistent with the polyp/cancer sequence hypothesis.