Hand movements in laparoscopic suturing: a simple vector analysis.

BACKGROUND: Laparoscopic suturing is a complex task that is vital to the performance of many advanced laparoscopic procedures. Mastery can be difficult and problematic for surgical trainees. METHODS: We present a description of hand movements in laparoscopic suturing. Complex maneuvers are simplified into linear motions using vectors. The analysis is intended to be a tool for training in the art of laparoscopic surgery. RESULTS: Linear hand movements in the x and y axes produce opposite motions at the instrument tip. Position along the z axis influences the extent of hand movement relative to the instrument tip. Rotational movements of the hand produce an equal rotation of the instrument tip. Revolution is a complex motion that combines movements in x and y axes. Vector analysis reveals that the arc of revolution must be reversed to produce the desired needle motion. CONCLUSIONS: A conceptual understanding of hand-movement vectors facilitates the efficient mastery of the complex skills required for laparoscopic suturing.

Laparoscopic assisted splenectomy for treatment of presumed immune thrombocytopenic purpura: initial results.

OBJECTIVE: To present the initial results of performance of laparoscopic splenectomy in two patients at Mayo Clinic Scottsdale. DESIGN: We describe two 18-year-old patients with idiopathic immune thrombocytopenic purpura and the technique of laparoscopic splenectomy used for treatment. MATERIAL AND METHODS: For adequate visualization of the spleen and exposure of the upper midline area should urgent laparotomy become necessary, we position the patient supine with a sandbag under the left lower costal margin. Insertion of five 10-mm trocars facilitates placement of instruments. Dissection of the spleen is begun inferiorly. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips, as are the short gastric vessels. Cautery is used for dividing the splenophrenic ligament. The spleen is placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision, after which the spleen is morcellated and then removed. Considerable care must be exercised to ensure that the plastic bag is not punctured and that no ectopic splenic tissue is present. RESULTS: Both laparoscopic splenectomies were successful, and no intraoperative or postoperative complications occurred. After dismissal on postoperative day 3, the patients quickly resumed all activities. The platelet counts returned to normal. CONCLUSIONS: These encouraging results support the use of laparoscopic splenectomy for immune thrombocytopenic purpura and suggest that this procedure may have a role in patients with other conditions of the spleen.

Torsion of the gallbladder.

Herein we report two cases of acute torsion of the gallbladder, including an extremely rare instance of torsion of the fundus of the organ. Because symptoms of torsion of the gallbladder are similar to those of other diseases and because of its rarity, preoperative diagnosis is difficult. The cause of this disorder had not been determined. Torsion of the gallbladder may occur as an acute event or be subtle and recurrent. Because of the potentially catastrophic consequences of delayed surgical intervention, an abdominal operation should be performed early in patients with symptoms suggestive of acute cholecystitis, especially if a mass is palpable. The recommended treatment is cholecystectomy.

Resection of select mediastinal parathyroid adenomas through an anterior mediastinotomy.

Two patients who had undergone thorough surgical exploration of the neck were found to have adenomas of fifth parathyroid glands within the mediastinum. After localization with computed tomographic scanning or thallium-technetium imaging, or both, these tumors were resected through a parasternal approach (anterior mediastinotomy); thus, median sternotomy was obviated. This approach has not been described previously for the removal of mediastinal parathyroid tumors.

Insulinoma in a patient with annular pancreas.

Intraoperative ultrasonography has facilitated the localization of insulinomas. In this report, we describe a patient who was found to have an insulinoma in association with an annular pancreas. Because such tumors can be in close approximation to major pancreatic ductal structures, intraoperative ultrasonography can be useful for not only localizing the lesion but also delineating the related anatomic features. Although the optimal management of an asymptomatic annular pancreas has not been determined, our patient had no evidence of chronic pancreatitis and no narrowing of the duodenal lumen; therefore, no bowel bypass procedure was done.

General surgical laparoscopic procedures for the "nonlaparologist".

OBJECTIVE: To assess our initial experience with a variety of laparoscopic procedures that can be performed by general surgeons with the basic skills used for laparoscopic cholecystectomy and without advanced laparoscopic expertise. MATERIAL AND METHODS: We retrospectively reviewed a 36-month experience (1991 through 1994) at our institution with a consecutive series of patients who underwent basic laparoscopic surgical procedures but specifically excluding cholecystectomy, appendectomy, herniorrhaphy, and colectomy. RESULTS: Procedures performed laparoscopically included gastrostomy, jejunostomy, small bowel resection, intra-abdominal and retroperitoneal biopsy, staging of intra-abdominal malignant lesions, and adhesiolysis for relief of small bowel obstruction. During the 3-year study period, 106 patients underwent 107 procedures, 89 of which were successful. Four patients had substantial complications, two of whom underwent surgical repair. CONCLUSION: A spectrum of procedures may be safely performed with the skills learned from laparoscopic cholecystectomy and without the need for advanced laparoscopic skills such as intracorporeal suturing or tying of knots.

Laparoscopic-assisted segmental colectomy: early Mayo Clinic experience.

OBJECTIVE: To present a large initial series of patients who underwent laparoscopic-assisted segmental colectomy and to assess the feasibility and safety of this procedure. DESIGN: We summarized the clinical outcome data for 122 Mayo Clinic patients selected for laparoscopic-assisted resection of the right, left, or sigmoid colon between 1991 and 1993. MATERIAL AND METHODS: Preexisting factors (such as obesity and prior abdominal operations), indications for surgical treatment, and intraoperative and postoperative complications were analyzed statistically in two groups of patients--those in whom the laparoscopic procedure was completed and those in whom conversion to an open surgical technique was necessary. RESULTS: Laparoscopic-assisted colectomy was successfully completed for a variety of colonic pathologic conditions, including polyps, cancer, and diverticulitis. No operative deaths occurred in this series, and the overall complication rate was low (11%). Patients in whom laparoscopic-assisted colectomy was completed had a more rapid return of bowel function and a briefer hospital stay than did those who required conversion to the traditional open surgical technique. Neither obesity nor previous abdominal surgical procedures precluded successful laparoscopic-assisted colectomy, although the conversion rate to open colectomy was 75% in patients whose weight exceeded 90 kg. CONCLUSION: These findings indicate that laparoscopic-assisted segmental colectomy is safe and feasible, and the procedure may offer patient-related advantages. Oncologic concerns, including recent reports of trocar site recurrences, suggest a cautious approach to its application for resection of colonic cancer.

Laparoscopic left adrenalectomy for aldosteronoma: early Mayo Clinic experience.

OBJECTIVE: To evaluate early results with laparoscopic left adrenalectomy in patients with an aldosteronoma. DESIGN: We retrospectively reviewed the medical records to Mayo patients in whom laparoscopic left adrenalectomy had been attempted for presumed aldosteronoma. MATERIAL AND METHODS: Data on the diagnosis, details about the procedure, occurrence of associated complications, and duration of recovery period were analyzed for all study patients. RESULTS: Of the nine patients who underwent attempted laparoscopic left adrenalectomy, seven had aldosteronoma. In six of the seven patients, the procedure was successful. No preoperative mortality occurred, and morbidity was limited to prolonged ileus in one patient. Of the other five patients with successful results, all tolerated liquids within 24 hours after the procedure. The mean postoperative hospital stay for the six patients with successful laparoscopic procedures was 2.3 days, and four patients were dismissed within 48 hours after the procedure. CONCLUSION: Laparoscopic adrenalectomy is a safe alternative for the management of aldosteronoma of the left adrenal gland.

Factors that predict malignant thyroid lesions when fine-needle aspiration is "suspicious for follicular neoplasm".

OBJECTIVE: To assess clinical factors that may improve the ability to predict the presence of a malignant lesion in thyroid nodules that are found to be "suspicious for follicular neoplasm" by fine-needle aspiration (FNA) cytology. MATERIAL AND METHODS: We undertook a retrospective review of the medical records of all patients at the three Mayo Clinic facilities who underwent a thyroid surgical procedure between January 1992 and December 1994 and had a preoperative FNA report of "suspicious for follicular neoplasm." Patient and nodule characteristics were analyzed statistically for associations with the presence of cancer. RESULTS: The study cohort consisted of 219 patients with a mean age of 54.3 years. Eighty-four percent of resections were done for benign disease. Of the 35 malignant lesions, 9 were incidental papillary cancers separate from the primary nodule; thus, only 26 cancers were found in the index nodule, and only 19 (9% of the total group) were follicular carcinomas. Clinical findings associated with a malignant index nodule were larger diameter, fixation of the mass, and younger age of the patient. CONCLUSION: Clinical characteristics may be used for more accurate assessment of the risk of the presence of a malignant lesion when FNA cytology of a thyroid nodule is reported as "suspicious for follicular neoplasm."

Long-term results of laparoscopic splenectomy for immune thrombocytopenic purpura.

OBJECTIVE: To assess the results of laparoscopic splenectomy as a treatment for immune thrombocytopenic purpura (ITP). MATERIAL AND METHODS: We conducted a retrospective study of all patients who underwent laparoscopic splenectomy for ITP at our institution between August 1992 and May 1997. RESULTS: Of 27 patients who underwent attempted laparoscopic splenectomy for ITP at our institution during the study period, 26 had completion of the procedure without conversion to an open splenectomy. The median postoperative hospital stay was 1.5 days, and no postoperative deaths occurred. In one patient, pancreatitis developed postoperatively. In four patients, splenectomy failed--two initially and two subsequently--and reinstitution of medical therapy was necessary. The other patients have remained free of medication, and 19 patients have platelet counts greater than 100 x 10(9)/L. The 3-year actuarial success rate was 81.5%. Response to corticosteroid therapy preoperatively may be an indicator of success of splenectomy. CONCLUSION: Laparoscopic splenectomy is safe and allows prompt recovery. Long-term response rates are similar to those achieved with open splenectomy.

Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients.

BACKGROUND: Few controlled studies have compared laparoscopic transabdominal adrenalectomy (LA) to conventional open posterior adrenalectomy (PA). METHODS: Five patients have undergone successful LA at our institution between 1992 and 1996. A matched case-control study of 50 PA patients was performed during a similar time period. RESULTS: Follow-up was complete in 82% of patients with a mean follow-up time of 25 months. There were no statistically significant differences between the LA and PA groups with regard to the following demographic features: age, gender, endocrine disorder, side and size of tumor, and body habitus. Statistically significant differences (p < 0.05), however, were present (LA vs PA) when we compared the following results: mean hospital stay (3.1 versus 5.7 days), narcotic equivalents (28 versus 48), return to normal activity (3.8 versus 7 weeks), patient satisfaction (9 versus 7 [scale 1 to 10, 10 being most satisfied]), late morbidity (0 versus 54%), and operating room time (167 versus 127 minutes). Median hospital charges ($7,000 versus $6,000) were slightly higher in the LA group (p = 0.05). CONCLUSIONS: Although LA is technically more demanding and slightly more expensive to perform, advances appear to exist for LA with regard to patient comfort, patient satisfaction, hospital stay, and return to normal daily activities. Late incisional complications are dramatically less in the LA group.

Laparoscopic splenectomy for immune thrombocytopenic purpura.

OBJECTIVE: To evaluate laparoscopic splenectomy as a treatment of immune thrombocytopenic purpura (ITP). DESIGN: Retrospective review of 18 patients followed up from 1 to 30 months. SETTING: Referral center using community hospital. PATIENTS: Consecutive series of patients undergoing laparoscopic splenectomy for ITP. INTERVENTION: Laparoscopic splenectomy. MAIN OUTCOME MEASURE: Surgical and hematologic results. RESULTS: Eighteen patients underwent laparoscopic splenectomy for ITP. All procedures were completed laparoscopically. There was no perioperative mortality. Pancreatitis developed in 1 patient (6%); 17 (94%) of 18 patients responded to splenectomy. The mean platelet count increased from 29 x 10(9) to 461 x 10(9)/L after laparoscopic splenectomy and stabilized at 327 x 10(9)/L (mean follow-up period, 15 months). Mean (+/- SEM) operative blood loss was 214 +/- 52 mL, necessitating no transfusions. Mean hospital stay was 2 days (range, 1-7 days). Most patients tolerated a liquid diet the day of the operation and a solid diet the next day. Parenteral narcotic usage averaged 12.3 morphine equivalent units, and 6 patients (33%) required no parenteral analgesia. An accessory spleen was identified in 1 patient (6%). Mean (+/- SEM) operative time was 130 +/- 8 minutes and was significantly less in the second half of our experience (117 vs 144 minutes, P = .04). CONCLUSIONS: Laparoscopic splenectomy is safe and effective for the management of ITP and allows rapid recovery. With increasing experience, operative times decrease. Laparoscopic splenectomy should be the treatment of choice for patients with ITP who require splenectomy.

Nitrogen embolus as a complication of hepatic cryosurgery.

A case of near-fatal nitrogen embolism during hepatic cryosurgery is presented. Modifications of liquid nitrogen probes, which prevent direct contact of liquid nitrogen with the tissue being frozen, can prevent this type of injury.

Corticotropin-independent macronodular adrenal hyperplasia: a clinicopathologic correlation.

OBJECTIVES: To investigate the clinical presentation, laboratory findings, and pathologic characteristics of patients with corticotropin (ACTH)-independent macronodular adrenal hyperplasia. DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: All patients with bilateral adrenocortical nodules associated with ACTH-independent hypercortisolism without clinicopathologic features of primary pigmented nodular adrenocortical disease with atrophic internodular adrenal cortex. MAIN OUTCOME MEASURES: Compare and contrast our findings with those previously reported; assess response to adrenalectomy. RESULTS: Nine patients met the criteria for corticotropin-independent macronodular adrenal hyperplasia. All patients had biochemical evidence of Cushing syndrome, although repetitive testing was frequently required. As a result, the diagnosis was delayed from 1 to 20 years. In all patients, both the low- and high-dose dexamethasone suppression tests failed to suppress cortisol secretion. No patient had elevated ACTH levels, and following curative bilateral adrenalectomy, no patient subsequently developed Nelson syndrome, with follow-up ranging from 1 to 8.5 years. Unique histologic features were identified in all cases. CONCLUSION: Amalgamating this series with other clinical reports plus basic research information, corticotropin-independent macronodular adrenal hyperplasia must be considered a separate and legitimate cause of Cushing syndrome.

Laparoscopic splenectomy: reduction of hospital charges.

Laparoscopic splenectomy has become our procedure of choice for the surgical management of immune thrombocytopenic purpura. Hospital charges for this procedure were analyzed for 24 consecutive patients undergoing laparoscopic splenectomy. Total charges have decreased over time and average a $233 decrease per patient treated. The decreased charges are related to decreased operating room charges. Furthermore, charges are shown to be related to the length of postoperative stay. Choice of instrumentation has kept intraoperative charges for disposables stable.

Hemangioma of the spleen: presentation, diagnosis, and management.

Splenic hemangioma is a rare disorder but remains the most common benign neoplasm of the spleen. It often has a latent clinical picture; however, spontaneous rupture has been reported to occur in as many as 25% of this patient population.1 Treatment most often consists of splenectomy. This report reviews an 8-year experience with splenic hemangioma at Mayo Clinic. Thirty-two patients were identified with SH during the 8-year study period. The average age was 63 years (range 23 to 94 years) with 17 women and 15 men. Six patients presented with symptoms potentially related to the SH. The remainder (80%) were asymptomatic, and the SH was discovered incidentally during evaluation for other disorders. A mass or palpable spleen was appreciated in only four patients (12.5%). SHs ranged in size from 0.3 to 7 cm maximum diameter. A diagnosis of SH was made in 11 patients based on the findings of a splenic mass on computed tomography or ultrasound. Each of these SHs was < or =4 cm. Three of the 11 patients had multiple SHs. All 11 patients were managed successfully with observation. All but one of the patients remains asymptomatic, and no complications have developed during follow-up (range 0.6 to 7 years, mean 2.9 years). The diagnosis of splenic hemangioma was made at the time of surgery in the remaining 21 patients (65%). Splenectomy was performed for suspicion of primary or secondary splenic pathology. There were no instances of spontaneous rupture of the SH. Small splenic lesions, which meet the radiologic criteria for hemangiomas, may be safely observed.

Laparoscopic management of small bowel obstruction: indications and outcome.

Our aim was to evaluate the feasibility of a laparoscopic, minimal access approach for the management of patients with small bowel obstruction. Forty patients underwent laparoscopic treatment of radiologically documented or suspected small bowel obstruction based on history and/or motility study. None had chronic abdominal or pelvic pain. The operation was completed laparoscopically in 14 patients (35%) and with laparoscopic-assisted procedures in 12 (30%); 14 (35%) required conversion to open celiotomy because of dense adhesions (precluding complete inspection or adhesiolysis), small bowel necrosis in the setting of small bowel obstruction, or neoplasia. Three iatrogenic enterotomies occurred while "running" the bowel. There were three (7%) postoperative procedure-related complications (wound infection, intra-abdominal abscess, ileus). The combined group of patients treated laparoscopically or with laparoscopic-assisted procedures had a shorter hospital stay than those converted to open celiotomy (4 +/- 0.6 vs. 7 +/- 0.7 days; P <0.003). At median follow-up of 12 months, 21 of 26 patients managed laparoscopically or with laparoscopic-assisted procedures remain asymptomatic; all 21 patients with an operatively confirmed site of mechanical obstruction managed by a minimal access approach remain asymptomatic. Laparoscopic treatment of small bowel obstruction is effective, leads to a shorter hospital stay, and has good long-term results. A minimal access approach to treatment of small bowel obstruction should be considered in selected patients.

Laparoscopic splenectomy offers advantages in selected patients with immune thrombocytopenic purpura.

BACKGROUND: Splenectomy plays a crucial role in the management of selected patients with immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy has been suggested as an alternative to open techniques. MATERIALS AND METHODS: A retrospective chart review was made for all patients undergoing splenectomy for ITP at our institution from June 1987 to August 1994. RESULTS: Twenty-one patients underwent splenectomy for ITP. Fourteen open procedures (group 1) and 7 laparoscopic procedures (group 2) were performed. Eleven of 14 patients in group 1 and all 7 patients in group 2 had appropriate increases in platelet count following surgery. There were 3 complications in group 1 and no major complications in group 2. Operative time was longer in group 2 (154 versus 68 minutes, P < 0.05), but decreased with experience (210 to 135 minutes). Compared with patients in group 1, patients in group 2 tolerated liquids sooner (0.7 versus 2.6 days, P < 0.05), required less parenteral narcotic (14 versus 65 morphine equivalents, P < 0.05), and were discharged sooner (2.1 versus 5 days, P < 0.05). All patients in group 2 remain well and require no medication after a mean follow-up of 11 months. CONCLUSIONS: Laparoscopic splenectomy is safe and effective in the management of select patients with ITP and offers advantages over open techniques.

Laparoscopic splenectomy for the treatment of gastric varices secondary to sinistral portal hypertension.

Portal hypertension presents significant challenges to the laparoscopic surgeon. Here we review the case of a successful laparoscopic splenectomy in a patient with sinistral portal hypertension. The value of preoperative splenic artery embolization is highlighted.

Eosinophil-mediated bile duct stricture. A case studied by immunohistochemistry.

Major basic protein accounts for the majority of the protein within the eosinophilic granule. Utilizing immunohistochemical staining for major basic protein, we have demonstrated the dominant role of the eosinophil in a reversible bile duct stricture.