Hand-assisted laparoscopic surgery: an emerging technique.

BACKGROUND: Some surgeons are finding that the placement of one hand in the abdomen during laparoscopic procedures returns tactile feedback lost during purely laparoscopic surgery and facilitates dissection, retraction, and control of bleeding. Studies comparing patient postoperative discomfort after laparoscopic and hand-assisted laparoscopic procedures have not found a significant difference. METHODS: This article is a review of the current literature on hand-assisted laparoscopic surgery and of the different hand-assisted devices on the market. Included in the review are opinions of expert laparoscopic surgeons who have used hand-assisted devices. RESULTS: More than 100 hand-assisted laparoscopic procedures have been described in the literature. At least four different companies are involved in hand-assisted laparoscopic devices. Three of these companies currently are Food and Drug Administration (FDA) approved in the United States. CONCLUSIONS: Hand-assisted laparoscopic surgery is not necessary for all laparoscopic procedures. Hand-assisted laparoscopic technique is advantageous for certain procedures and clinical situations such as en bloc resections and removal of solid organ tumors, large colon tumors, and the kidney after donor nephrectomy. This technique offers benefits when a large incision is necessary to complete surgery such an open colon anastomosis.

Durability of laparoscopic repair of paraesophageal hernia.

OBJECTIVES: To define a method of primary repair that would minimize hernia recurrence and to report medium-term follow-up of patients who underwent laparoscopic repair of paraesophageal hernia to verify durability of the repair and to assess the effect of inclusion of an antireflux procedure. SUMMARY BACKGROUND DATA: Primary paraesophageal hernia repair was completed laparoscopically in 55 patients. There were five recurrences within 6 months when the sac was not excised (20%). After institution of a technique of total sac excision in 30 subsequent repairs, no early recurrences were observed. METHODS: Inclusion of an antireflux procedure, incidence of subsequent hernia recurrence, dysphagia, and gastroesophageal reflux symptoms were recorded in clinical follow-up of patients who underwent a laparoscopic procedure. RESULTS: Mean length of follow-up was 29 months. Forty-nine patients were available for follow-up, and one patient had died of lung cancer. Mean age at surgery was 68 years. The surgical morbidity rate in elderly patients was no greater than in younger patients. Eleven patients (22%) had symptoms of mild to moderate reflux, and 15 were taking acid-reduction medication for a variety of dyspeptic complaints. All but 2 of these 15 had undergone 360 degrees fundoplication at initial repair. Two patients (4%) had late recurrent hernia, each small, demonstrated by esophagram or endoscopy. CONCLUSIONS: Laparoscopic repair in the medium term appeared durable. The incidence of postsurgical reflux symptoms was unrelated to inclusion of an antireflux procedure. In the absence of motility data, partial fundoplication was preferred, although dysphagia after floppy 360 degrees wrap was rare. With the low morbidity rate of this procedure, correction of symptomatic paraesophageal hernia appears indicated in patients regardless of age.

The difficult cholecystectomy: problems related to concomitant diseases.

The difficult gallbladder is the most common "difficult" laparoscopic surgery performed by general surgeons. It is also "potentially" the one that places the patient at significant risk. This article reports on our first 1,900 laparoscopic cholecystectomies. With this report, it is the desire of the authors to share our experiences and lessons learned from more than 300 difficult gallbladder cases. We surgeons must strive for no bile duct injuries. If certain principles are followed, the surgeon will be able to improve his or her completion rate and decrease (if not eliminate) bile duct injuries. First and foremost is to know when to convert to open. Performance of fluorocholangiography to define anatomy is also very helpful in avoidance of bile duct injury. The laparoscopic surgeon should start with simple cases before "graduating" to more complex cases. Lastly, the ability to suture and knot tie is key in performing advanced procedures. This skill will allow completion of cases that otherwise would have to be converted to traditional surgery.

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes.

BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.