Emergency laparoscopic splenectomy for splenic trauma in a Jehovah's Witness patient.

The safety and efficacy of laparoscopic splenectomy in the management of benign hematologic diseases is well established. However, most consider the laparoscopic approach to splenectomy in trauma patients contraindicated. We present a 76-year-old Jehovah's Witness who sustained a blunt abdominal trauma, rib fractures, and grade III splenic injury. She continued to lose blood, albeit slowly, for which she underwent preemptive urgent laparoscopic splenectomy with the use of the red cell saver. The operating time was 65 minutes. She was discharged on the 16th postoperative day after recovering from fractured ribs with subsequent pulmonary atelectasis and basal pneumonia. Whereas the majority of grade I to III splenic injuries in adults can be managed conservatively, some 20% will fail and require emergency splenectomy for delayed rupture of the spleen. In a Jehovah's Witness patient, early splenectomy for injury with the use of red cell saver is advised. This may be accomplished laparoscopically in the hemodynamically noncompromised patient.

Laparoscopic enterolithotomy for gallstone ileus.

BACKGROUND AND AIMS: Gallstone ileus (GSI) is an uncommon complication of gallstone disease that usually occurs in debilitated elderly patients in whom the minimal trauma of laparoscopic surgery might be advantageous. The outcome of laparoscopic surgery in 3 consecutive patients with GSI is presented, and its role is discussed. METHODS: The laparoscopic approach was attempted in all patients with suspected GSI. RESULTS: Three consecutive patients (2 female) aged 64 to 85 years with a median American Society of Anesthesiology score of 3E were admitted with small bowel obstruction. A laparoscopic enterolithotomy was carried out in all patients, and was completed successfully with a median operative time of 90 minutes. There were no intraoperative or postoperative complications, and the median postoperative hospital stay was 5 days. CONCLUSIONS: Small bowel obstruction due to GSI may be safely managed using minimally invasive surgery with suggested benefits in these elderly patients.

Laparoscopic endogastric and transgastric cystgastrostomy and pancreatic necrosectomy.

BACKGROUND/AIMS: Pancreatic pseudocysts (PP) that complicate acute necrotizing pancreatitis (ANP) and require internal drainage may be managed laparoscopically. We present our experience with the laparoscopic endogastric and transgastric approaches to pseudocyst-gastrostomy (PCG). METHODOLOGY: Seven patients (4 female) aged 25-75 (median, 60) years with large (median, 12cm), symptomatic and persistent (median, 5 months) retrogastric PP underwent PCG. All procedures were attempted laparoscopically. The endogastric approach was applied in the initial three patients and was replaced with the transgastric approach in the subsequent four patients. All patients underwent concomitant necrosectomy for sterile pancreatic necrosis. Patients were followed up with regular abdominal ultrasonography. Results shown represent median (range). RESULTS: There were no conversions to open surgery. The operating time was 135 (60-200) minutes and was longer with the endogastric approach (165 vs. 112 minutes). There were no postoperative complications and the postoperative hospital stay was 2 (1-4) days. There were no recurrences at a follow-up of 12 (2-21) months. CONCLUSIONS: Laparoscopic PCG with concomitant necrosectomy for PP that complicate ANP is feasible and safe and is associated with smooth and rapid recovery. The transgastric approach provides better access and is simpler to apply than that of the endogastric approach.

Timing of laparoscopic cholecystectomy for acute cholecystitis: evidence to support a proposal for an early interval surgery.

We evaluated the safety and feasibility of delayed urgent laparoscopic cholecystectomy (LC) performed beyond 72 hours to overcome the logistical difficulties in performing early urgent LC within 72 hours of admission with acute cholecystitis (AC), and to avoid earlier readmission with recurrent AC in patients awaiting delayed interval. Patients admitted with AC were scheduled for urgent LC. Patients who underwent early urgent LC were compared with those who had delayed urgent surgery. Fifty consecutive patients underwent urgent LC for AC within 2 weeks of admission. There were no conversions and no bile duct injuries. Delayed surgery (n=36) neither prolonged operating time (90 vs. 85 minutes), nor increased operative morbidity (9.7% vs. 7.7%) or mortality (2.4% vs. 7.7%) compared with early surgery (n=14). Although delayed surgery was associated with shorter postoperative hospital stay (1 vs. 2 days, P = 0.029), it prolonged total hospital stay (9 vs. 5 days, P < 0.0001). Delay of LC beyond 72 hours neither increases operative difficulty nor prolongs recovery. It might be more cost effective to schedule patients who could not undergo early urgent LC but are responding to conservative treatment for an early interval LC within 2 weeks of presentation with AC.

Laparoscopic versus open splenectomy for massive splenomegaly: a comparative study.

BACKGROUND: Despite the benefits of the laparoscopic approach to splenectomy, its application in patients with massive splenomegaly (splenic weight >or= 1000 g) remains controversial. In this study we evaluated the safety and feasibility of laparoscopic splenectomy for massive splenomegaly compared with open splenectomy. MATERIALS AND METHODS: One surgeon applied the laparoscopic approach to splenectomy to all comers with massive splenomegaly, while other surgeons carried out the surgery through a laparotomy. The outcomes of the two approaches were compared on an intention-to-treat basis. Results of continuous variables are shown as medians. RESULTS: Fifteen patients underwent laparoscopic splenectomy between 2000 and 2005, and 13 underwent open splenectomy between 1996 and 2003. The two groups were comparable for age, sex, American Society of Anesthesiologists score, and splenic weight (1.3 vs. 1.1 kg). There was one conversion (6.6%) to open surgery. Although laparoscopic splenectomy was associated with significantly longer operating time (175 vs. 90 minutes, P < 0.001), it carried lower postoperative morbidity and mortality (13.3 vs. 30.8% and 0 vs. 7.7%, respectively). Laparoscopic splenectomy was associated with significantly lower total dose (29 vs. 264 mg morphine-equivalent, P < 0.0001) and duration of opiate usage (1 vs. 4 days, P < 0.0001); duration of parenteral hydration (24 vs. 96 hours, P = 0.006) and more rapid resumption of oral diet (24 vs. 72 hours, P = 0.017); and a shorter postoperative hospital stay (3 vs. 10 days, P < 0.0001). CONCLUSIONS: The laparoscopic approach to splenectomy for massive splenomegaly is feasible and safe. Despite a longer operating time, the postoperative recovery following laparoscopic splenectomy is smoother, with lower morbidity and shorter postoperative hospital stay compared with open splenectomy.

Laparoscopic gastric and biliary bypass: a single-center cohort prospective study.

PURPOSE: Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS: Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS: Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION: Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.