[Omental infarct after a gastric by-pass]. / Infarctus épiploïque après by-pass gastrique.

The authors describe the case of a 56 year old woman 25 days status post laparoscopic gastric bypass who presented with an acute onset of severe epigastric pain with signs of inflammation and localized peritoneal irritation. Although her findings suggested a late anastomotic leak, an abdominal CT scan revealed only necrosis of the greater omentum beneath the left hepatic lobe. This finding permitted a non-surgical approach; after observation over several days, the patient's symptoms resolved completely.

[Contribution of laparoscopy in the management of abdominal stab wounds]. / Apport de la coelioscopie dans la prise en charge des plaies par arme blanche de l'abdomen.

Laparotomy is useless in 5 to 39% of patients suffering from penetrating abdominal trauma. The objective of this study is to try to determine the value of laparoscopy in the management of such patients. Thirteen patients underwent laparoscopy for abdominal wound. 11 of these patients had a penetrating abdominal trauma and only 4 of them suffered from lesions requiring surgical treatment (2 intestinal wounds, 1 gastric wound and 1 coeliac artery disruption). No treatment was required in 30 cases (1 wound of intestinal serosa and 2 superficial hepatic wounds). In the last 6 cases no intra-abdominal wound was found. There was no mortality or morbidity. No lesions were missed at laparoscopy. Laparoscopy avoided useless laparotomy in 9 out of 13 patients. This suggests that laparoscopy is a reliable method in the management of patients suffering from abdominal wounds, allowing a very sensitive and specific diagnosis of penetration and visceral injuries. In some cases, is allows laparoscopic treatment of the visceral injury.

[Splenectomy in Gaucher's disease. Apropos of 2 cases, one of which was preceded by embolization]. / La splénectomie dans la maladie de Gaucher. A propos de deux cas dont l'un précédé d'une embolisation.

Two cases of Gaucher's disease type I are reported Splenectomy was indicated because of hypersplenism and massive splenomegaly. In one case hypersplenism was treated with pre-operative selective embolization because of the volume of the spleen (20 kg). The embolization corrected the thrombopenia but not the size of the spleen. Four years after operation for case 1 and eight months for case two, there is an improvement in the clinical status.

[Place of celio-video-surgery in splenectomy for hematologic diseases]. / Place de la coelio-vidéo-chirurgie dans les splénectomies pour maladie hématologique.

In order to evaluate the place of the laparoscopic approach in splenectomy for haematological disease, the authors prospectively studied a series of 25 consecutive patients requiring splenectomy. There were 11 cases of thrombocytopenic purpura, 9 lymphomas, 2 cases of herediary spherocytosis, 1 Felty syndrome, 1 idiopathic myelofibrosis and 1 Hodgkin disease. Twelve patients (48%) underwent an immediate conventional procedure for huge splenomegaly (10), obesity (1), unavailability of video-equipment. Thirteen patients (52%) underwent a laparoscopic approach. Five of these operations were converted into a conventional approach for various reasons. In the other 8 patients, the spleen was completely released laparoscopically. In two of these 8 patients, the spleen was removed via a sub-pubic Pfannenstiel incision due toits volume. The last 6 spleens (24%) were removed in a plastic bag, corresponding to 5 cases of one thrombocytopenic purpura and one Hodgkin disease. None of these patients were obese. These results suggest that the laparoscopic approach is indicated in case of moderate splenemegaly in non-obese patients.

[Long-term results of the treatment of eventrations by intraperitoneal non-absorbable prosthesis (149 patients)]. / Résultats à long terme du traitement des éventrations par prothèse non résorbable intrapéritonéale (149 patients).

The authors report a series of 149 cases of incisional hernia, operated between 1983 and 1993, by insertion of a non-absorbable prosthetic mesh within the intraperitoneal cavity. This series consisted of 93 women and 56 men, with a mean age 57 years. One third of repairs were performed because of primary treatment failure. One or more operative risk factors were present in 127 patients. A non-absorbable intraperitoneal prosthetic mesh was inserted with tension to allow good musculo-aponeurotic repair. Postoperative mortality was 0.6%. All but 13 of the patients, were reviewed with a mean follow-up of 83 months. Twenty eight patients (20%) developed recurrence. In 8 cases, the cause of recurrence was failure of prosthetic mesh insertion because of excessive tension. Three patients (1.7%) developed a fistula in contact with the prosthetic mesh, that had to be removed. A small bowel fistula was observed in 2 cases after an intraoperative wound in 1 case, and a colonic fistula in 1 case. The results of incisional hernia repair with nonabsorbable intraperitoneal prosthetic mesh can be compared with these of other techniques using prosthetic materials. This technique does not require dissection of the intermediate planes and avoids undermining which causes substantial bleeding. The risk of sepsis is also decreased by deep placement of the prosthesis. The exceptional cases of fistula or the possibility of migration of the prosthesis are not exclusively observed with this technique, but must clearly encourage a very strict aseptic technique, with placement of omentum between the prosthetic mesh and the viscera.

[Medico-economic evaluation of treatment of inguinal hernia: Shouldice vs. laparoscopy]. / Evaluation médico-économique de la cure de hernie inguinale: Shouldice vs laparoscopie.

Between May 1994 and September 1995, 64 men were included in a randomized prospective study comparing conventional Shouldice repair (S group) and transperitoneal laparoscopic repair with polypropylene mesh (L group). Cost evaluation was divided into distinct parts: drugs, non usable surgical materials, medico-technical procedures food and employees costs. In group S, mean operating time was 56', total cost was 3,922 FF in the case of unilateral hernia and 4,808 FF and respectively 77' in the case of bilateral hernia. In group L, mean operative time was 89', total cost 8,949 FF (disposable trocars) and 7,136 FF (non-disposable trocars) in the case of unilateral hernia and 116', 9,570 FF and 7,763 FF in case of bilateral hernia. Postoperative stay was 4.2 days in group S and 4 days in group L. Return to work was 28.6 days in group L and 35.5 days in group S (ns). In conclusion laparoscopic hernia repair does not decrease post operative pain, hospital stay and return to work, but is twice as expensive.

[Short hospitalization in routine surgery. Experience with an unselected population]. / Hospitalisation courte en chirurgie courante: Expérience sur une population non sélectionnée.

Three hundred and ninety eight consecutive patients about to be operated upon for inguinal hernia (165), varicose veins (101) or thyroid gland hyperplasia (132) were offered short stay surgery. Patients who left the hospital at day 1 and those who left after day 1 for personal convenience were compared as regards age, sex, occupation, one-sided or two-sided pathology, assisted or non assisted convalescence, life style and drug consumption after discharge. Hernia patients showed no difference in all these parameters. Among varicose vein patients, the proportion of short stay refusals was significant only in women. As for patients undergoing thyroidectomy, only those who had simple lobectomy were in the short stay group. In all cases, short stay had no adverse effect. The main obstacle to short stay surgery might well be the patient himself, as he benefits from full social cover and has access to surgical treatment without being on a long waiting list.

[Cancers of the left colon with occlusion. Treatment by subtotal colectomy with immediate ileo-sigmoid anastomosis]. / Cancers du côlon gauche en occlusion. Traitement par colectomie sub-totale avec anastomose iléo-sigmoïdienne immédiate.

The technique of subtotal colectomy with immediate ileo-sigmoid anastomosis in the treatment of the carcinoma of the left colon revealed by obstruction is described. This operation treats, in one stage, both the obstruction and the cancer. The mortality, morbidity and duration of stay in hospital are less than with the usual sequential treatment. Social rehabilitation is quicker, which is particularly valuable since the expected survival of these patients is short due to old age, poor general condition or spreading of the malignancy.

[Celioscopic treatment of perforations of duodenal ulcers. 6 cases]. / Traitement coelioscopique des perforations d'ulcère duodénal. 6 observations.

Traditionally, perforations of duodenal ulcers are managed by suturing followed by peritoneal lavage and the underlying cause is addressed secondarily. Laparoscopy provides a means of meeting the different therapeutic needs. From May to October 1993, we treated 6 consecutive perforations of duodenal ulcers laparoscopically. In 5 cases, the perforation was the first manifestation of acute duodenal ulceration and the other case was chronic. The laparoscopic operation included peritoneal lavage and simple suture of the ulcer. The immediate post-operative period was uneventful. With a current follow-up of 3.6 months, 5 patients are asymptomatic and ulcer cicatrization has been confirmed by fibroscopy. In the sixth case with a past history of chronic duodenal ulcer, re-operation was required after a delay of 2 months for acido-fundic vagotomy (performed laparoscopically). The local presentation was satisfactory in this patient. Extensive peritoneal lavage, which can be performed with laparoscopy together with suture when the ulcer is recent, allows managing such patients according to Taylor's method. The usefulness of vagotomy can then be addressed and performed later laparoscopically after the initial lavage. This new approach offers a means of complete cure and has all the advantages of the classical technique.

[Pelvic lymphoceles after kidney transplantation. Intraperitoneal marsupialization by celioscopy]. / Lymphocèles pelviennes après transplantation rénale. Marsupialisation intrapéritonéale par coelioscopie.

OBJECTIVES: The appropriate treatment for symptomatic pelvic lymphoceles occurring after renal transplantation is still debated. External drainage exposes to risk of recurrence, infection or graft sclerosis and laparotomy has been required for intraperitoneal marsupialization in patients at risk. We report our experience with two cases treated by laparoscopic intraperitoneal marsupialization. PATIENTS: From November 1986 to September 1992, 170 renal transplantations were performed at our University Hospital. Lymphoceles developed in 12 cases and percutaneous puncture and irrigation was performed in all, successfully in 10. Relapse occurred in 2 patients--one 50-year-old woman with chronic glomerulonephritis and one 41-year-old man on peritoneal dialysis for polycystic renal disease--recipients of cadaver kidneys. SURGICAL TECHNIQUE: The laparoscopy was conducted under general anaesthesia. Four trocars were inserted, a 10 mm via the umbilicus for the optical system and three 5 mm trocars via the right and left flank and the left iliac fossa. A long puncture needle was used to drain the lymphocele and a localized collection and a large peritoneal window was created. The abdominal cavity was abundantly washed before withdrawing. RESULTS: Operation time was 35 minutes and conversion to laparotomy was not required. The only complication was a haematoma at one insertion site. Patients were discharged on day 2 and on day 1 with an unchanged immunosuppressor regimen. At 10 months follow-up, the patients were symptom-free and echography was normal. CONCLUSIONS: Surgical treatment of lymphoceles can be successfully performed by laparoscopy. The choice between conservative treatment and laparoscopic surgery remains to be determined.

[Radiation enteritis after pelvic irradiation of cancer of the rectum. Prevention by omentoplasty and pelvic partitioning with polyglactin 910 mesh]. / Entérite radique après irradiation pelvienne des cancers du rectum. Prévention par omentoplastie et cloisonnement pelvien par treillis de polyglactine 910.

To prevent radiation enteritis during post-operative irradiation of the pelvis for rectal carcinoma, the greater omentum, fed by the left gastro-epiploic pedicle, is pulled down into the pelvis which is separated from the abdomen by an absorbable polyglactin 910 mesh. The mesh, under tension, is attached superiorly to the lips of the posterior peritoneal section and anteriorly to the upper border of the pubis. This procedure has been used in seven patients, four of whom have been irradiated post-operatively without any gastrointestinal complication.

[One-stage treatment of neoplastic occlusions of the left colon. Apropos of 3 cases. Review of the literature]. / Traitement en un temps des occlusions coliques gauches néoplasiques. A propos de trois cas. Revue de la littérature.

The authors report of 3 news of subtotal colectomy with immediate anastomosis in the treatment of neoplastic occlusion of the left colon. They review all the cases (153) actually published. The advantages of this technic are: treatment of the occlusion and of the cancer in one stage; quicker social rehabilitation (14.8 days) useful overall in patients whom survival is short, lower mortality rate (10.45%) lower morbidity rate (25.6%) and quite none sequellae.

Laparoscopic anatomical hepatic resection. Report of four left lobectomies for solid tumors.

Four patients underwent a laparoscopic left hepatic resection for solid tumor, two for metastasis from colonic cancer, and two for focal nodular hyperplasia (final diagnosis). The procedure was performed according to the rules of conventional hepatic surgery and cancer surgery. No blood transfusion was necessary. No surgical complication occurred. In malignant disease, laparoscopy allows a good staging and the performance of a real no-touch technique; the specimen is removed in a plastic bag without contact to the abdominal wall. In symptomatic benign disease the esthetic benefit of the laparoscopic approach is real. In asymptomatic benign disease, laparoscopy could allow large biopsies in the case of uncertain diagnosis or dangerous resection. It allows safe resections in the case of small, well-located tumors. This approach requires sophisticated material and extensive experience in both laparoscopy and hepatobiliary surgery.

[Laparoscopic treatment of common bile duct lithiasis. Study of 56 cases]. / Traitement laparoscopique de la lithiase de la voie biliaire principale. Etude de 56 cas.

AIM OF THE STUDY: The aim of this retrospective study was to report the results of the laparoscopic management of common bile duct stones in an unicentric series of 56 patients. PATIENTS AND METHOD: From January 1993 to April 1998, 56 patients, 38 women, 18 men (mean age: 59.2 years), underwent a common bile duct exploration for lithiasis through a laparoscopic approach. The patients were hospitalised for angiocholitis (n = 13), cholecystitis (n = 11), biliary pain (n = 29, nine with jaundice), pancreatitis (n = 3), abnormality of hepatic profile (n = 1). All the patients underwent an intraoperative cholangiography. Removal of the stones was tried in 50 cases through a choledochotomy, in four through the cystic duct, using Mirrizi forceps, or Dormia and Fogarty catheters in case of failure. External biliary drainage and postoperative cholangiography were done systematically. The average diameter of the common bile duct was 10.5 mm (6-20 mm). RESULTS: In 41 patients, removal of the stones was laparoscopically successful. In 11 patients, a conversion into laparotomy was necessary for several reasons. In three patients with common bile duct of small diameter, the stones were abandoned for a further endoscopic sphincterotomy. There was no mortality and the morbidity rate was 7%. The mean postoperative hospital stay was 8.6 days (4-20) for all the series and 7.8 days in case of successful laparoscopic management. CONCLUSION: In 73% of the patients, the treatment of the common bile duct lithiasis could be achieved laparoscopically, but conventional approach and endoscopic sphincterotomy are still useful in case of failure of the laparoscopic management.