Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years.

BACKGROUND: Two revolutions in inguinal hernia repair surgery have occurred during the last two decades. The first was the introduction of tension-free hernia repair by Liechtenstein in 1989 and the second was the application of laparoscopic surgery to the treatment of inguinal hernia in the early 1990s. The purposes of this study were to assess the safety and effectiveness of laparoscopic totally extraperitoneal (TEP) repair and to discuss the technical changes that we faced on the basis of our accumulative experience. METHODS: Patients who underwent an elective inguinal hernia repair at the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS), Bordeaux, between June 1990 and May 2005 were enrolled retrospectively in this study. Patient demographic data, operative and postoperative course, and outpatient follow-up were studied. RESULTS: A total of 3,100 hernia repairs were included in the study. The majority of the hernias were repaired by TEP technique; the repair was done by transabdominal preperitoneal (TAPP) repair in only 3%. Eleven percent of the hernias were recurrences after conventional repair. Mean operative time was 17 min in unilateral hernia and 24 min in bilateral hernia. There were 36 hernias (1.2%) that required conversion: 12 hernias were converted to open anterior Liechtenstein and 24 to laparoscopic TAPP technique. The incidence of intraoperative complications was low. Most of the patients were discharged at the second day of the surgery. The overall postoperative morbidity rate was 2.2%. The incidence of recurrence rate was 0.35%. The recurrence rate for the first 200 repairs was 2.5%, but it decreased to 0.47% for the subsequent 1,254 hernia repairs CONCLUSION: According to our experience, in the hands of experienced laparoscopic surgeons, laparoscopic hernia repair seems to be the favored approach for most types of inguinal hernias. TEP is preferred over TAPP as the peritoneum is not violated and there are fewer intra-abdominal complications.

Totally laparoscopic trans-hiatal gastroesophagectomy for benign diseases of the esophago-gastric junction.

AIM: To prospectively present our initial experience with totally laparoscopic transhiatal esophagogastrectomies for benign diseases of the cardia and distal esophagus. METHODS: Laparoscopic gastric mobilization and tubularization combined with transhiatal esophageal dissection and intrathoracic esophagogastric anastomosis accomplished by a circular stapler was done in 3 patients. There were 2 females and 1 male patient with a mean age of 73 +/- 5 years. RESULTS: Two patients were operated on due to benign stromal tumor of the cardia and one patient had severe oesophageal peptic stenosis. Mean blood loss was 47 +/- 15 mL and mean operating time was 130 +/- 10 min. There were no cases that required conversion to laparotomy. All patients were extubated immediately after surgery. Soft diet intake and ambulation times were 5.1 +/- 0.4 d and 2.6 +/- 0.6 d, respectively. There were no intraoperative and postoperative complications and there were no perioperative deaths. The average length of hospital stay was 9.3 +/- 3 d. All procedures were curative and all resected margins were tumor free. The mean number of retrieved lymph nodes was 18 +/- 8. CONCLUSION: Laparoscopic transhiatal esophago-gastrectomy for benign lesions has good effects and proves feasible and safe.

Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study.

BACKGROUND: Laparoscopic rectopexy offers the advantages of the open transabdominal approach while decreasing the surgical comorbidity. The aim of this prospective study was to assess the clinical and functional outcome of laparoscopic Wells procedure for full-thickness rectal prolapse. METHODS: Between 1999 and 2005, 77 patients underwent laparoscopic modified Wells procedure for full-thickness rectal prolapse. The patients were evaluated postoperatively for resolution of their prolapse and functional outcome, as well as for their satisfaction level regarding the procedure. RESULTS: Laparoscopy was successful in all but one case. There were no major intra- or postoperative complications and the mean hospital stay was 4.9 days. Approximately half of the patients had some degree of fecal incontinence preoperatively. At long-term follow up, 89 percent experienced alleviation of symptoms. Constipation was improved in 36% of cases. Eighteen percent of the patients suffered a new onset of constipation. Recurrent prolapse was observed in one patient. Ninety percent of the patients were satisfied at long-term follow-up. CONCLUSION: The laparoscopic Wells procedure for rectal prolapse had good functional results, a low recurrence rate and proved to be a feasible and safe procedure. Postoperative constipation remains a problem, which should be solved.

Virtually bloodless laparoscopic liver resection of recurrent hepatoma with a new laparoscopic sealer device: report of our initial laparoscopic experience.

Liver resections have always been challenging especially when dealing with hemostasis. This is even more true in the laparoscopic approach. Excessive intraoperative blood loss is known to increase morbidity and reduce survival of patients undergoing major cancer procedures. Multiple techniques and devices have been employed in the past to deal with this problem. Use of recent technologies such as radiofrequency energy for hemostasis in solid organs of both human and animals have been reported with promising results. The Habib Laparoscopic Sealer 4XL device is a new instrument that functions using such energy sources. Since the first successful use of a similar device for removing a liver tumor was performed in September 2005, new hopes and horizons have been generated for the laparoscopic approach. We report our initial experience of using such a device for laparoscopic liver resections in our center.

Isolated laparoscopic resection of the hepatic caudate lobe: surgical technique and a report of 2 cases.

The caudate lobe of the liver, segment 1 (S1), is located between the hepatic hilum and the inferior vena cava. Resection of S1 alone, without sacrificing other parts of the liver, is a surgical challenge. We present 2 cases of isolated laparoscopic resections of hepatic S1. We are the first to describe this laparoscopic technique. Two patients affected by colorectal liver metastases confined to S1 underwent laparoscopic isolated resections of S1 using a left approach. One of them also underwent left lateral segmentectomy. Both interventions were accomplished laparoscopically without conversion. Operative time for the first patient was 150 minutes and that for the second patient was 105 minutes. Blood loss was 200 and 100 mL for the first and second patients, respectively. There were no major intraoperative complications except for a tear in the inferior vena cava in the first patient that was repaired without the need for conversion. The postoperative course was uneventful for both patients. The duration of hospital stay was 10 and 8 days, respectively. The resected margins of the specimens were tumor-free (R0 resections). The 2 patients are alive and disease-free 7 and 5 months after the procedure. Isolated laparoscopic resection of the hepatic caudate lobe can be performed by a highly skilled surgeon, but should be performed only in selected cases.

Completely laparoscopic total and partial gastrectomy for benign and malignant diseases: a single institute's prospective analysis.

BACKGROUND: Laparoscopic surgery for gastrointestinal benign disease has gained worldwide acceptance; totally laparoscopic surgery for malignant diseases remains controversial. The purposes of this study were to examine prospectively our experience with laparoscopic gastric resections, to evaluate the surgical outcomes, and to discuss the role of these procedures in the treatment of benign and malignant diseases of the stomach. To the best of our knowledge, this is the largest prospective study of totally laparoscopic total and partial gastrectomies in Western countries. STUDY DESIGN: Thirty-three patients who underwent totally laparoscopic gastric resection between April 1995 and January 2004 were studied prospectively. Eight patients underwent laparoscopic total gastrectomy and 25 patients had laparoscopic partial gastrectomy. There were 21 women and 12 men with a mean age of 71 +/- 10 years. RESULTS: Twenty-one patients (63.6%) were operated on for malignant diseases and 12 patients (36.4%) had benign lesions. Conversion to laparotomy was not required in any case. Mean operative time was 138 +/- 40 minutes and mean blood loss was 58 +/- 85 mL. There were no major intraoperative complications except for one splenectomy, and there were no perioperative deaths. Two postoperative complications occurred; one patient developed an intraperitoneal abscess with a small duodenal fistula after total gastrectomy and was treated by peritoneal lavage and drain placement. The other patient developed delayed gastric emptying after subtotal gastrectomy and was managed conservatively. Mean ambulation time and mean hospital stay were 2.3 +/- 0.7 days and 14.6 +/- 5 days, respectively. All resected margins were tumor free. The mean number of retrieved lymph nodes for the malignant lesions was 22 +/- 12 (range 10 to 53). CONCLUSIONS: This prospective trial demonstrated that totally laparoscopic total and partial gastric resections had good results and were feasible and safe procedures. In addition, we concluded that the totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.

One-stage laparoscopic colorectal resection after placement of self-expanding metallic stents for colorectal obstruction: a prospective study.

The aim of this study was to assess the clinical outcomes of self-expandable metallic stents placing followed by laparoscopic resection and primary anastomosis for the treatment of acute colonic obstruction. From January 2003 to December 2004, 14 patients diagnosed with acute and complete colonic obstruction were treated with endoscopic colonic stenting as a bridge to an elective 1-stage laparoscopic resection. Three patients who underwent a successful stent insertion but had an inoperable tumor were excluded from the analyzed data. Ninety-three percent technical and clinical success was achieved. The stent insertion related perforation rate was 7% (1/14). The mean duration of stent insertion was approximately 1 hour and the mean time between the stent insertion and surgery was 6.2 days. Mean operating time was 132 +/- 38 minutes. No cases required conversion to laparotomy and there were no intraoperative complications. One case of anastomotic leakage was observed and treated by laparoscopic drainage and protective ileostomy. Ambulation time after operation was 1.8 +/- 0.6 days and total hospital stay length was 16.4 +/- 5.0 days. During a period of 11 +/- 7 months of follow-up, neither recurrences nor port-site metastases were observed. The management of acute colonic obstruction using endoscopic stent decompression, followed by laparoscopic resection, had good results and can be considered feasible and safe. Larger comparative studies may help to establish this approach.