Diagnostic laparoscopy: a survey of 92 patients.

From January 1991 to June 1993 the authors performed 92 diagnostic laparoscopies when physical examination, laboratory tests, and noninvasive imaging techniques failed to provide accurate diagnoses. Thirty-three patients (36%) underwent laparoscopy to ensure or exclude diagnosis in suspected intra-abdominal malignancy or to assess the operability in the cases of known cancer; 31 patients (34%) were evaluated for chronic abdominal pain; 15 patients (16%) were evaluated for acute abdominal pain; 9 trauma patients (10%) were evaluated to exclude or confirm penetration of the peritoneum or laceration of intra-abdominal organs; and 4 patients (4%) were operated on for miscellaneous conditions. Of the 92 patients, laparoscopy led to diagnosis in 80 patients (87%), a laparotomy was avoided in 78 patients (85%), and operative treatment was done laparoscopically in 65 patients (71%). Diagnostic laparoscopy will not replace laparotomy in every instance. However, in selected groups of patients, it may be used to yield diagnosis and help to avoid unnecessary laparotomy.

[The status of laparoscopic cholecystectomy in Austria. AMIC--Study Group for Minimally Invasive Surgery]. / Der Stand der laparoskopischen Cholezystektomie in Osterreich. AMIC--Arbeitsgemeinschaft für minimal invasive Chirurgie.

The complete 1992 register of minimal invasive operations at all surgical departments in Austria has been compiled for the third year running, representing questionnaires returned from 107 departments reporting a total of 11,591 laparoscopic cholecystectomies (LC). Evaluation of the data from the 81 departments with a least 2 years' experience showed an increase of 56.60% in the number of LCs and an overall increase in cholecystectomies of 18.50% in comparison with 1991. Sonography and/or intravenous cholangiography remain the standard procedures for the pre-operative diagnosis of bile-duct concrements, undertaken in 98.05% and 71.70%, respectively, of all cases in 1992. Intra-operative cholangiography has been implemented with increasing frequency (17.56% of all cases in 1992), especially in those departments with longer experience on LC. The conversion rate to open cholecystectomy was 6.09%, and the incidence of secondary cholecystectomy was 1.26%. The mortality rate was 0.11%. Our register now contains the data on 19,872 LCs. Our evaluation of the multicentric data aims at a complete documentation of the frequency of this surgical procedure and the incidence of complications in Austria with a view to establishing guidelines for the indications for LC and planning of this operation, as well as following up current trends in the regional implementation of LC in Austria.

[Initial results of minimally invasive lung surgery]. / Erste Ergebnisse der minimal-invasiven Lungenchirurgie.

From June 1991-February 1992 we have performed in 10 patients wedge resection of the lung by means of minimally invasive surgery. Indications were: spontaneous pneumothorax (5), tumours (3), suspected systemic disease (2). In all patients the pathological specimen preoperatively diagnosed by x-ray and CT, could be harvested without any problem. Minimally invasive, atypical wedge resection is considered as an effective procedure with low risk and discomfort for the patient.

[Laparoscopic resection of liver metastasis]. / Laparoskopische Resektion einer Lebermetastase.

Six weeks after a partial colon resection because of an adenocarcinoma of the sigmoid we removed a solitary liver metastasis (6th segment) by laparoscopic technique in a 63-year-old patient. Operation time was 95 min, the postoperative course was uneventful and the patient was discharged at day 6 postoperatively.

[Laparoscopic cholecystectomy in Austria. The Austrian 1991 register]. / Laparoskopische Cholecystektomie in Osterreich. Osterreiches Register 1991.

The number of surgical units, performing laparoscopic cholecystectomies (LC) in Austria increased from 24 hospitals (20%) in 1990 to 85 hospitals (70%) in 1991, performing 7351 LCs. In 97% the outcome was uneventful, the conversion rate was 2.1%; 0.85% required secondary laparotomy. Common bile duct lesion occurred in 0.5%, lethality was 0.1% (n = 4). Because of the cooperation of all surgeons Austria is the only country to present actual numbers concerning acceptance and penetration rate of LC.

Laparoscopic cholecystectomy--how does it work and how long does it take?

In the present paper we report on our experience with laparoscopic cholecystectomy in 145 patients. The success rate was 95.2%; during the procedure, seven cases had to be converted to conventional laparotomy. During the study period, the duration of laparoscopic cholecystectomy decreased from 180 to 45 min.

[Surgical therapy of complicated diverticular disease]. / Die operative Therapie der komplizierten Divertikelerkrankung.

From 1975-1989 55 patients were operated on for complicated diverticular disease at our unit. Intraoperative we found the following complications: 21 walled of perforations, 22 stenosis of the sigmoid colon combined with obstruction of the small and/or large bowel, 8 free perforations with generalized, faecal peritonitis, 7 diverticular fistulae (5 colovesical, 1 colojejunal and 1 colocutaneous fistula) and diverticular bleedings. In 33 cases we performed a resection with primary anastomosis (8 times with protecting stoma). 17 times the Hartmann's procedure was carried out and 5 times a transverse colostomy and drainage was elected. Lethality was 20% and morbidity came to 25%. We consider the primary resection with primary anastomosis to be the procedure of choice for complicated diverticulitis except for free perforation with generalized and faecal peritonitis where we prefer the Hartmann's procedure.

Prospective randomized trial comparing postoperative pain and return to physical activity after transabdominal preperitoneal, total preperitoneal or Shouldice technique for inguinal hernia repair.

In a prospective randomized study postoperative pain, analgesic consumption, return to physical activity and work, cosmetic result and experience with the type of operation were assessed in 86 patients undergoing inguinal hernia repair by means of either the Shouldice technique (n = 34), the laparoscopic transabdominal preperitoneal (TAPP) (n = 28) or total preperitoneal (TPP) (n = 24) repair. Patients having TAPP repair had decreased visual analogue scale scores for pain on the day of operation compared with those undergoing TPP and Shouldice repair (4.8 versus 6.5 and 6.2 respectively, P = 0.02) and on the first postoperative day compared with TPP (4.0 versus 6.0, P = 0.01). There was no difference between the three groups for days 2, 3, 4, 5 and 30 after operation. Patient satisfaction with the operation, analgesic consumption, return to physical activity such as walking, driving, climbing stairs, running, bicycling and sexual intercourse, as well as return to work, was comparable in the three groups. There was a better cosmetic result after TAPP and TPP repair. This study failed to demonstrate significant benefits from laparoscopic hernia repair over the Shouldice technique.

Laparoscopic removal of dislocated ventriculoperitoneal shunts. Report of two cases.

In two patients the dislocated abdominal catheter of a ventriculoperitoneal (VP) shunt was successfully removed from the abdominal cavity by laparoscopy. Avoiding laparotomy, only two small abdominal incisions were necessary to insert the laparoscope and the grasping forceps. Postoperative course was uncomplicated except for protrusion of a part of the greater omentum through the umbilical incision in one patient. Both patients were mobilized on the operative day. Surgery required only 10 min, provided an excellent view of the entire abdomen, and led to prompt identification and removal of the lost catheter.

Thoracoscopic wedge resection of peripheral lung lesions.

The increasing experience with minimally invasive surgery and advances in endoscopic equipment have expanded the role of thoracoscopy to include thoracoscopic pulmonary resections. In 11 patients we have evaluated the technical feasibility of thoracoscopic wedge resection of single peripheral lung lesions. In 8 patients the lesion could be exactly identified by thoracoscopy and be effectively resected using an automatic endoscopic stapler. All lesions were located within the outer third of the lung parenchyma with a maximum distance of 1.4 cm between lesion and visceral pleura. Mean diameter of the nodules was 1.9 cm and ranged from 1.0 to 4.1 cm. Histological analysis revealed completely excised tuberculomas in 4, carcinomas in 2, hamartoma in 1, and localised fibrosis in one patient. In 3 patients the thoracoscopic approach was unsuccessful because of difficulty in identifying the lesion or impossibility of achieving a reliable assessment of the intraparenchymal extension of the tumor. In conclusion, thoracoscopic wedge resection is helpful for the diagnostic and therapeutic management of peripheral lung lesions in carefully selected patients. Continued experience is necessary to be able to establish reliable criteria to assess which types of lung lesion can be excised safely and effectively by videothoracoscopy.

Laparoscopic cholecystectomy. Cause of conversions in 1,300 patients and analysis of risk factors.

In 1,300 patients undergoing laparoscopic cholecystectomy (LC) 56 patients (4.3%) required conversion to open cholecystectomy (OC); 41 (73%) of the conversions were elective, whereas 15 (27%) were enforced. The causes of the 56 conversions are described and analyzed. Logistic regression analysis of 23 parameters identified the following data as associated with a higher risk for conversion: pain or rigidity in the right upper abdomen (P < 0.01), thickening of the gallbladder wall on preoperative ultrasound (P < 0.05), intraoperatively found dense adhesions to the gallbladder or in Calot's triangle (P < 0.001), and intraoperatively found acute inflammation of the gallbladder (P < 0.01). Clinical findings of an acute cholecystitis associated with intraoperative dense scarring in Calot's triangle were the best factors predicting conversion from LC to OC. As a result of the study we preoperatively select our patients for either LC or OC, and a difficult case is performed by a more experienced surgeon to keep conversion rate and complications low.

A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables.

BACKGROUND: Modified logistic regression analysis of 24 variables in 300 patients undergoing laparoscopic cholecystectomy found the following parameters independently predictive for a difficult operation: right upper quadrant pain (p < 0.01), rigidity in right upper abdomen (p < 0.01), previous upper abdominal surgery (p < 0.01), biliary colic within the last 3 weeks (p < 0.05), white blood cell count > 10 x 10(9)/l (p < 0.05), thickening of the gallbladder wall (p < 0.05), hydroptic gallbladder (p < 0.05), pericholecystic fluid (p < 0.01), shrunken gallbladder (p < 0.01), and no filling of the gallbladder in preoperative intravenous cholangiography (p < 0.05). METHODS: Based on these variables a diagnostic model was developed to predict the difficulty of a laparoscopic cholecystectomy, with scores ranging from 0 (ideal case) to IV (conversion to open cholecystectomy expected) prior to surgery. RESULTS: When the reliability of our model was examined in a second study in 340 consecutive patients undergoing laparoscopic cholecystectomy 80% of the patients were predicted correctly. CONCLUSIONS: Our model should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties and the experience of the surgeon.

Thoracoscopic bleb resection selectively combined with pleurectomy for complicated spontaneous pneumothorax.

OBJECTIVE: To evaluate the short and long term results of video-assisted thoracoscopic surgery for complicated pneumothorax. DESIGN: Retrospective study. SETTING: General hospital, Linz, Austria. SUBJECTS: 76 consecutive patients with complicated pneumothorax. INTERVENTIONS: 57 patients with primary and 19 with secondary spontaneous pneumothorax underwent video-assisted thoracoscopic surgery. Depending on the findings at thoracoscopy, patients were allocated to have stapled bleb resection (n=29), multiple bleb resection combined with apical pleurectomy (n=40), or apical segmental resection combined with apical pleurectomy (no visible disease on the lung surface, n=7). MAIN OUTCOME MEASURES: Efficacy, morbidity, mortality, and late recurrence rate. RESULTS: No conversions to open thoracotomy were necessary and early lung reexpansion was achieved in all but one patient (99%). There was one postoperative death (1%) and morbidity was 7%, including one persistent air leak and one early recurrence, both of which required thoracotomy. All postoperative complications developed in patients with spontaneous pneumothorax secondary to diffuse bullous emphysema. At a median follow up of 34 months there were 4 ipsilateral pneumothorax recurrences (5%), two of which developed after bleb resection combined with pleurectomy and two after bleb resection alone. CONCLUSION: Video-assisted thoracoscopic surgery was safe and effective for the treatment of complicated spontaneous pneumothorax. It is our procedure of choice for complicated primary spontaneous pneumothorax and is a valuable alternative to open thoracotomy for patients with secondary spontaneous pneumothorax.

Videothoracoscopy for the management of mediastinal mass lesions.

BACKGROUND: The indications for video-assisted thoracoscopy have steadily expanded during recent years and include now the management of various mediastinal disorders. METHODS: Until now we have used videothoracoscopy for the diagnosis or treatment of mediastinal mass lesions in 28 patients. The indication for the procedure was bilateral or unilateral mediastinal adenopathy in 16, a suspected malignant anterior mediastinal mass lesion in six, and a presumable benign tumor of the posterior or anterior mediastinum in six patients. RESULTS: Video-assisted thoracoscopy provided an accurate tissue diagnosis in all patients with adenopathy and in all but one patient with a malignant mass lesion of the anterior mediastinum. It further allowed complete excision of all benign tumors of the anterior or posterior mediastinum. There were no intra- or postoperative complications, but conversion to open thoracotomy was necessary in one patient. CONCLUSIONS: Video-assisted thoracoscopy is a valuable adjunct to traditional surgical techniques for the diagnosis of malignant mediastinal disease and may overcome some of the limitations of mediastinoscopy and mediastinotomy. In the future, it may become the procedure of choice for the resection of small benign tumors of the anterior or posterior mediastinum.

Mechanism, management, and prevention of laparoscopic bowel injuries.

BACKGROUND: Inadvertent injury to the bowel is a rare but potentially fatal complication of laparoscopy. Such injury often goes unrecognized at the time of the procedure and only later is manifest by high morbidity and mortality. METHODS: We reviewed the mechanism and management of 10 instances of bowel injury known to have been encountered in a series of 4672 laparoscopic procedures performed at our hospital over the past 5 years. RESULTS: The usual causes of injury to the bowel wall were thermal burns, sharp dissection, and needle punctures. Six of the injuries were readily evident and treated immediately; four were unrecognized until 2 to 14 days after the procedure. One patient died of multiple organ failure on the third day after laparoscopy. Operative management in nine cases required simple closure or segmental resection. A high index of suspicion and vigilant physical examination were the keys to early recognition of bowel injury; laboratory and radiographic findings were nonspecific. CONCLUSIONS: Suspected bowel injury following laparoscopy mandates early laparotomy to avoid life-threatening complications.

[Laparoscopic cholecystectomy--advantages and disadvantages]. / Laparoskopische Cholezystektomie--Vor- und Nachteile.

From march 1990 to february 1992 we performed 600 laparoscopic cholecystectomies. In 18 cases we had to change to a laparotomy because of intraoperative problems, in 3 cases we had to laparotomise patients because of postoperative complications. 9 patients (1.5%) had a wound infection. In two prospective studies we could prove that patients after laparoscopic cholecystectomy have less pain and are in a better respiratory condition than after open cholecystectomy.

Laparoscopic cholecystectomy: the Austrian experience.

The number of surgical units performing laparoscopic cholecystectomies (LCH) increased from 24 hospitals (20%) in 1990 to 85 hospitals (70%) in 1991, performing 7351 LCHs. Of those, for 97% the outcome was uneventful, and the conversion rate was 2.1%. 0.8% required secondary laparotomy. Common bile duct damage occurred in 0.5% and overall mortality in 0.1% of cases (4 patients). Thanks to the cooperation of its surgeons, Austria is the only country to present actual numbers concerning acceptance and penetration of LCH.

Hemodynamic changes during prolonged laparoscopic surgery.

7 healthy pigs, anesthetized with ketamine/azaperon/thiopentone and ventilated with O2/N2O by volume control, underwent anterior resection of the descending colon by laparoscopic view. During operation of pneumoperitoneum by inflating CO2 to an abdominal pressure of 14 mm Hg was installed. Immediately (+2 min) after the onset of insufflation, both systemic and pulmonary arterial pressure increased. However, pulmonary artery pressure started to decrease after 10 min, whereas systemic arterial pressure remained elevated until the end of the experimental protocol. Left ventricular (LV) pressure and LV dp/dt increased in parallel with the systemic arterial pressure. Peak inspiratory pressure and central venous pressure increased in parallel with the abdominal pressure. Blood gas analysis of arterial and pulmonary blood demonstrated increased pCO2 associated with mild acidosis. Arterial pO2 did not change significantly indicating that the decreased pulmonary distensibility did not endanger the oxygenation. Pulmonary pO2 and pulmonary O2 saturation increased early (+10 min) after start of insufflation and were stable during the 2 h of observation indicating either increased cardiac output or decreased O2 extraction. We conclude that the sharp initial rise of both arterial pressures could be the effect of a mechanical action, whereas sustained hemodynamic alterations would involve complex regulatory mechanisms like an increase of sympathetic activity, baroreceptor control, or a response to acidosis. The acute and, in the systemic circulation, stable increase of ventricular afterload should be considered in patients with underlying cardiac diseases such as ischemic heart disease or valvular dysfunction or in patients taking drugs which interfere with normal compensatory processes.

Selective use of ERCP in patients undergoing laparoscopic cholecystectomy.

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.