A new groin hernia classification with clinical relevance.

INTRODUCTION: Groin hernia is one of the most commonly managed surgical diseases around the world. The typical question asked by patients is "Does my hernia require urgent surgery?". The currently available classifications are insufficient to stratify patients into different groups. We propose a new classification that incorporates diverse clinical elements together with anatomical and other vital information, which allows us to stratify patients into different groups. METHOD: A task force was formed by the Hong Kong Hernia Society, working with international expert hernia surgeons. The framework of the classification system was formulated. Clinical elements that are important in groin disease stratification were identified. A comprehensive literature review was conducted using PubMed. Those which dictate the severity of the disease were selected and compiled to form the new proposed classification. Application of this classification model to a single hernia surgeon's registry in The Hong Kong Adventist Hospital Hernia Centre was done for initial evaluation. RESULT: This new classification incorporates important clinical characteristics forming a total of nine grades of differentiation, together with the anatomical details and special information. This comprehensive system allows the stratification of patients into different groups based on disease severity. It also enables more accurate data collection for future audits, comparisons of disease progression over time, and the effect of different management strategies for different-stage patients. CONCLUSION: This is the first classification system which incorporates essential clinical parameters, which allows the stratification of groin hernia into different stages. Further studies and validation should be performed to evaluate the usefulness and value of this classification in groin hernia management.

Hand-assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial.

AIM: Laparoscopic colectomy for colorectal cancer is associated with definite short-term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand-assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand-assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right-sided colonic cancer. METHODS: Adult patients with carcinoma of the caecum and ascending colon were recruited and randomized to undergo either HALC or TLC. Measured outcomes included operative time, blood loss, conversion rate, postoperative morbidities, postoperative pain, length of hospital stay, disease recurrence and patient survival. RESULTS: Sixty patients (HALC=30, TLC=30) were recruited. The two groups were comparable with regard to age, gender distribution, body mass index and final histopathological staging. No difference was observed between the groups in terms of operating time, conversion rate, operative blood loss, pain score and length of hospital stay. With a median follow-up of 27 to 33 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83%vs 80%, P=0.923). CONCLUSION: HALC is safe and feasible, but it does not show any significant benefits over TLC in terms of operating time and conversion rate. Routine use of the hand-assisted laparoscopic technique in right hemicolectomy is therefore not recommended.

The outcome of laparoscopic colorectal resection in T4 cancer.

AIM: Laparoscopic surgery for locally advanced tumours with extramural involvement is still controversial. It is believed that laparoscopic excision of T4 cancers is technically difficult and may result in prolonged operative time, increased conversion rate, added postoperative morbidity, and suboptimal oncological clearance. METHOD: Our unit has been practising laparoscopic colorectal surgery since 1992, and all data are entered into a database prospectively. Since 1999 we have routinely used the laparoscopic approach for colorectal cancer resections. Data regarding patients with a histologically T4 cancer operated on between 1999 and 2008 were analysed. Outcomes included operating time, conversion rate, postoperative complications and oncological outcome. RESULTS: Over a 10-year period, 146 patients (male 75) with a T4 cancer underwent laparoscopic resection. The median operating time was 125 (range, 46-285) min and the median blood loss was 50 (0-1800) ml. The conversion rate was 16%. Six (4.1%) patients experienced anastomotic leakage. The median number of lymph nodes harvested was 13 (2-40). One hundred and two (70%) patients underwent curative resection. The recurrence rates were 41% and 53% for stage II and III patients, respectively. Four (3.9%) patients had local recurrence. At a median follow up of 18 (1-118) months, the overall survival was 25 months, with median overall survival for patients with stage II, III and IV disease being 63, 36 and 12 months, respectively. CONCLUSION: Laparoscopic colectomy in histologically T4 cancer is safe. Oncological outcomes remain satisfactory. Based on our data, provided expertise is available, patients with locally advanced tumours should not be excluded from a laparoscopic approach.

Laparoscopic sphincter-preserving total mesorectal excision: 10-year report.

AIM: Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long-term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long-term oncological outcome after laparoscopic sphincter-preserving TME with a median follow up of about 4 years. METHOD: Patients with mid or low rectal cancer who underwent laparoscopic sphincter-preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis. RESULTS: During the 10-year study period, 177 patients underwent laparoscopic sphincter-preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow-up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5-year survival and 5-year disease-free survival in the present study were 74% and 71%, respectively. CONCLUSION: The results of this study show that laparoscopic sphincter-preserving TME is safe with long-term oncological outcomes comparable to those of open surgery.

Immunoglobulin G4-related sclerosing disease: experience with this novel entity in a local hospital.

OBJECTIVE: To review the site of involvement, clinical presentation, and treatment outcome of patients having immunoglobulin G4-related sclerosing disease in a local regional hospital. DESIGN: Retrospective case series. SETTING: Pamela Youde Nethersole Eastern Hospital, Hong Kong. PATIENTS: All patients with a diagnosis of immunoglobulin G4-related sclerosing disease in the hospital diagnosed in the period from April 2008 to March 2010. RESULTS: A total of 12 patients with involvement of various organs were identified. There was a male predominance (male-to-female ratio=5:1). The mean age at diagnosis was 65 years. The salivary glands, biliary tract, pancreas, and cervical lymph nodes were the commonest involved sites. The immunoglobulin G4 level was elevated in 83% of the patients. Patients usually appeared to respond well to steroid treatment. CONCLUSION: Immunoglobulin G4-related sclerosing disease is a systemic disease and can involve various systems.

Laparoscopic anterior resection.

Laparoscopic colectomy for cancer is increasingly practiced worldwide in the last 2 decades. However, due to procedural complexity, laparoscopic rectal cancer excision had not proceeded at a similar pace. This article deals with the technique of laparoscopic anterior resection. Resection of rectosigmoid or upper rectal tumors is first described, followed by the more difficult sphincter-saving total mesorectal excision. We have been using and modifying this technique of laparoscopic anterior resection for rectal cancer since 1990 s. In our recent review, the local recurrence rate was 7.4%, and the overall 5-year survival was 70%. Our data suggest laparoscopic resection for rectal cancer is safe and is the procedure of choice in selected patients.

Immunoglobulin G4-associated sclerosing cholangitis mimicking cholangiocarcinoma.

Immunoglobulin G4-related lymphoplasmacytic sclerosing disease is an emerging disease. Recently, it has been shown to be responsible for autoimmune pancreatitis-induced strictures of the bile duct mimicking cholangiocarcinoma. Making a diagnosis of immunoglobulin G4-associated sclerosing cholangitis requires a high index of suspicion. The differential diagnoses include primary sclerosing cholangitis, cholangiocarcinoma, and pancreatic cancer. The preoperative diagnosis is likely to be missed due to the lack of specific symptoms; a clinical presentation that may mimic other disorders, especially malignant biliary strictures; and the lack of specific imaging features. This article reports on a 51-year-old man with immunoglobulin G4-associated sclerosing cholangitis without autoimmune pancreatitis. He underwent resection of his extrahepatic bile duct with a hepaticojejunostomy. The diagnosis was confirmed after a histopathological examination. This case highlights the obstacles to making a preoperative diagnosis of immunoglobulin G4-associated sclerosing cholangitis.

Effect of endorectal coils on staging of rectal cancers by magnetic resonance imaging.

OBJECTIVE: To compare the use of endorectal plus phased-array coils with use of phased-array coil alone with respect to the accuracy of magnetic resonance imaging for detecting mesorectal involvement of rectal cancer. DESIGN: Retrospective study. SETTING: A tertiary referral centre in Hong Kong. PATIENTS: Ethnic Chinese patients with rectal adenocarcinoma who underwent staging magnetic resonance imaging during the years 2003 to 2008 in our centre were selected; those who received preoperative neoadjuvant therapy were excluded. Unless otherwise contra-indicated, endorectal coils have been used since 2006. MAIN OUTCOME MEASURES: Magnetic resonance images were retrieved and reviewed by two radiologists blinded to the pathological results. The radiological findings were then correlated with the pathological reports to determine diagnostic accuracy. RESULTS: A total of 50 patients were studied; 13 of the examinations were in patients having an endorectal coil. The overall accuracy of magnetic resonance imaging in detecting mesorectal tumour involvement was 80%. Subgroup analysis showed higher accuracy in the group with endorectal coils than in those with phased-array coils alone. Over-detection of mesorectal involvement was noted in 12% of the cases, with lower rate being observed in patients with endorectal coils. Underdetection of mesorectal tumour involvement was only noted in the group without endorectal coils. With the use of endorectal coils, the sensitivity reached 100% and the specificity increased to 86%. CONCLUSION: Use of endorectal coil in staging magnetic resonance imaging of the rectum improves diagnostic accuracy. Whenever feasible, endorectal coil use is therefore recommendable to enhance diagnostic accuracy. The study results substantiate the understanding of staging by magnetic resonance imaging of rectal cancer in the local Chinese population.

Obstructive complications of laparoscopically created defunctioning ileostomy.

PURPOSE: The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. METHODS: A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. RESULTS: In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. CONCLUSIONS: Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided.

Laparoscopic exploration of common bile duct in post-gastrectomy patients.

BACKGROUND/AIMS: To evaluate the results of laparoscopic exploration of the common bile duct (LECBD) in patients with previous gastrectomy. METHODOLOGY: This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994-2005. Those cases of LECBD with previous open gastrectomy were sorted out and analyzed. Indications of operation included unsuccessful endoscopic extraction due to altered anatomy and some explorations were performed together with side-to-side choledochoduodenostomy so as to eliminate biliary stasis and decrease stone recurrence. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. After confirmed ductal clearance, the common bile duct was routinely closed with t-tube diversion. The perioperative parameters of these patients were analyzed and compared to those receiving open exploration of common bile duct due to previous gastrectomy during the same study period. RESULTS: Of the 184 LECBD performed between 1994 and 2005, 33 patients had previous open upper gastrointestinal operations and among them 18 LECBD were performed in post-gastrectomy patients (2 with previous classical Whipple's operation). There were 10 male and 8 female patients with mean age of 77.5 (58-97 years). Of the 14 patients undergoing preoperative endoscopic retrograde cholangiopancreatography, there were 10 failed cannulations and 4 failed extractions. Altogether 17 choledochotomies and 1 transcystic duct exploration was performed whereas 4 patients with recurrent primary stones received additional choledochoduodenostomy. Median operating time was 120 min (60-390 min). Open conversion was required in 3 patients (16.6%) because of jammed basket, extensive adhesion and "through & through" bile duct injury respectively. Postoperative complications occurred in 4 patients (22.2%), which included 3 bile leaks and also the previously mentioned bile duct injury. The median hospital stay was 9 days (4-82 days). Upon a median follow-up of 17.5 months, there was only 1 patient found to have recurrent common bile duct stone and he was managed by laparoscopic exploration and choledochoduodenostomy. When the results were compared to those 12 open explorations because of previous open gastrectomy, longer operation time (120 vs. 75 min, p=0.004) and slightly shorter hospital stay (9 vs. 14 days, p=0.104) were noted in the LECBD group but without increased complication rate (22.2 vs. 25%, p=1). CONCLUSIONS: These results suggest that LECBD is worth attempting even in patients with previous open gastrectomy.

Cholecystectomy or not after percutaneous cholecystostomy for acute calculous cholecystitis in high-risk patients.

BACKGROUND/AIMS: This study aims to evaluate the outcomes of percutaneous cholecystostomy for acute calculous cholecystitis in patients with high surgical risk and determine whether subsequent cholecystectomy is beneficial and necessary. Percutaneous cholecystostomy has been shown to be a safe treatment option for patients suffering from acute cholecystitis but at high risk for emergency surgery. Controversies still exist on the approach of the cholecystostomy and the subsequent management of these patients. METHODOLOGY: From January 1996 to March 2004, percutaneous cholecystostomy was performed on 65 patients that suffered from acute calculous cholecystostomy but were considered high risk for emergency surgery (American Society of Anesthesiologists grade III or IV). Their clinical outcomes were described and risk factors for in-hospital mortality and recurrence of cholecystitis were identified by univariate and multivariate analysis. RESULTS: Percutaneous cholecystostomy was successfully performed in all patients (100%). The clinical response rate was 91%. The in-hospital mortality was 12.3%. Shock on admission was found to be a single independent risk factor for in-hospital death (p=0.006; odd ratio = 16.5; 95% CI = 2.2-123.1). Twenty-four patients underwent subsequent cholecystectomy whereas 33 did not. The 1-year and 3-year recurrence of acute cholecystitis were 35% and 46% respectively in patients who did not have subsequent cholecystectomy. Stone size > or = 1cm was independently associated with higher recurrence of acute cholecystitis (p=0.01; hazard ratio = 6.3, 95% CI 1.6-25.5). However, there was no difference in 1-year and 3-year overall survival between patients with or without cholecystectomy (82% Vs 81% and 59% Vs 63%, p=0.79). CONCLUSIONS: Percutaneous cholecystostomy is a safe and promising treatment for acute calculous cholecystitis in patients who are at high risk for emergency surgery. Cholecystectomy after the resolution of cholecystitis and optimization of associated medical illnesses is always advisable in order to prevent recurrent cholecystitis. However, the limited survival of these patients because of their old age and medical co-morbidities should be taken into consideration.

Laparoscopic distal pancreatectomy: a comparative study.

BACKGROUND/AIMS: This article aims to describe the different techniques of laparoscopic distal pancreatectomy and to compare the results of our series of 9 laparoscopic resections against the historical open control in the same institution. With the advent of laparoscopic surgery, there is an increasing number of patients with different pancreatic pathologies that can now be managed by minimal access surgery. The initial results of laparoscopic pancreatectomy are quite promising particularly for those small neuroendocrine and cystic neoplasms located at the body and tail of pancreas. METHODOLOGY: The different techniques of laparoscopic distal pancreatectomy are described in detail with special emphasis on the need of "hand assistance" and the different methods of splenic preservation. The perioperative data of 9 laparoscopic distal pancreatectomies are analyzed and compared against the 5 historical open controls in the same institution. RESULTS: There were 9 laparoscopic pancreatic resections performed in our institution since 1999. Indications for surgery included 5 cystic neoplasms (1 patient with concomitant splenic artery aneurysm), 1 chronic pancreatitis with pancreatic duct stricture and a small pseudocyst, 1 pseudopancreatic tumor secondary to seal off perforated posterior gastric ulcer, 1 pseudopapillary tumor and 1 neuroendocrine tumor. There were 6 females and 3 males with median age of 61 years (range 18-79). The majority of patients was of low anesthetic risk (ASA 1 or 2). Total laparoscopic resection was performed in 7 cases and 2 resections were performed using the hand-assisting technique. Out of the 4 cases with splenic preservation, only one patient had both splenic artery and vein successfully preserved, whereas the other 3 cases had to rely on the short gastric arcade. Median operating time was 180 minutes (range 120-250) and median blood loss was 100cc (range 50-500). Pancreatic leak occurred in two patients (22.2%) and 1 patient developed intraabdominal collection, all of which settled upon conservative treatment. In our series, clear resection margin was obtained for all the neoplastic cases. Median hospital stay was 7 days (4-53). Postoperatively, patients consumed an average of 15 tablets of dologesic. No other complications were observed upon a median follow-up of 15 months (1-50). When results were compared to the 5 historical open controls (excluding those malignant tumors), patients managed with this new approach had significantly less intraoperative blood loss (100 vs. 450 mL, P = 0.021). CONCLUSIONS: Our initial experience not only confirmed the feasibility oflaparoscopic pancreatectomy, but also demonstrated the promising results of this approach in selected patients.

Laparoscopic biliary bypass--a single centre experience.

BACKGROUND/AIMS: To review the results of laparoscopic biliary bypass for both benign and malignant pathologies in a minimal access surgery training center. METHODOLOGY: Retrospective review of a prospectively maintained database of laparoscopic biliary bypass during the period 1995-2004. RESULTS: During the review period 1995-2004, there were 26 laparoscopic biliary bypasses performed in our center which included 23 laparoscopic choledochoduodenostomy (LCD), 2 laparoscopic roux-en-Y choledochojejunostomy (LCJ) and 1 laparoscopic cholecystojejunostomy (LCCJ). Of the 23 LCD, all except 1 patient were operated for recurrent pyogenic cholangitis (RPC). The 2 LCJ and 1 LCCJ were performed for patients with advanced carcinoma in the periampullary region and simultaneous laparoscopic gastrojejunostomy (LGJ) was also performed to relieve the gastric outflow obstruction. Among the 23 LCD, there were 2 open conversions (7.7%) for lost broken tip of ultrasonic dissector and significant bleeding during choledochotomy respectively. Major complications occurred in 6 patients (23%), which included 3 bile leaks (11.5%), 1 intraabdominal collection (3.8%). 1 wound infection (3.8%) and 1 gastric stasis (3.8%). The only mortality in our series was a patient with carcinoma of head of pancreas undergoing simultaneous roux-en-Y LCCJ and LGJ. He had persistent gastric stasis after operation and required revision surgery for the kinked cholecystojejunostomy anastomosis. He finally died of myocardial ischemia after the second operation. As for the postoperative pain control, the mean pethidine consumption was 243.4 +/- 254.7 mg (range 0-1200 mg) and mean dologesic usage was 16.2 +/- 20.4 tablets (range 0-94 tablets). The average postoperative hospital stay was 12.6 +/- 11.5 days (range 5-60 days). The long-term functional results were satisfactory and only 1 patient had recurrent stone upon a mean follow-up of 32.3 months. Among the patients with malignant biliary obstruction, the only mishap was as previously mentioned and the remaining 2 patients could enjoy satisfactory palliation for more than a year before death. CONCLUSIONS: Laparoscopic bypass is not only feasible but also highly effective in relieving biliary obstruction with good postoperative results in both benign and malignant conditions.

Endo-Lap OR: an innovative "minimally invasive operating room" design.

BACKGROUND: A newly constructed Endoscopic-Laparoscopic operating room (Endo-Lap OR) started to operate in our department in January 2005. A prospective study was conducted to evaluate its feasibility, efficacy, and safety, as well as the staff's satisfaction. PATIENTS AND METHODS: From January 2005 to September 2005, all patients undergoing operation in this Endo-Lap OR were included in the study. The patient's diagnosis, types of operating procedures, incidents of operating failure (either due to the hardware or the software of Endo-Lap OR) that led to a delay in the patient's transfer or that extended the total operating time were recorded. In addition, questionnaires regarding staff satisfaction with the new operating room were distributed to nurses, anesthetists, and surgeons. RESULTS: A total of 640 cases were included in the study period, 245 cases of open surgery, 282 cases of laparoscopic surgery, 82 cases of endoscopic surgery, 17 cases of video-assisted thoracoscopic surgery, and 14 cases of combined endoscopic-laparoscopic surgery. There were no reported incidents of operating failure related to hardware or software problems. The overall staff satisfaction was excellent. CONCLUSIONS: The integration of endoscopic and laparoscopic surgery into this newly constructed Endo-Lap OR is feasible and safe. The running of the operating room was smooth and it received a high level of acceptance and satisfaction from different staff members.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus.

BACKGROUND: Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus. METHODS: A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated. RESULTS: Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives). CONCLUSION: Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

A simple and secure method to fix laparoscopic trocars in children.

We introduce a simple method of fixing trocars to the abdominal wall in children. Before anchoring the trocar, a piece of Tegaderm polyurethrane adhesive (3M Healthcare, St. Paul, Minnesota) is attached to the trocar. A silk stitch is anchored to neighboring skin, and then transfixed over the shaft of the trocar through the adhesive. Both inward and outward movement of the trocar can be restrained. This method is simple, fast, secure, and can be applied to trocars of any size.

Colonic amoebic abscess mimicking carcinoma of the colon.

Amoebiasis is an uncommon disease in developed countries. Its clinical presentation can be variable and non-specific, and the diagnosis can be easily overlooked. We report a case of colonic amoebic abscess mimicking advanced colonic cancer with acute intestinal obstruction and liver metastasis. The presentation, diagnosis, and treatment of amoebiasis are also reviewed.

Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single centre.

OBJECTIVES: To evaluate the role of laparoscopic exploration of the common bile duct in the management of common bile duct stones. DESIGN: Retrospective study. SETTING: Regional minimal access surgery training centre in Hong Kong. PATIENTS: Patients undergoing laparoscopic exploration of the common bile duct from 1995 to 2005. MAIN OUTCOME MEASURES: Demographic information, reasons for failed endoscopic retrograde cholangiopancreatography and open conversions, and operative morbidity and mortality. RESULTS: A total of 174 laparoscopic explorations of the common bile duct were performed. Indications for surgery (some overlapping) included: concomitant gallstones and common bile duct stones (n=68, 39%) in young persons (<60 years), previously failed endoscopic extraction (n=59, 34%), large (>2 cm) or multiple common bile duct stones (n=40, 23%), and need for laparoscopic bypass to improve bile drainage (n=34, 20%). Mean patient age was 63 (standard deviation, 16) years and 103 were female. Altogether 156 choledochotomies and 18 transcystic duct explorations were performed, with 12 (7%) open conversions. The mean operating time was 129 (standard deviation, 57) minutes. Additional procedures included: 54 laparoscopic operative cholangiographies, 34 laparoscopic biliary bypasses, and 31 instances of adhesiolysis in patients with a history of open upper gastro-intestinal surgery. Complete stone clearance was achieved in 160 (92%) patients. Non-lethal complications occurred in 34 (20%) patients and one died of sepsis after a major bile leak. The mean postoperative stay was 9 (standard deviation, 9) days. Stone recurrence ensued in seven (4%) patients after a mean follow-up of 37 (standard deviation, 29) months. CONCLUSIONS: Laparoscopic exploration of the common bile duct is highly successful and can achieve satisfactory ductal clearance even after unsuccessful endoscopic extraction and previous upper gastro-intestinal surgery. In skilled hands, for selected patients laparoscopic bypass can also achieve improved bile drainage.

A single-centre experience of 40 laparoscopic liver resections.

OBJECTIVE: To review results of laparoscopic liver resections, particularly in those patients with hepatic malignancy and recurrent pyogenic cholangitis. DESIGN: Retrospective analysis. SETTING: Minimal access surgery training centre, Hong Kong. PATIENTS: Patients with pathologies located at anterio-inferio-lateral segments (Couinaud segments 2, 3, 4b, 5, 6) for laparoscopic resection were recruited during the period 1998 to 2005. Patients were excluded from review if they had: pathologies at central locations and the superior and posterior segments (4a, 7, 8), large tumours (>5 cm in diameter), and those close to major vasculature or the liver hilum. RESULTS: During the study period, we attempted 40 such laparoscopic liver resections, excluding marsupialisations and resections for simple liver cysts. There were 20 female and 20 male patients, with a mean age of 57 (standard deviation, 13; range, 29-81) years. All but one underwent a successful laparoscopic operation. Pathology included hepatocellular carcinoma (n=17), recurrent pyogenic cholangitis (n=14), colorectal liver metastasis (n=4), benign liver tumour (n=4), and intrahepatic cholangiocarcinoma (n=1). All except four were hand-assisted laparoscopic liver resections. The mean operating time was 169 (range, 60-290) minutes and mean blood loss amounted to 270 mL (range, 0-1000 mL). Complications occurred in eight (20%) patients, which included six wound infections, one postoperative bile leak, and two incisional hernias. There was no operative or hospital mortality. For hepatocellular carcinoma, clear resection (>10 mm) was achieved in all except five patients, and the 1-year and 2-year survival rates were 86% and 59% respectively. Favourable results were also obtained for resections in patients with recurrent pyogenic cholangitis; after a mean (standard deviation) follow-up of 29 (23) months, only one was readmitted (for cholangitis). CONCLUSION: In appropriately selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy and very favourable long-term outcomes in those with recurrent pyogenic cholangitis undergoing hand-assisted laparoscopic segmentectomy.