Open laparoscopic cholecystectomy in pregnancy.

Since the introduction of laparoscopic cholecystectomy in 1989, surgeons worldwide have become familiar with the basic techniques involved. Pregnancy has previously been considered an absolute contraindication to laparoscopic cholecystectomy; however, we present three cases of laparoscopic cholecystectomy in pregnancy. If conservative management fails, this method, far from being absolutely contraindicated, should be the procedure of choice in pregnancy, as it has already become in nonpregnant patients. Transvaginal ultrasound allows continuous monitoring of fetal heart rate in all stages of pregnancy after the 7th week. The open (Hasson) technique should be strongly considered if accidental uterine puncture and potential fetal damage are to be avoided.

Laparoscopic herniorrhaphy.

Laparoscopic inguinal hernia repair could represent an attractive alternative to conventional inguinal herniorrhaphy if it can be shown to result in less perioperative morbidity (primarily postoperative pain) or a decreased long-term recurrence rate. The data addressing either of these concerns will be forthcoming in ensuing years. The variations in the laparoscopic approach to the preperitoneal space and the differences in dissection and fixation techniques outlined in this article reflect the fact that the procedure is still evolving, and there is not yet a consensus on the best laparoscopic herniorrhaphy. It is likely that there will not be one laparoscopic technique applicable to all inguinal hernias. Rather, the patient's body habitus and the type of hernia encountered at laparoscopy will persuade the surgeon to use one of several techniques. Once a consensus is reached among surgeons as to the optimal laparoscopic hernia repair(s), it will be possible to begin gathering data concerning perioperative morbidity and recurrence rates. Only then can the question be answered whether laparoscopic inguinal herniorrhaphy has any advantages over the conventional extraperitoneal operation. A multicenter prospective nonrandomized trial has been initiated by our group in an attempt to determine whether laparoscopic inguinal herniorrhaphy has efficacy. The exact technique employed by the individual centers has not been strictly regulated, but general guidelines have been given. It is hoped that this project will provide information on whether laparoscopic inguinal herniorrhaphy is a useful alternative to conventional repair. Most of the laparoscopic inguinal herniorrhaphy techniques described in this article expose the patients to the inherent risks of initial laparoscopic penetration of the abdomen and the long-term possibility of adhesions to the sites where the peritoneum has been breached. Because these risks are not present in a conventional repair, the laparoscopic technique must have other advantages if it truly is to obtain a place in the armamentarium of general surgeons.