Laparoscopic sonography of the biliary tree and pancreas.

LUS has a crucial role in minimally invasive approaches to diseases of the pancreatico-biliary system. The superior imaging capability of modern sonography devices and the growing interest and expertise in their use are optimizing surgical management and decision making during laparoscopic cholecystectomy, staging of pancreatic malignancy, and other procedures discussed in this article. The authors and their colleagues continue to modify these techniques as they learn more about LUS and its clinical capabilities. As the technology progresses, surgeons should embrace it and use it to its fullest potential.

Laparoscopic inguinal herniorrhaphy. Techniques and controversies.

Because of the remarkable success of laparoscopic cholecystectomy, numerous investigators have attempted to duplicate this success with laparoscopic herniorrhaphy. This article presents a different view of the preperitoneal anatomy, reviews the rationale behind the various laparoscopic approaches, and presents, in detail, the laparoscopic preperitoneal repair with mesh, including complications and early recurrences. An attempt is made to put the new laparoscopic procedures into perspective with regard to economic issues and safety.

Ultrasound of the inguinal floor for evaluation of hernias.

BACKGROUND: This study aimed to evaluate the utility of ultrasound in the diagnosis of inguinal hernias and obscure groin pain. METHODS: A series of 65 consecutive groin explorations performed subsequently to percutaneous ultrasound examination were prospectively evaluated. Patients were examined in an office setting. The examination included a history and a physical. Then an ultrasound of the inguinal region was performed. Ultrasound was performed by the staff surgeon and fellows. Patients then were taken to surgery for either a laparoscopic or open hernia repair. The preoperative and operative findings were compared to determine the utility of groin ultrasound. RESULTS: A series of 41 patients presenting with symptoms of groin pain or palpable groin bulge were evaluated with ultrasound of the groin. Of these patients, 24 went on to have bilateral repairs, bringing the study total to 65 groins. Surgery involved 50 laparoscopic and 15 open hernia repairs. This included 20 groins without hernia, as determined by physical examination, and 45 groins with a palpable hernia. Overall, ultrasound was used to identify the type of hernia correctly (direct vs indirect) with 85% success. In the 20 patients who had no palpable bulge, ultrasound identified a protrusion (hernia or lipoma) in 17. Two of these were false positives, and the three negative ultrasound examinations were false negatives. Thus ultrasound identified the pathology in a groin without a palpable bulge at an accuracy of 75%. The overall accuracy in finding a hernia of any kind by ultrasound was 92%. CONCLUSION: Ultrasound is a useful adjunct in evaluating the groin for hernia, and can be performed by surgeons.

The use of enteral stents in colonic and gastric outlet obstruction.

BACKGROUND: Enteral stenting is emerging as a viable treatment option for malignant obstructions of the gastrointestinal (GI) tract. We describe our experience and review the literature on techniques and complications. METHODS: A retrospective chart review of a single surgical service from 1998 to January 2002 was performed for all cases of endoscopic stenting for obstruction of the GI tract. Demographics, indications, success rate, complications, and outcomes were evaluated. RESULTS: There were nine female and two male patients aged 31-88 years (mean, 64.6). Six stents were placed in five patients with malignant gastric outlet obstruction. Technical success was achieved in 100%, and all patients improved clinically. Seven stents were placed in six patients with colon obstruction. Technical success was achieved in 100%, and six of seven obstructions were relieved. There was one perforation, which required a colostomy. A review of the literature showed overall technical success rates as high as 100%, 80-100% improvement in obstructive symptoms, and a 0-30% complication rate. Complications include perforation (0-16%), bleeding, occlusion, migration, and pain. CONCLUSION: Enteral stenting is effective in relieving GI obstruction, but it carries a risk for perforation. It should be considered an option to gastroenteric bypass, colostomy, or resection in debilitated patients.

A balanced approach to choledocholithiasis.

BACKGROUND: We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS: We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. RESULTS: A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). CONCLUSIONS: Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.

Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation.

BACKGROUND: Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes. METHODS: A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized. RESULTS: The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were "round." Remaining nodes were "oblong." All nodes had a hyperechoic center with a hypoechoic rim. CONCLUSION: In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.

Staging of pancreatic and ampullary cancers for resectability using laparoscopy with laparoscopic ultrasound.

BACKGROUND: Cancers of the pancreas and periampullary region are rarely curable. We set out to determine the efficacy of laparoscopy with laparoscopic ultrasound in the staging of pancreatic and ampullary malignancies for resectability. METHODS: Between January 1994 and September 1999, we retrospectively reviewed the laparoscopic staging (LS) of tumors already deemed resectable by standard radiologic criteria in 27 patients using laparoscopy with laparoscopic ultrasound (LUS). Patients found to be resectable by LS evaluation underwent laparotomy (LA). We then compared the results of the LS and LA findings. RESULTS: Of the 27 patients evaluated, 17 were men and 10 were women. Their mean age was 66 years. Preoperative computerized tomography (CT) scans were done in all 27 patients (100%), and transabdominal and endoscopic ultrasound (EUS) was done in 21 (78%). By LS, seven patients (26%) were found to have unresectable disease. Two patients with mesenteric tumor infiltration (one with peritoneal implants, and one with a visible liver metastasis) were judged to be unresectable by laparoscopy alone. LUS revealed that one patient had portal vein (PV) occlusion and two had metastases to the lymph nodes or liver that were not revealed by preoperative studies or laparoscopy alone. Among 20 patients (74%) deemed resectable by LS, two (10%) were found to be unresectable at LA, one due to PV involvement and the other due to local tumor extension with superior mesenteric lymph node metastasis. Eighteen of those in whom resection was attempted (90%) were resectable, with no unexpected findings of distant lymph node or hepatic metastasis. Pathology examination showed that eight had regional metastases (44%). The sensitivity of LS in determining unresectability was 77% (seven true positives and two false negatives). The negative predictive value (reflecting resectability) was 90%. Laparoscopy alone had a sensitivity of 44%, with a negative predictive value of 78%. The sensitivity and positive predictive value of LS was 100%, reflecting no false positive examinations. CONCLUSIONS: LS can effectively stage most patients and reliably predict which of them will benefit from LA. Intervention for unresectable patients can then be limited to laparoscopic or endoscopic bypass. The main limitation is that LS may underestimate PV and regional lymph node involvement.

Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two hundred three repairs without recurrence.

Laparoscopic extraperitoneal hernia repair has several distinct advantages over the anterior repair and the laparoscopic transabdominal preperitoneal method. Laparoscopic extraperitoneal hernia repair allows detection and repair of occult contralateral defects with minimal risk of intraabdominal injury or adhesion formation and is associated with less pain and a quicker recovery. However, there are disadvantages. Circumferential mobilization of the spermatic cord and the use of staples to secure the mesh have been associated with injury to the spermatic cord and nerves. The cost of the laparoscopic approach is higher than that of open herniorrhaphy. Additionally, it is more difficult to do because there is a poor understanding of the preperitoneal fascial anatomy. A method of totally extraperitoneal inguinal herniorrhaphy emphasizing anatomic dissection and landmarks is described. The authors use only reusable instruments, no balloon dissector, and no fixation of the mesh. The wide dissection of the myopectineal orifice allows placement of a large mesh and utilizes intraabdominal pressure alone to secure the mesh on the posterior aspect of the abdominal wall, as described by Stoppa et al. (1). Operative costs are minimized. From experience with 203 sutureless extraperitoneal repairs, a low incidence of complications and no recurrences are demonstrated. It is extrapolated that the cost of this laparoscopic repair will approximate more closely that of open anterior herniorrhaphy.

Laparoscopic transcystic sphincter of Oddi manometry is not affected by carbon dioxide pneumoperitoneum.

Sphincter of Oddi (SO) dysfunction as a potential cause of chronic acalculous cholecystitis (CAC) has not been studied in cases for which intraoperative SO manometry was used during laparoscopic cholecystectomy. In this study, we evaluated the effects of carbon dioxide pneumoperitoneum on laparoscopic transcystic SO manometry. In 27 patients with CAC, transcystic SO manometry had been attempted during laparoscopic cholecystectomy. The mean age of the patients was 46 years (range, 22-71). Complete manometric data sets were obtained in 18 patients. The mean SO pressure, phasic SO pressure, and phasic frequency were 35.4 +/- 29.1 mm/Hg versus 30.8 +/- 23.8 mm/Hg, 104.8 +/- 63.0 mm/Hg versus 73.6 +/- 34.6 mm/Hg, and 2.1 +/- 1.8 contractions/min versus 2.8 +/- 3.4 contractions/min with and without pneumoperitoneum, respectively. All differences were nonsignificant (P > 0.05). Two complications (7.4%) were observed: pancreatitis and jaundice. SO manometry is not affected by CO2 pneumoperitoneum. It may be used to study SO motility in patients with CAC.

Ultrasound-guided laparoscopic resection of pancreatic islet cell tumors.

Pancreatic islet cell tumors represent a diverse group of neuroendocrine lesions. These tumors may be singular or multiple, benign or malignant, sporadic, or part of the constellation of multiple endocrine neoplasia type 1. Tumors such as insulinomas and gastrinomas produce gastrointestinal peptides that lead to diagnosis. Nonfunctioning lesions may be found incidentally or by screening patients at high risk for such tumors. Successful management of patients with pancreatic islet cell tumors relies on accurate localization and sound operative technique. With proper preoperative localization, advanced laparoscopic methods can be used to manage patients with these pancreatic neoplasms. Preoperative localization of pancreatic islet cell tumors was difficult in the past. Standard imaging and localizing modalities, such as computed tomography scanning, magnetic resonance imaging, angiography, transabdominal sonography, and portal venous sampling, yield only 24% to 75% accuracy. Consequently, many biochemically suspected lesions cannot be imaged with current techniques. Decreased tactile sensation of laparoscopy adds complexity to intraoperative identification. Endoscopic sonography and laparoscopic sonography provide accurate preoperative and intraoperative localization to enhance laparoscopic and open resection. The authors treated two patients with islet cell neoplasms using endoscopic sonography to preoperatively visualize the tumors and laparoscopic sonography to guide laparoscopic enucleation. Their approach and difficulties are discussed.

Minimally invasive surgery for inguinal hernia.

The use of minimally invasive techniques in surgery for inguinal hernias has become an established approach to inguinal hernia repair. A brief history of laparoscopic hernia surgery is presented, including evolution of techniques. Several prospective randomized trials comparing open repairs with laparoscopic procedures are reviewed, and the results of the experience at the authors' institution are presented. Studies on the advantages of laparoscopic hernia repair vary, many showing advantages of the laparoscopic approach over open techniques. With continuing refinement of technique and efforts to minimize the cost differential, there should be a continuing role for minimally invasive hernia repair.

Role of laparoscopic ultrasound in cancer management.

Laparoscopic ultrasound (LUS) has become an important tool in the staging of hepatic, pancreatic, and gastrointestinal malignancies. It also plays an important role in the palliation and treatment of these malignancies. The use of laparoscopy and LUS in diagnosis, staging, palliation, and treatment of intra-abdominal malignancies is discussed, with a focus on the literature and our own experience.

Endoscopic palliation for pancreatic cancer with expandable metal stents.

Pancreatic cancer is generally not amenable to curative resection. Consequently, therapeutic efforts for these patients are most commonly directed at palliation of symptoms. Historically, surgery has been considered the most effective method of providing relief for biliary and/or enteric obstruction. However, less invasive methods have become available that can provide effective relief of jaundice and duodenal obstruction. Surgeons should still play an integral role in the management of these patients. We present a case report in which self-expanding metallic stents were used to relieve obstruction of the bile duct and duodenum in a patient with unresectable pancreatic cancer.

Electrohydraulic lithotripsy combined with laparoscopy and endoscopy for managing difficult biliary stones.

Large or impacted bile duct stones can be difficult to manage with endoscopic and laparoscopic techniques. Electrohydraulic lithotripsy (EHL) seems to be ideally suited for these difficult cases. We report our experience and review the literature. Adjunctive use of EHL was attempted in seven patients with complicated stones. In six, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. Five were accessed with laparoscopic transcystic technique, one by T-tube tract, and one with open common bile duct (CBD) exploration. EHL was successful in six. The unsuccessful attempt was with a 5-cm CBD stone. No complications of EHL were encountered. In review of the literature, we have found 256 cases of biliary lithiasis successfully treated with EHL without bile duct perforation. Based on our own experience and review of the literature, we conclude that properly used EHL is safe and effective in managing complicated biliary lithiasis.

The use of intraoperative ultrasound in laparoscopic adrenal surgery: the Saint Vincent experience.

BACKGROUND: Laparoscopic adrenalectomy has been shown to be a safe and effective therapy for benign adrenal lesions. We review our experience with this procedure, including the use of laparoscopic ultrasound. METHODS: We retrospectively reviewed our experience with 36 patients who underwent resection of 42 adrenal glands. Data gathered included preoperative evaluation and diagnosis, operative time, blood loss, complications, and follow-up status. Laparoscopic ultrasound was used to guide dissection and characterize a variety of adrenal lesions. RESULTS: Thirty-five of 36 patients underwent successful laparoscopic adrenalectomy. There was one conversion to the open procedure in a patient with bilateral adrenal metastases from an endometrial cancer. For the bilateral laparoscopic procedure, the operative time averaged 262 mins, blood loss was 160 cc, and hospital stay was 3.0 days. For unilateral cases, operative time averaged 193 min, blood loss was 108 cc, and hospitalization was 1.1 days. Six patients experienced perioperative complications, most of which were minor and transient. Laparoscopic ultrasound was useful to define anatomy and to identify the adrenal vein, especially on the left side. CONCLUSIONS: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal disease. Laparoscopic ultrasound is useful to localize and aid in the dissection of the left adrenal vein.

A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy.

Indications for intraoperative evaluation of the common bile duct during laparoscopic cholecystectomy are controversial, as is the goal of either anatomic definition or assessing for choledocholithiasis. One hundred twenty-five consecutive patients undergoing laparoscopic cholecystectomy underwent both intraoperative ultrasound and intraoperative cholangiography. Cholangiography required slightly more time to perform; it was more sensitive (92.8% vs 71.4%) but less specific (76.2% vs 100%) for choledocholithiasis than was ultrasound. Ultrasound was somewhat more difficult to perform, and, particularly in the setting of intraabdominal obesity, was often inadequate at providing clear visualization of the intrapancreatic common bile duct. It did not provide the same anatomic definition as an adequate cholangiogram. The overall incidence of choledocholithiasis was 11.2%.