Laparoscopic azygoportal disconnection procedure with a bipolar feedback controlled sealing system in a porcine model.

BACKGROUND: To examine the feasibility of a new, minimally invasive procedure for the devascularization of the proximal stomach and distal esophagus to prevent recurrent variceal bleeding in portal hypertension in a new animal model. MATERIAL AND METHODS: Portal hypertension was created by laparoscopic clip ligation of the portal vein on 20 pigs. After 2 weeks the azygoportal disconnection procedure was performed with the LigaSure-ATLAS instrument. RESULTS: There were 16 pigs out of 20 that survived both operations. Two died during introduction of anesthesia, one because of a cardiac arrest (second operation). One pig died resulting from necrosis of the gastric and esophageal wall. Autopsy (2 weeks later) showed that there was a complete arterial devascularization. At autopsy, none of the remaining 16 pigs had esophageal varices or necrosis of the stomach or esophagus. CONCLUSION: Laparoscopic azygoportal disconnection is a less invasive method for the prevention of rebleeding and seems to be safely performed with the LigaSure-ATLAS instrument.

Novel technique of laparoscopic azygoportal disconnection for treatment of esophageal varicosis: preliminary experience with five patients.

BACKGROUND: Liver cirrhosis leads frequently to the development of ascites and a formation of varicose veins in the esophagus. The latter presents increased mortality risk. Recently, significant progress in laparoscopic technology enabled devascularization of the proximal stomach in a less invasive way. The results experienced by five patients are presented. METHODS: Laparoscopic azygoportal disconnection was performed by means of novel technique (Danis procedure) in five men with esophagus varices bleeding (2nd to 11th events) and liver cirrhosis stage Child-Pugh B and C. This procedure was performed after all other methods had either failed to prevent recurrent bleeding or were refused by the patient. Five ports were positioned on the upper abdominal wall. The veins in the lesser omentum were divided by means of the LigaSure-Atlas device. The stomach coronary vein was visualized, and all the proximal branches toward the esophagus as well as the short gastric vessels were divided. The diaphragm hiatus was opened, and the distal esophagus was dissected. The paraesophageal venous collaterals also were divided, and the remaining varicose veins of the esophagus were interrupted by transmural stitching. RESULTS: All the patients survived the minimally invasive procedure. Two of them died 9 and 16 months after surgery, respectively, because of liver insufficiency. No bleeding event from varicose veins in the esophagus occurred postoperatively. CONCLUSION: Laparoscopic azygoportal disconnection is a less invasive method for prevention of rebleeding from varicose veins in the esophagus. Further studies are necessary to confirm these preliminary results.

Prospective randomized blind controlled trial comparing sutures, tape, and octylcyanoacrylate tissue adhesive for skin closure after phlebectomy.

BACKGROUND: The patient's view of the outcome after phlebectomy is mainly dependent on the cosmetic result. OBJECTIVE: To compare 5-0 monofilament sutures with tapes and tissue adhesive for wound closure after varicose vein surgery. METHODS: Seventy-nine patients undergoing varicose vein surgery were prospectively randomized in three groups (tissue adhesive, sutures, tape) for skin closure and compared. The follow-up 1 year postoperatively was done by a senior dermatologist who was blinded in the method of skin closure. RESULTS: The cosmetic outcome showed little advantage for the suture group. Taping the incisions is faster than suturing them but without significance; closure with tissue adhesive takes nearly the double of time. The closure for one incision with tissue adhesive is 40 times more expensive than with tapes and 14 times more expensive than with sutures. CONCLUSION: This study failed to demonstrate an advantage of tissue adhesive and tapes over monofilament sutures for skin closure after phlebectomy.

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.

Metabolic responses after laparoscopic or open hernia repair.

BACKGROUND: The purpose of a prospective randomized study was to compare the surgical trauma in patients undergoing laparoscopic or open hernia repair. METHODS: Postoperative pain, analgesic consumption, and metabolic response to surgery were assessed in 30 patients undergoing laparoscopic (group 1; n = 15) or open (group II; n = 15; Shouldice repair) unilateral inguinal hernia repair. Both groups were comparable with respect to age, sex, and type and size of inguinal hernia. RESULTS: Postoperative visual analogue scales (VAS) for pain were reduced on mobilization for patients of group I with a significant difference (P = 0.02) on the operative day, whereas pain scores at rest and analgesic requirements were similar for both groups. No differences between groups I and II were found in postoperative levels of interleukin-1, interleukin-6, tumor necrosis factor alpha, C-reactive protein, fibrinogen, transferrin, alpha-1-antitrypsin, and white blood cells. Postoperative polymorphonuclear (PMN) elastase concentrations remained within normal range in group II but showed a significant increase in patients operated laparoscopically for postoperative days 1 and 2. CONCLUSIONS: No major surgical trauma was found after herniorraphy compared to open hernia repair.

Pancreatic microcirculation in the monkey with special reference to the blood drainage system of Langerhans islets: light and scanning electron microscopic study.

The microcirculation of the pancreas in 20 monkeys (Macaca mulatta) was further studied by scanning electron microscopy (SEM) of vascular corrosion casts and light microscopy (LM) of Chinese ink-injected/cleared tissues. The results revealed that 91% of islets observed received arterial blood from the terminal branches of the intralobular arteries--the afferent arterioles, and 9% received no arterial blood, being entirely supplied by the efferent vessels of the intermediate or large islets. Some islets received blood from the translobular afferent arterioles of the adjacent lobule. Two patterns of islet drainage channels with different features in the monkey were demonstrated in our study. These patterns might be termed as continuous or convergent portal vessels. All islets possessed continuous portal vessels, 7-8 microns in diameter, which ran a short distance (approximately 100 microns) and then drained into the peri-islet acinar region, forming a typical continuous insulo-acinar portal system. About 21% of the islets possessed one or two convergent portal vessels, occasionally more. This was first observed in the monkey. These vessels were relatively long and/or thick and drained into different regions: (1) the acinar region far from the islet in the lobule, forming a convergent insulo-acinar portal system, (2) crossed the interlobular septum into an adjacent lobule where sometimes no islet existed and then drained into the exocrine acinar region, forming a translobar convergent insulo-acinar portal system, (3) drained into an adjacent small islet through the insulo-insular drainage vessels--one part of the drainage system of the islets. Translobular vascular anastomoses observed between the microcirculation of pancreatic lobules in the monkey formed a new arrangement of pancreatic microcirculation-translobular pancreatic microcirculation. The functional and clinical significance of the pancreatic portal circulation and translobular circulation is discussed in this report.

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.

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.

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.

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.