Five-year results of laparoscopic Toupet fundoplication as the primary surgical repair in GERD patients: is it durable?

INTRODUCTION: Most surgeons operate on gastroesophageal reflux disease (GERD) patients using the concept of "tailored approach," which depends on esophageal motility. We have abandoned this concept and performed laparoscopic Toupet fundoplication in all patients suffering from GERD, independent of their esophageal motility. METHODS: In a prospective trial we have assessed and evaluated our 5-year results of the first 100 consecutive patients treated with laparoscopic Toupet fundoplication. All patients were evaluated preoperatively by endoscopy and 24-h pH manometry. The patients were followed up clinically 1, 2, 6, 12 and 60 months postoperatively. The course of clinical DeMeester score, appearance and treatment of wrap-related side-effects as well as long-term outcome and patient satisfaction were evaluated. RESULTS: The 5-year follow-up rate was 87%. Laparoscopic Toupet fundoplication achieved a 5-year healing rate of GERD in 85%. Of all operated patients, 3.5% had to be reinstalled on a regular PPI treatment because of postoperative GERD reappearance. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.47 +/- 0.9 points 5 years postoperatively (p < 0.0005). Because of persistent postoperative dysphagia, 5% of the patients required endoscopic dilatation therapy. Persistent postoperative gas-bloat syndrome occurred in 1.1%. Wrap dislocation was identified in 3.4% of patients. Reoperation rate was 5%. Total morbidity rate was 19.5% and operative related mortality rate was 0%. Overall, 96.6% of patients were pleased with their outcome at late follow-up, and 95.4% of patients stated they would consider undergoing laparoscopic fundoplication again if necessary. CONCLUSION: Our long-term results showing a low recurrence and morbidity rate of laparoscopic Toupet fundoplication encourage us to continue to perform this procedure as the primary surgical repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet fundoplication has proven to be a safe and successful therapeutic option in GERD patients.

Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement.

BACKGROUND: The recurrence rate after laparoscopic repair of hiatal hernias with paraesophageal involvement (LRHP) is reported to be high. Mesh reinforcement has been proposed with the objective of solving this problem. This study aimed to compare the outcome of LRHP before and after the introduction of mesh reinforcement. METHODS: Between 1992 and 2003, 56 consecutive patients received LRHP including posterior crurorrhaphy and additional fundoplication. Of these 56 patients, 17 underwent a mesh-reinforced hiatoplasty. Perioperative outcome was assessed retrospectively, and follow-up assessment was performed according to protocol including a barium contrast swallow. RESULTS: The follow-up period averaged 52 +/- 31 months (range, 9-117 months). The recurrence rate for hiatal hernia without mesh reinforcement was 19% (7/36). No recurrence (0/16) was observed in patients with mesh reinforcement. The intraoperative complication rate was 9%, and the perioperative morbidity rate was 14%. There were neither mesh-related complications nor operation-related deaths. CONCLUSIONS: Although challenging, LRPH is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement.

Laparoscopic cholecystectomy: quality of care and benchmarking. Results of a single-institution specialized in laparoscopy compared with those of a nationwide study in Switzerland.

BACKGROUND: Quality control is an important issue in surgery. Therefore, we assessed the outcome of laparoscopic cholecystectomies (LC) performed at our institution specialized in laparoscopic surgery in order to do a benchmarking. METHODS: The perioperative courses of the first 1000 LCs performed in Aarberg hospital were recorded, analyzed, and compared with the results of a recent study including 10, 174 patients published by the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS). RESULTS: The following quality indicators were compared with the corresponding SALTS rates: primary conversion rate 1.5% (SALTS 8.2%; p <0.01); conversion rate for intraoperative complications 6.5% (63.8%; p <0.01); intraoperative complication rate 22.2% (34.4%; p <0.01); postoperative morbidity rate 8.1% (10.4%; n.s.); in-hospital mortality rate 0.1% (0.2%; n.s.); and reoperation rate 0.8% (1.7%; n.s.). CONCLUSIONS: LC has reached a high quality level in its widespread use, but in a small specialized center even a higher quality level can be achieved. Favorable results seem to depend on structural advantages of a surveyable unit in association with a continuously motivated surgical team.

[Trocar site hernias. A rare but potentially dangerous complication of laparoscopic surgery]. / Trokarhernien Eine seltene, potenziell gefährliche Komplikation nach laparoskopischen Eingriffen.

With increasing numbers of laparoscopic procedures more postoperative trocar site hernias can be expected. This complication of minimally invasive surgery is rare but potentially dangerous. According to the literature, the overall incidence of trocar site hernias is expected to be around 1%. Among trocar site hernias, Richter's hernias are the most frequent, accounting for two-thirds of all small intestinal hernias. The following risk factors for the development of trocar site hernias have been identified: the trocar diameter, the trocar design, preexisting fascial defects, and some operation- and patient-related factors. Peritoneal and fascial closure should be done when blunt trocars of >10 mm have been employed. Based on the literature and our own experience, some preventive recommendations are given to further reduce the risk of hernia formation at trocar sites.

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair.

BACKGROUND: There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. METHODS: A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. RESULTS: Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). CONCLUSION: The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.

Pneumatosis cystoides intestinalis as a complication of celiac disease.

Pneumatosis cystoides intestinalis (PCI) is an uncommon but important condition characterized by the presence of gas-filled cysts in the submucosa and subserosa of the gastrointestinal tract. PCI has been associated with several clinical settings. We report a case where PCI developed in a patient with known celiac disease. To our knowledge, this type of coincidence has been described in seven prior cases. Since PCI often results in pneumoperitoneum through rupture of the cysts, it is important to differentiate the benign form of pneumoperitoneum, in which no intervention is indicated, from the life-threatening form with intestinal infarction and/or perforation, in which immediate surgery is mandatory. Differentiating between them can be difficult; this explains the high rate of negative laparotomy, which, in the past, occurred in 27% of cases. By performing diagnostic laparoscopy, we were able to establish the diagnosis of PCI and exclude intestinal perforation or infarction, thus permitting the patient to avoid an unnecessary laparotomy. Although diagnostic laparoscopy is not routinely indicated as a diagnostic tool for the detection of PCI, it proved to be a safe and accurate method to differentiate between the benign form of PCI and the life-threatening form. Whenever this differentiation has to be made, we recommend that diagnostic laparoscopy be performed first rather than primary laparotomy. Herein, the laparoscopic features of PCI are described and the coincidence of PCI with celiac disease is reviewed.

[Laparoscopic Toupet partial fundoplication as general surgical therapy of gastroesophageal reflux. 1-year results of a 5-year prospective long-term study]. / Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastrooesophagealen Refluxkrankheit. 1-Jahresresultate einer auf 5 Jahre ausgelegten prospektiven Langzeitstudie.

INTRODUCTION: A variety of laparoscopic antireflux operations exist for patients with gastroesophageal reflux diseases (GERD). Most surgeons operate using the concept of "tailored approach", which depends on esophageal motility. We have abandoned this concept because of the relatively high incidence of wrap-related complications in patients treated with laparoscopic Nissen fundoplication compared with patients treated with partial fundoplication. It is our policy to perform laparoscopic Toupet partial fundoplication in all patients suffering from GERD, independent of their esophageal motility. METHODS: In a prospective trial we have assessed and evaluated our 1-year results of the first 100 consecutive patients treated with Toupet partial fundoplication. All patients underwent esophagogastroscopy and 24-h pH manometry before operation. One third of patients (n = 34) underwent control manometry 8 weeks postoperatively. The patients were followed up clinically 1, 2, 6 and 12 months postoperatively. RESULTS: In this study group we achieved a healing rate in GERD of 97%. In 3% of patients GERD recurred. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.25 +/- 0.5 points 1 year postoperatively (P < 0.0005). The median fractional time with pH < 4 decreased from 17.8% +/- 12.5% preoperatively to 0.9% +/- 1.2% 8 weeks postoperatively (P < 0.0005). Because of persistent dysphagia 5% of our patients required postoperative dilatation therapy. The rate of reoperation and mortality was 0%. The total morbidity rate was 18%. In 50% of patients with preoperatively recorded esophageal motility disorder, an improvement of esophageal motility was found postoperatively. CONCLUSIONS: Our 1-year results encourage us to continue to perform laparoscopic Toupet partial fundoplication as the primary repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet partial fundoplication has proven to be a safe and highly successful therapeutic option in these patients.

[Total endoscopic pre-peritoneal mesh implant in primary or recurrent inguinal hernias]. / Total endoskopische präperitoneale Netzplastik bei primären und Rezidivleistenhernien. Gibt es Unterschiede?

INTRODUCTION: Since 1994 we perform laparoscopic total extraperitoneal hernia repair (TEP) for primary and recurrent inguinal hernias at our institution. The aim of this study was to investigate and compare the results of TEP in primary inguinal hernias and recurrent inguinal hernias and to determine whether there are differences in patient data, complication rates and outcome between these two groups. METHODS: In a prospective trial 338 patients were analyzed who underwent 500 laparoscopic TEP repairs. In all, 431 TEP repairs were performed for primary inguinal hernias, and 69 for recurrent inguinal hernias. For data acquisition the SALTC study protocol was used. All patients were clinically examined 3 and 12 months after the operation. RESULTS: The mean operation time was 67.3 min for TEP repair of primary hernias and 68.1 min for TEP repair of recurrent hernias, respectively. The conversion rate to an open procedure was 0%. Conversion from TEP into TAPP was required in 0.5% of patients with primary inguinal hernias and 1.4% of patients with recurrent inguinal hernias. As the sole difference between the two groups the intraoperative complication rate could be identified. In the TEP repair group of recurrent inguinal hernias a higher incidence of injury to the peritoneum and a higher occurrence of bleeding from the epigastric vessels was found (P = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1% and 5.7%, respectively. No differences were found in the 1 year follow-up between the two groups. The 1-year recurrence rate was 0.5% for primary hernias. However, in the group of recurrent hernias there have been no recurrences to date. CONCLUSIONS: The use of laparoscopic TEP repair has proven to be a safe and effective treatment in patients with primary and recurrent inguinal hernias. Because of scar tissue with possible adhesions a higher intraoperative complication rate was observed in the TEP repair of recurrent hernias than in TEP repair of primary inguinal hernias. However, no single recurrence was observed in the TEP repair group of recurrent hernias. In our opinion TEP is the optimal hernia repair for recurrent and bilateral inguinal hernias.

[Laparoscopic gastric banding]. / Laparoskopisches gastric banding.

The introduction of laparoscopic gastric banding appears to have revolutionized bariatric surgery. This review presents this new method in terms of indications, operative technique and preliminary results according to our own experience as well as reports in the literature. It seems that a long-term weight reduction of more than 50% excess weight can be achieved with a low morbidity rate. In the near future laparoscopic gastric banding can possibly become the procedure of choice for the treatment of morbid obesity.

Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC).

BACKGROUND: This article reports the results of a multicenter prospective audit of totally extraperitoneal (TEP) inguinal hernia repair conducted by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC) from May 1995 to August 1996. METHODS: At 29 Swiss centers 1,605 inguinal hernia repairs were performed in 1,186 patients. Half of the repairs were performed by operators whose experience consisted of fewer than 51 procedures. Patients were followed up for 1 year. RESULTS: Bilateral repairs were performed in 35% of the patients, and 15% of all repairs were for recurrent hernia. Conversion rates to the transabdominal preperitoneal (TAPP) technique and open surgery were 1.8% and 1.6%, respectively. Main postoperative complications were hematoma and urinary retention. At 3 months, seroma was more frequent with slit prosthesis. The recurrence rate was 0.6% at 3 months and 1.6% at 1 year, not depending on the type of implant. The rate for recurrent hernias did not differ from that for primary repairs. CONCLUSIONS: Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Primary neuroendocrine tumors of the cystic duct.

Primary neuroendocrine tumors of the cystic duct are extremely rare. Only 4 cases have been described to date. We report 2 patients in whom a primary neuroendocrine tumor of the cystic duct was incidentally detected during histological examination following cholecystectomy. With regard to the primary neuroendocrine tumor both patients were asymptomatic at the time of diagnosis. However, histologic examination did not confirm that the neuroendocrine tumors had been completely removed. Both patients underwent a second procedure. They are well after 47 and 49 months, respectively.

Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma.

BACKGROUND: We sought to determine the incidence of recurrence of carcinoma at the port site and the outcome of patients with such recurrences after exploratory laparoscopy/laparoscopic cholecystectomy for unsuspected gallbladder carcinoma and analyzed aspects of the laparoscopic procedure associated with recurrences at the port site. METHODS: Thirty-seven patients with preoperatively unknown adenocarcinoma of the gallbladder were analyzed. The patients were part of a large prospective study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery including 10,925 patients undergoing laparoscopic cholecystectomy. RESULTS: Preoperatively undiagnosed adenocarcinoma of the gallbladder is rarely encountered in patients undergoing laparoscopic cholecystectomy (0.34%). The incidence of recurrence of carcinoma at the port site in these patients is 14% (5 of 37) and is similar whether the primary tumor is confined to the gallbladder (T1/T2) or locally advanced (T3/T4). The recurrences at the port site were diagnosed within 6 to 16 months (median 10 months) after the operation. Patients with an intraoperative perforation of the gallbladder had a higher incidence of recurrences at the port site (40%) than had patients without perforation (9%; P = .13). All patients with recurrences at the port site had distant metastases and all died of the disease 12 to 35 months (median 19 months) after cholecystectomy; all patients with such recurrences and stage T1/T2 tumors subsequently had peritoneal metastases. CONCLUSIONS: Patients with a preoperatively undiagnosed adenocarcinoma of the gallbladder undergoing laparoscopy or laparoscopic cholecystectomy have a high incidence of recurrences at the port site, and the incidence increases when a gallbladder perforation occurs during the operation. All patients with such recurrences died of the disease. The diagnosis of an isolated recurrence at the port site may therefore be an indicator of disseminated disease in most cases.

Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery.

BACKGROUND: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland. METHODS: Data were collected from 10,174 patients from 82 surgical services. A total of 353 different parameters per patient were included. RESULTS: We found intraoperative complications in 34.4% of patients and had a conversion rate of 8.2%. This rate was significantly increased in patients with complicated cholelithiasis and in those with previous upper-but not lower-abdominal surgery. In most cases, conversions to open procedures were required because of technical difficulties due to inflammatory changes and/or unclear anatomical findings at the time of operation. Bleeding was a common intraoperative complication, that significantly increased the risk of conversion. Patients with loss of gallstones in the peritoneal cavity had increased rates of abscesses. The rate of common bile duct injuries was 0.31%, but it decreased significantly as the laparoscopic experience of the surgeon increased. The rate of common bile duct injuries was not increased in patients with acute cholecystitis or in the 1.32% of patients undergoing laparoscopic common bile duct exploration. Intraoperative cholangiography did not reduce the risk of common bile duct injuries, but it allowed them to be diagnosed intraoperatively in 75% of patients. Local complications were recorded in 4.79% of patients, and systemic complications were seen in 5.59%. The mortality rate was 0.2%. CONCLUSIONS: Although laparoscopic cholecystectomy is a safe procedure, the rate of conversion to open cholecystectomy is still substantial. The conversion rate depends both on the indication and intraoperative complications. There is still a 10.38% morbidity associated with the procedure; however, the incidence of common bile duct injuries, which decreases with growing laparoscopic experience, was relatively low.

Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic cholecystectomies.

BACKGROUND: Spilled gallstones after laparoscopic cholecystectomy may cause abscess formation, but the exact extent of this problem remains unclear. METHOD: The data (collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery) on 10,174 patients undergoing laparoscopic cholecystectomy at 82 surgical institutions in Switzerland between January 1992 and April 1995 were retrospectively analyzed with special interest in spilled gallstones and their complications. RESULTS: In 581 cases (5.7%) spillage of gallstones occurred; 34 of these cases were primarily converted to an open procedure for stone retrieval. Of the remaining 547 cases only eight patients (0.08%) developed postoperatively abscess formation requiring reoperation. CONCLUSIONS: Spillage of gallstones after laparoscopic cholecystectomy is fairly common and occurs in about 6% of patients. However, abscess formation with subsequent surgical therapy remains a minor problem. Removal of spilled gallstones is therefore not recommended for all patients, but an attempt at removal should be performed whenever possible.

[Simultaneous laparoscopic therapy of cholecysto- and choledocholithiasis. An analysis of results]. / Die einzeitige laparoskopische Therapie der Cholezysto- und Choledocholithiasis. Eine Resultatanalyse.

INTRODUCTION: With the advent of laparoscopic cholecystectomy, ERCP has gained importance in the treatment of choledocholithiasis. Laparoscopic cholecystectomy with intraoperative cholangiography and common bile duct surgery allows diagnosis and treatment of cholecystolithiasis and choledocholithiasis in a single procedure. PATIENTS AND METHODS: Laparoscopic treatment of choledocholithiasis was evaluated in 99 consecutive patients with choledocholithiasis. 28 patients underwent successful preoperative ERCP. Of the patients with intraoperative confirmation of choledocholithiasis, removal was attempted by a transcystic approach in 36 and 23 underwent choledochotomy. 24 patients with a high operative risk underwent postoperative ERCP. RESULTS: The transcystic approach was successful in 72.2%. Choledochotomy was successful in 91.3%, yielding a combined success rate of 80%, 3.4% had local complications and 8.4% had other complications (complication rate 11.8%), 20.3% of the patients underwent ERCP after failed laparoscopic procedures. One patient had a laparoscopic redo. There was no mortality and no conversion to open surgery. CONCLUSION: ERCP and laparoscopic common bile duct surgery are complementary, efficient and safe modalities of treatment for choledocholithiasis. Choice of procedure is influenced by the surgeon's experience and institutional infrastructure, and the individual patient.

Acute postoperative pancreatitis after laparoscopic cholecystectomy. Results of the Prospective Swiss Association of Laparoscopic and Thoracoscopic Surgery Study.

BACKGROUND: The introduction of laparoscopic cholecystectomy (LC) changed the treatment strategies for patients undergoing biliary surgery. There is a lack of data about acute postoperative pancreatitis (APP) as a complication of LC. OBJECTIVES: To determine the incidence, morbidity, and mortality of APP after LC and to analyze the possible intraoperative and pathogenic factors associated with APP. DESIGN: A prospective cohort study of 10174 patients who underwent LC. The data for 32 patients with APP after the completion of LC and 8 patients with APP after an attempted LC that was converted to an open cholecystectomy were analyzed. SETTING: A multi-institutional study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Eighty-one surgical services or surgeons in private practice participated. RESULTS: The incidence of APP after a completed LC was 0.34%. In comparison, the incidence of APP after conversion to an open procedure (0.96%) was significantly (P = .02) increased. A biliary origin of APP could be established in 4 (12.5%) of the 32 patients. No evidence for a causative role of intraoperative cholangiography or trauma to the pancreas was found. Factors shown to be associated with APP were the surgeon's experience level and a high morbidity of 31.3%. The mortality was 3%. CONCLUSIONS: The incidence of APP after LC is low; the risk increases after conversion to an open procedure. In the rare event of an APP after LC, a biliary cause should be suspected. The mortality of patients with APP did decrease substantially compared with those undergoing open biliary surgery.

Abdominal fat tissue necrosis as a cause of acute abdominal pain. Laparoscopic diagnosis and therapy.

BACKGROUND: Infarctions of the greater omentum and of the epiploic appendages are rare etiologies of acute abdominal pain. The aims of the study were to determine the incidence of abdominal fat tissue necroses and to discuss the clinical features and the role of laparoscopy in the treatment of these conditions. METHODS: A retrospective study in 563 consecutive patients with acute abdominal pain was performed. In all patients diagnostic laparoscopy was indicated. RESULTS: The incidence of abdominal fat tissue necroses in 563 patients with acute abdominal pain was 1.1%. Six patients had either infarctions of the omentum or of the epiploic appendages. Pain was the predominant clinical symptom and the preoperative diagnosis depended upon the location of the omental or epiploic necroses. Diagnosis and treatment were performed laparoscopically without morbidity. CONCLUSION: The incidence of abdominal fat tissue necroses in our patients was increased compared to the prelaparoscopic period. Omental and epiploic necroses are significant in the differential diagnosis of appendicitis, acute cholecystitis, and diverticulitis.

[Right-sided diverticulitis: new diagnostic and therapeutic aspects]. / Die rechtsseitige Divertikulitis: neue diagnostische und therapeutische Aspekte.

Because of its rarity in the Western World, diverticulitis of the ascending colon is often not taken into account in the differential diagnosis of abdominal pain in the right lower quadrant or is misdiagnosed as appendicitis. Of five patients who were treated for right-side diverticulitis in our hospital between April 1995 and April 1996, one underwent right hemicolectomy and one laparoscopic diverticulectomy. In three cases we succeeded with antibiotics alone. In three cases the diagnosis was made on the basis of CT-scan, prompted by peridiverticular changes. In one case the diagnosis was made at laparoscopy and confirmed by CT. In one case diagnosis and therapy were carried out only by laparoscopy. From the moment of diagnosis the average stay in hospital was twelve days and no complications occurred. During an average follow-up time of twelve months, all patients remained free of pain. On the basis of the case reports and a literature review we discuss the diagnostic value of CT and laparoscopy as well as the benefit of conservative therapy, which to us--in contrast to other authors--seems appropriate at least for the first bout of uncomplicated diverticulitis.

Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases.

BACKGROUND: The value of laparoscopic appendectomy remains controversial. Therefore, we investigated the accuracy of diagnostic laparoscopy in detecting acute appendicitis and tested the applicability and safety of stapling appendectomy as a routine procedure. METHODS: Data from 267 consecutive patients with suspicion of acute appendicitis were recorded prospectively. RESULTS: Histopathological examination revealed nonperforated and perforated appendicitis in 63.3% and 13.1%, respectively, and no inflammation in 10.8%. Other pathological findings were observed in 12.7%. Diagnostic laparoscopy detected appendicitis with a sensitivity and specificity of 95.6% and 96.6%, respectively; the positive and negative predictive value were 99.5% and 74.3%, respectively. Morbidity was 10.2% in total and 40% for perforated appendicitis. Planned laparoscopic reexploration reduced morbidity by 23.4% in patients with perforated appendicitis and substantial peritonitis. Mortality was 0.4%. CONCLUSIONS: Laparoscopy improves diagnostic accuracy for acute appendicitis and laparoscopic stapling appendectomy is a safe and efficient procedure for all forms of appendicitis.

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results.

BACKGROUND: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. METHODS: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). RESULTS: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. CONCLUSIONS: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.