[Clinical and functional results of the Broström-Gould technique for lateral ankle instability: evaluation with three scales]. / Resultados clínicos y funcionales de la plastía Broström-Gould para inestabilidad lateral de tobillo: evaluación con tres escalas.

BACKGROUND: The most frequent sequel to the ankle sprain is the instability of the lateral ligament complex; the results of surgical treatment have not been evaluated with multiple scales simultaneously. The objective of the study was to assess the clinical and functional results with three scales in patients with lateral instability of ankle undergoing Broström-Gould technique, using for fixation, anchors with suture to distal fibula. MATERIAL AND METHODS: The design of the study was cross-sectional and descriptive; we included patients with lateral instability of ankle and partial or complete rupture of the APA or CP ligament subject to repair with Broström-Gould technique. Magnetic resonance imaging was performed to confirm the diagnosis; clinical and functional outcomes were determined with three scales: EVA, SF-36 and AOFAS. Patients were evaluated at six months, or more, after the surgical procedure. RESULTS: We included 13 patients; quality of life (SF-36 questionnaire) showed a good result with average score of 90; 10 (77%) patients showed excellent results in function, absence of pain and alignment of the ankle (AOFAS 90-100). Also found significant improvement in pain (presurgical EVA: 6, compared with 1 in the postoperative period). CONCLUSIONS: The surgical procedure showed excellent results, in the short term with resolution of pain and ankle stability.

ANTECEDENTES: La secuela más frecuente del esguince de tobillo es la inestabilidad del complejo ligamentario lateral; los resultados del tratamiento quirúrgico no han sido evaluados con varias escalas simultáneamente. El objetivo del estudio fue evaluar los resultados clínicos y funcionales con tres escalas en pacientes con inestabilidad lateral de tobillo sometidos a plastía de Broström-Gould, utilizando para su fijación anclas con sutura al peroné distal. MATERIAL Y MÉTODOS: El diseño del estudio fue transversal y descriptivo; se incluyeron pacientes con inestabilidad lateral de tobillo y ruptura parcial o completa del ligamento PAA y/o PC, sometidos a reparación con plastía de Broström-Gould. Se realizó resonancia magnética nuclear para confirmar el diagnóstico; los resultados clínicos y funcionales se determinaron con tres escalas: EVA, SF-36 y AOFAS. Los pacientes fueron evaluados a los seis meses o más posteriores al procedimiento quirúrgico. RESULTADOS: Se incluyeron 13 pacientes; la calidad de vida (cuestionario SF-36) arrojó un resultado bueno con promedio de 90; 10 (77%) pacientes mostraron resultados excelentes en la función, ausencia de dolor y alineación del tobillo (AOFAS 90-100). Asimismo, se observó mejoría importante en el dolor (EVA prequirúrgico: 6, comparado con 1 en el período postquirúrgico). CONCLUSIONES: El procedimiento quirúrgico demostró excelentes resultados en el corto plazo con resolución del dolor y estabilidad del tobillo.

Treatment-Based Three-Dimensional Classification and Management of Anorectal Infections.

This article provides a current overview on clinical anatomy, pathophysiology, workup and surgical management of anorectal abscesses. Based on the three-dimensional nature of anorectal abscesses, a novel treatment-based classification is proposed. It examines the basis of a philosophic shift from simple drainage to concomitant definitive treatment of abscesses and their underlying primary fistulous trajectories. Complications are discussed specifically in this context.

The WAND local anesthetic delivery system: a more pleasant experience for anal anesthesia.

PURPOSE: The WAND is a computer-controlled local anesthetic delivery system. Its use has been proven to be more comfortable for dental patients. The purpose of this study is to explore its applicability to anal procedures. Our hypothesis is that the WAND will provide greater comfort during anesthesia delivery while achieving the same anesthetic effect as traditional syringe technique. METHODS: Twenty patients with painless anal pathology were randomized to receive anal anesthesia using either the WAND or traditional syringe technique to a randomly selected half of the anoderm (right or left). The opposite side was then anesthetized by the alternate method, allowing patients to act as their own control. Objective and subjective pain scores were obtained from the patient after each mode of delivery. An independent observer interpreted the patient's tolerance by giving a subjective pain score. The volume of anesthetic used was recorded. Adequacy of anesthesia was tested by a pinch test. RESULTS: Sixteen (80 percent) of the 20 patients preferred the use of the WAND. Objective and subjective pain scores per the patients and subjective pain scores per the observer were significantly lower for the WAND than for traditional syringe technique (P < 0.05). The mean volume of local anesthetic used with the WAND was 1.7 ml compared with 3.2 ml for traditional syringe technique (P < 0.005). Anesthesia achieved with the WAND was as good as that achieved with traditional syringe technique when the pinch test was used. CONCLUSION: The WAND is as effective as the traditional syringe technique in the delivery of anal anesthesia while providing a more comfortable experience for the patient.

New technique for mesh repair of paracolostomy hernias.

Paracolostomy hernias are common and require treatment when symptomatic. Traditional methods of repair have high recurrence rates. We describe a new technique using polytetrafluoroethylene mesh, which offers preservation of stoma site, lack of recurrences, ease, and safety.

Variations in treatment of rectal cancer: the influence of hospital type and caseload.

PURPOSE: Surgical options for the treatment of rectal cancer may involve sphincter-sparing procedures (SSP) or abdominoperineal resection (APR). We sought to examine variations in the surgical treatment of rectal cancer for a large, well-defined patient population and specifically to determine if differences exist in management and survival based on hospital type and surgical caseload. METHODS: The Cancer Surveillance Program database for Los Angeles County was used to retrospectively retrieve data on all patients who underwent SSP or APR for rectal adenocarcinoma between 1988 and 1992. RESULTS: A total of 2,006 patients with adenocarcinoma of the rectum underwent SSP or APR during the study period. Overall, 55 percent underwent SSP, and the remaining 45 percent underwent APR. Use of SSP remained relatively constant for each year of the five-year period. Substantial variability was seen in the use of SSP at various hospital types. For localized disease, this varied from as low as 52 percent at teaching hospitals to as high as 78 percent at hospitals approved by the American College of Surgeons (P = 0.067). To examine the role of caseload experience, hospitals were divided into those completing an average of five or fewer rectal cancer cases per year vs. those completing an average of more than five cases per year. For localized disease, hospitals with higher caseloads performed SSP in significantly more cases, 69 vs. 63 percent (P = 0.049). Survival was seen to be significantly improved for patients operated on at hospitals with higher caseloads, in cases of both localized and regional diseases (P < 0.001). CONCLUSION: Surgical choices in the treatment of rectal cancer may vary widely, even in a well-defined geographic region. Although the reasons for this variability are multifactorial, hospital environment and surgical caseload experience seem to have a significant role in the choice of surgical procedure and on survival.

Intra-abdominal abscesses following laparoscopic and open appendectomies.

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailed P value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an overall abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%). For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%, P = 0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with perforated appendicitis.

Unresolved issues in laparoscopic splenectomy.

BACKGROUND: Laparoscopy is now expanding to surgery of intra-abdominal solid organs such as splenectomy for hematologic diseases. The purpose of this study is to further demonstrate that laparoscopic splenectomy is feasible for the surgeon, teachable for the resident, and beneficial to the patient and to revise prior contraindications to this minimally invasive approach. METHODS: Thirty-three consecutive cases of laparoscopic splenectomy were performed between May 1992 and March 1996. The series included 21 females and 12 males with a median age of 42 years (range 19-79) and a median weight of 73 kg (range 36-115). Indications included: immune thrombocytopenic purpura (20), hemolytic anemia (5), hereditary spherocytosis (4), infarction with abscess (1), Hodgkin's lymphoma (1), Gaucher's disease (1), and AIDS-related thrombocytopenia (1). Dissection was predominately performed with a new surgical instrument, the harmonic shears, and main vessels were controlled with clips. RESULTS: Thirty-two (97%) of the cases were completed laparoscopically, with 1 (3%) conversion to control hilar bleeding. Four patients underwent simultaneous cholecystectomy. The median spleen size was 13 cm (range 8-28) and median weight was 256 g (range 40-2100). Median operating time was 242 minutes (range 85-515). Morbidity occurred in 2 (6%) patients: ileus and small bowel obstruction. Median hospital stay was 4 days (range 2-14). There was no mortality in our series. Median follow-up was 20 months (range 1-46) with no evidence of late surgical complication or recurrent disease. CONCLUSION: Laparoscopic splenectomy may be successful in cases previously considered contraindicated, particularly splenomegaly and splenic infarct with abscess. It is a procedure that can be learned under appropriate guidance in academic centers.

Wound recurrence following laparoscopic colon cancer resection. Results of the American Society of Colon and Rectal Surgeons Laparoscopic Registry.

INTRODUCTION: Multiple case reports have suggested that laparoscopic resection of colon cancer may alter the pattern or incidence of cancer recurrence. All reports lack a significant denominator to evaluate the incidence of surgical wound recurrence. We hypothesized that wound recurrence incidence is not increased by laparoscopic resection of colon cancer. METHODS: A prospective registry was initiated under the auspices of The American Society of colon and Rectal Surgeons, American College of Surgeons, and Society of American Gastrointestinal Endoscopic Surgeons in 1992. Patients having laparoscopic colon resection were voluntarily entered and followed until June 1995. Recurrences were evaluated by the primary surgeon and reported to the registry. RESULTS: A total of 504 patients treated for cancer were identified in the registry. A minimum follow-up of one year was obtained for 480 of 493 evaluable patients (97.4 percent). Wound recurrence was identified in five patients (1.1 percent). Recurrence status was unknown in 18 patients (3.8 percent). CONCLUSION: Wound recurrence rates appear to be low. Although length of follow-up is limited, patterns of recurrence from previous studies suggest that 80 percent of recurrences should have occurred within one year. Given the limitations of a Phase II study, the hypothesis that recurrence rate is low is supported. However, prospective randomized trials are needed to establish if any difference in wound recurrence rates after laparoscopic or open resection of colorectal cancer exists.

A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy.

BACKGROUND: In a relatively short period of time, therapeutic laparoscopy has become an everyday part of the general surgeon's life. Although laparoscopy provides distinct clinical advantages, it is not yet clear that it lessens the stress response typical of elective surgical procedures, and as such, the morbidity of surgery. The hypothesis that laparoscopic cholecystectomy produces less of a metabolic and stress hormonal response than open cholecystectomy was tested in a prospective randomized trial. STUDY DESIGN: Twenty otherwise healthy women between 18 and 45 years of age with a history of uncomplicated symptomatic cholelithiasis undergoing either laparoscopic (n = 10) or open cholecystectomy (n = 10) were studied. The hormonal response of the adrenocortical (serum adrenocorticotropic hormone, cortisol, and urinary free cortisol), adrenomedullary (plasma and urinary epinephrine and norepinephrine), thyroid (thyroid-stimulating hormone, thyroxine, and triiodothyronine), pituitary (antidiuretic hormone and growth hormone), and glucose (serum glucose, glucagon, and insulin) homeostatic axes were measured serially over a 24-hour period. RESULTS: No difference was seen between the laparoscopic and open groups in operative time (mean plus or minus standard error of the mean, 70 +/- 6 minutes compared with 77 +/- 6.3 minutes) or hospital stay 1.3 +/- 0.2 compared with 1.1 +/- 0.1 days). Assessment of postoperative pain using an analog pain score was less in the laparoscopic group (4.9 +/- 1.3 compared with 12.3 +/- 2.5, p = 0.01). The response of the adrenocortical, adrenomedullary, thyroid, and glucose axes were similar or identical in both groups. Antidiuretic hormone levels were greater in the laparoscopic group at one hour intraoperatively (281 +/- 79 pg/mL compared with 54 +/- 18 pg/mL, p < 0.01), and at extubation (122 +/- 18 pg/mL compared with 36 +/- 7 pg/mL, p < 0.01). Serum glucose levels were greater immediately following laparoscopic cholecystectomy. Glucose and insulin levels were greater at four, 12, and 24 hours after open cholecystectomy. CONCLUSIONS: Elective laparoscopic and open cholecystectomy for uncomplicated cholelithiasis result in similar degrees of perioperative hormonal stimulation. The different hormonal responses in the immediate and later postoperative periods after laparoscopic and open cholecystectomy suggest differential stressful stimuli between the two procedures.

Inferior vena caval blood flow and cardiac hemodynamics during carbon dioxide pneumoperitoneum.

BACKGROUND: The effects of carbon dioxide pneumoperitoneum on venous return and cardiac hemodynamics during laparoscopic surgery were studied. METHODS: Twelve adult pigs underwent placement of an electromagnetic flow meter across the infrarenal vena cava (IVC) as well as placement of Swan Ganz and arterial monitoring catheters. Measurements of the flow through infrarenal IVC, cardiac output (CO), pulmonary capillary wedge pressure (PCWP), mean arterial pressure (MAP), and heart rate were recorded at baseline, 5 and 60 min following insufflation to 15 mmHg with CO2, and 5 min following desufflation. Stroke volumes and systemic vascular resistance (SVR) were calculated as well. RESULTS: Flow through the IVC dropped by 24 and 31% at 5 and 60 min (p = 0.03 and 0.02, respectively). Paradoxically, cardiac output rose by 14 and 28% at 5 and 60 min (p = 0.03 at 60 min). Central venous and pulmonary capillary wedge pressures rose transiently by 35 and 36% at 5 min before returning to baseline (p < 0.01). Mean arterial pressure and heart rate remained relatively constant during insufflation. Systemic vascular resistance diminished from 938 dynes/cm/s prior to insufflation to its nadir at 60 min of 650 dynes/cm/s (p < 0.01). CONCLUSIONS: These observations suggest potentially complex interactions between the mechanical and systemic effects of the CO2 pneumoperitoneum on venous return. Transient elevations in cardiac filling pressures occur by an unknown mechanism, and a generalized enhanced inotropic state mediated via increased sympathetic outflow is observed in this hypercapnic anesthetized animal model.

Basal and meal-stimulated colonic absorption.

PURPOSE: Few quantitative experiments evaluating colonic absorption of water and electrolytes have been performed using an awake, conscious animal model. The purpose of these experiments was to develop this type of model and evaluate both basal and meal-stimulated colonic absorption of water and electrolytes. METHODS: Canine Thiry-Vella fistulas were created using a 20 cm segment of distal colon under general anesthesia. Colonic absorption studies were performed using infusion of the Thirty-Vella fistulas with a buffer solution containing [14C]polyethylene glycol. Electrolyte analysis and concentration of radioactivity in the effluent were obtained and used to calculate the net flux of water, sodium, and chloride. Each study consisted of an one-hour basal period and a three-hour experimental period divided into two groups. Group 1 received no meal. Group 2 orally ingested a mixed meal at the completion of the basal hour. RESULTS: In the basal state, water and electrolytes are absorbed from the distal colon at a steady and constant rate. An orally ingested meal produces a statistically significant increase in the rate of absorption, independent of direct colonic luminal contact with the nutrients of the meal given. CONCLUSIONS: These studies demonstrate an in vivo quantitative and qualitative measure of mammalian colonic water and electrolyte absorption. An increase in absorption rate occurs in response to a meal that is probably the result of an unidentified neural or humoral signal.

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature.

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.

Intraabdominal abscesses following laparoscopic and open appendectomies.

BACKGROUND: The purpose of this review was to evaluate the incidence of postoperative intraabdominal abscess formation following laparoscopic and open appendectomies. METHODS: The current study retrospectively examines appendectomies performed during the period from January 1993 to July 1994. Excluded were cases which were started laparoscopically but converted to open procedures. There were 1,287 cases identified; 597 were perforated (46%), 114 were gangrenous (9%), and 576 were acute (45%). These diagnoses represent intraoperative diagnoses. RESULTS: Of the 576 appendectomies for acute appendicitis, 64 (11%) were performed laparoscopically. There were four intraabdominal abscesses (0.7%), all occurring after open procedures. Of the 114 appendectomies for gangrenous appendicitis, 16 (14%) were done laparoscopically. There were two postoperative abscesses (1.8%), one following an open and one following a laparoscopic procedure. There was no significant difference in abscess rate between laparoscopic and open appendectomies for either acute or gangrenous appendicitis. Of the 597 appendectomies for perforated appendicitis, 28 (5%) were done laparoscopically. There were 19 postoperative abscesses in the whole group, accounting for a 3.2% abscess rate. Sixteen abscesses occurred after open appendectomies and three occurred after laparoscopic appendectomies (2.9% vs 11%, P = 0.054). The preoperative diagnosis was incorrectly identified as acute appendicitis in 95 cases subsequently found to have perforated appendicitis; there was only 1 postoperative abscess in this group. There was no difference in postoperative stay in the open vs laparoscopic group (6.3 days vs 6.1 days). CONCLUSIONS: We found no significant difference in the rate of postoperative intraabdominal abscess formation between laparoscopic and open appendectomies in cases of acute or gangrenous appendicitis. However, laparoscopic appendectomy for perforated appendicitis was associated with an important trend toward a higher rate of postoperative intraabdominal abscess formation than open appendectomy. This observation calls for closer prospective scrutiny of laparoscopic appendectomy in the setting of perforated appendicitis.

Safe application of diagnostic laparoscopy during biventricular assistance.

We performed diagnostic laparoscopy in a patient who was critically unstable while on an ABIOMED BVS 5000 biventricular assist system. A relatively unique feature of the ABIOMED is the venous return being dependent only on gravity and the drawing force of venous return being the height of the inflow cannula compared with the level of the ABIOMED blood pump assembly; this did not preclude the use of pneumoperitoneum necessary for laparoscopy. The safe application of diagnostic laparoscopy in patients on a ventricular assist device is of importance in an era of increasing use of these devices and the increased potential for intraabdominal complications in this population.

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries.

BACKGROUND: General surgeons' recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma. METHODS: Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared. RESULTS: Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs. CONCLUSIONS: DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.

Does peritoneal mobilization increase laparoscopic acidosis?

PURPOSE: It was hypothesized that laparoscopic colon surgery may be associated with increased absorption of CO2 resulting from mobilization of lateral peritoneal reflections. METHODS: Six pigs underwent laparotomy with removal of a measured quadrant of peritoneum before insufflation to 15 mmHg with CO2. Six paired control animals also underwent insufflation with CO2 to 15 mmHg. Measurements of the end-tidal CO2 (PetCO2), arterial blood gas analysis for CO2 (PaCO2), and pH were performed before insufflation, at 5 and 10 minutes following insufflation, then at successive 15-minute intervals for a total of two hours, and 15 minutes following desufflation. No attempt was made to correct the hypercarbia by increasing minute ventilation. RESULTS: PaCO2 reached its maximum level at two hours with values of 70.77 +/- 5.54 mmHg and 64.62 +/- 5.18 mmHg in the peritonectomized and control groups, respectively. PetCO2 also peaked at two hours to 60 +/- 13 mmHg for the study group and 54 +/- 11 mmHg for controls. pH reached its nadir at two hours, falling from a baseline of 7.45 +/- 0.08 to 7.23 +/- 0.09 in the study group, and from 7.42 +/- 0.04 to 7.24 +/- 0.04 in the control group. There were no statistically significant differences between the two groups for any of the parameters measured at each time interval. CONCLUSIONS: The hypothesis that peritonectomy produces greater CO2 absorption during CO2 pneumoperitoneum was disproved under these experimental conditions.

Laparoscopic Bowel Surgery Registry. Preliminary results.

UNLABELLED: Laparoscopic surgery has evolved rapidly since 1989. The American Society of Colon and Rectal Surgeons, the Society of American Gastrointestinal Endoscopic Surgeons, and the American College of Surgeons Commission on Cancer jointly sponsored a registry to identify as early as possible the patterns of practice and acute complications of laparoscopic colectomy. METHODS: Cases were voluntarily registered by community and academic surgeons. Information was entered in the EPI-5 database. RESULTS: One thousand fifty-six cases were contributed by 118 surgeons; 763 patients were completed laparoscopically. The most common indication for surgery was cancer in 453 patients. The right colon (n = 364) and sigmoid (n = 294) were most frequently resected. Respondents felt adequate cancer resections were performed. Although several unique complications were noted, intraoperative complications were similar in type and frequency to open cases. CONCLUSION: Laparoscopic colorectal surgery can be performed with acceptable complications. It remains unclear if this approach is adequate for long-term management of colon and rectal cancer.

Laparoscopic-assisted colectomy learning curve.

PURPOSE: The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS: Data were obtained by chart review and by individually completed questionnaires. RESULTS: A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeon's operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS: This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.

Role of laparoscopy in colorectal surgery. A prospective evaluation of 200 cases.

PURPOSE: The aim of this study was to prospectively evaluate the role of laparoscopic-assisted surgery in patients presenting for routine colorectal surgical procedures. METHODS: Two hundred consecutive patients were assessed for the possible use of laparoscopic surgery. The decision regarding suitability of the patient for the procedure was made by the operator. For the purpose of analysis, patients were assigned to open, converted, and laparoscopic groups. RESULTS: Ninety-five of 200 patients were considered appropriate for laparoscopic surgery, 62 (65.3 percent) being successfully completed. These completed operations included right colectomy (24/30), sigmoid colectomy (22/36), appendectomy (9/10), anterior resection (3/8), abdominoperineal resection (3/5), and left colectomy (1/2). Complications attributable to laparoscopy were infrequent (6.3 percent) and were not responsible for any deaths. Patients in the laparoscopic group required less analgesia, tolerated oral intake earlier, and were discharged from the hospital earlier than those who were converted or who had open procedures. CONCLUSIONS: Laparoscopic-assisted surgery is safe, effective, and applicable to many of the standard colorectal procedures. Observed benefits include less postoperative pain and shorter hospital stay.