A new minimally invasive technique for cholecystectomy. Subxiphoid "minimal stress triangle": microceliotomy.

OBJECTIVE: The authors devised a minimally invasive technique for cholecystectomy via microceliotomy that provides safety attainable with the open conventional approach and postoperative results comparable to laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy has evolved as a minimally invasive outpatient procedure. Patients can return rapidly to preoperative status with minimal postoperative morbidity and pain, and the small scar size is cosmetically desirable. Unfortunately, there are reports of serious intraoperative complications, including injury to blood vessels, bowel, and the bile ducts, caused by failure to identify structures properly. The conventional cholecystectomy technique currently is relegated to patients on whom the laparoscopic procedure cannot be performed. METHODS: Cholecystectomy was performed through a 3-cm transverse high subxiphoid incision in the "minimal stress triangle." The location, anterior to Calot's triangle, was critical in providing a direct vertical view of the biliary ducts during dissection. Direct view cholecystectomy was performed using endoscopic instruments without pneumoperitoneum. Postoperative data were compared with both laparoscopic and open cholecystectomy results. RESULTS: Using the microceliotomy technique in the ambulatory setting, cholecystectomy was performed successfully in 99.3% (N = 143) of cases. Biliary leakage beyond the third postoperative day was caused by failure of clips or obstruction to bile flow. The postoperative morbidity, acceptability of scar, and analgesic requirements compare favorably with other techniques. Microceliotomy is cost effective. Portal hypertension is a contraindication for this procedure. CONCLUSIONS: The microceliotomy approach offers a viable, safe, and cost-effective alternative to the laparoscopic technique for cholecystectomy, especially when facilities for laparoscopy are not available or when the laparoscopic procedure cannot be performed.

Hemostasis and healing of superficial splenic injuries using Nd:YAG laser and nonsuture techniques: preliminary report.

This study was designed to compare Nd:YAG laser to fibrin glue, electrocautery, and avitene in the management of superficial splenic injury. Six dogs were submitted to laparotomy. A #11 blade scalpel was used to sharply excise the splenic capsule inflicting four 1" x 1" superficial injuries on each spleen. The lesions were treated. All animals had a second laparotomy ("first relaparotomy"); 2 dogs each were reexplored on postop days 3, 7, and 14. Morphologic and histologic observations were made. A third and final relaparotomy was performed on all dogs at 21 days with repeated morphologic and histologic assessments. Hemostatic times, grades of adhesions, and microscopic changes were not significantly different among the various treatments (P > 0.25). Capsular plaque formations were significantly different at the first relaparotomy (P < 0.01) and at final relaparotomy (P < 0.05). Both adhesions and capsular plaque formation were least at fibrin glue-treated sites, whereas Nd:YAG (1.06 microns) was most effective for average hemostatic time (mean = 109.67 s). Electrocautery produced the greatest necrosis at treatment sites. We conclude that all modalities are effective in controlling hemorrhage.

Primary closure of choledochotomy using CO2 laser: comparison with suture closure.

This study was designed to compare laser welding to suture closure of the common bile duct (CBD). A 12 mm linear choledochotomy was closed in 12 mongrel dogs using tissue welding low-energy CO2 laser. Tissue welding was accomplished at 5.0 w/cm2 for 120 sec. Twelve similar mongrel dogs (control) were treated with CBD closure using 5/0 Vicryl (polyglactin 910, Ethicon, Inc., Somerville, NJ) interrupted simple stitches. All animals were sacrificed at six weeks. Gross and histologic evaluation of the choledochotomy site were performed. There were no statistical differences in parameters of comparison in the two groups. These parameters were pre- and post-treatment measurements of liver function tests, stenosis, and dehiscence. However, it must be noted that there was a 33% (4/12) incidence of dehiscence and death in the CO2 laser welded choledochorrhaphy. This result, although not statistically significant, is clinically significant. We conclude that the tensile strength of CO2 laser welded CBDs must be optimized and that these results are preliminary and still unreliable to recommend for clinical adaptability.