Preperitoneal bupivacaine attenuates pain following laparoscopic inguinal hernia repair.

BACKGROUND: Laparoscopic preperitoneal inguinal hernia repair is associated with a short hospital stay and an early return to normal activity. Therefore, early postoperative pain control is important. The aim of this study was to evaluate the effect of preperitoneal Bupivacaine instilled into the preperitoneal cavity on pain following laparoscopic mesh repair of inguinal hernia. METHODS: After institutional review board approval, 44 patients undergoing elective laparoscopic inguinal hernia repair were prospectively randomized into two groups. Upon completion of the Prolene mesh repair, group A received 80 mg of Bupivacaine in 25 cc of saline installed into the preperitoneal space, whereas group B received normal saline installed into the preperitoneal space. Pain was assessed using a visual analog scale at fixed time intervals; the amount of analgesics required was also recorded. RESULTS: Twenty-two patients were included in each group. The demographic characteristics and type of surgery (unilateral vs bilateral) did not significantly differ between the two groups. The average pain levels were significantly attenuated in group A compared to group B at 1 (4.0 vs 5.0, respectively; p = 0.0038), 2 (4.0 vs 5.9, respectively; p = 0.0015), and 4 (4.3 vs 5.8, respectively; p = 0.0038) h after surgery. Furthermore, the analgesic intake was significantly decreased in group A compared to group B. CONCLUSION: Preperitoneal Bupivacaine attenuates pain following laparoscopic inguinal hernia repair and should be considered in these cases.

Laparoscopic distal pancreatectomy.

BACKGROUND: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies. METHODS: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded. RESULTS: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases. CONCLUSIONS: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.

140 consecutive cases of minimally invasive, radio-guided parathyroidectomy: lessons learned and long-term results.

BACKGROUND: The advent of highly accurate parathyroid imaging and the ever-increasing trend towards minimally invasive procedures have changed considerably the surgical approach to the patient with primary hyperparathyroidism (PHPT) caused by a single parathyroid adenoma. This study analyzes the short- and longer-term results of 140 patients who underwent minimally invasive, radio-guided parathyroidectomy. METHODS: Demographic, clinical, and pre-operative imaging data, operative findings, and short- and long-term results of 140 consecutive patients operated within a 20 months period (8/1999-4/2002), were prospectively entered into a database. Immediate pre-operative sestamibi scintigraphy with skin marking of focal adenoma uptake were followed by intraoperative hand-held gamma probe for the removal of the parathyroid adenoma by unilateral minimal access surgery. Preoperative and surgical data were analyzed and correlated to outcomes, measured by success or failure to cure PHPT, associated morbidity and mortality, predictive value of localizing studies, and postoperative laboratory results in the immediate as well as long-term period. RESULTS: 140 patients, mean age: 55.1 +/- 14.1 years (range 19-88 years), female to male ratio 94:46 with PHPT proven by concomitantly elevated serum calcium and parathormone (PTH) levels, with a single adenoma identified by sestamibi single photon emission tomography (SPECT) scintigraphy and high-resolution sonography, underwent minimally invasive, radio-guided parathyroidectomy. Mean serum levels of preoperative calcium, phosphorus, and PTH were 11.6 +/- 0.8 mg/dL (range 9.1-14), 3.0 +/- 0.3 mg/dL, and 147.1 +/- 94.3 pg/mL (range 68-784), respectively. Overall, in 3 out of 140 patients (2.1%), focused, minimally invasive surgery failed to identify and remove the adenoma. Positive predictive value when both localizing modalities concurred was 99.2%. Positive predictive value of SPECT scan alone was 97.2%. Overall success rate was 97.8% (137/140). 24 hours postoperative mean serum calcium was 9.2 +/- 0.8 mg/dL and at 6 months mean serum calcium, phosphorus, and PTH were 9.4 +/- 1.06 mg/dL, 3.2 +/- 0.8 mg/dL, and 32.1 +/- 11.9 pg/mL, respectively (p = 0.0001). There was no mortality. In 2 patients (1.4%) there was transient vocal cord paresis and there were 8 instances of clinically significant hypocalcemia. In 3 cases (2.1%), a second adenoma manifested itself 9-14 months following surgery and was removed by minimal access procedure. CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is safe and effective in curing hyperparathyroidism with a 97% success rate. A second adenoma occurring in less than 3% may be successfully treated with a second minimal access operation. The combined positive predictive value of concurring sestamibi SPECT scintigraphy and sonography of 99.2% may increase success rate, and thus implementing this technique in patients with concurring sonography and scintigraphy may be advocated.

Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia.

BACKGROUND: This study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair. METHODS: Clinical data from the first 100 cases were analyzed retrospectively. RESULTS: Between 1997 and 2000, 64 women and 36 men (mean age, 58.4 +/- 13.6 years; range, 27-87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 +/- 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 +/- 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n = 6), seromas (n = 11), prolonged ileus (n = 4), and prolonged fever (n = 3). Seven cases were converted; to repair accidental enterotomies (n = 4) due to difficult adhesiolysis (n = 2), or to control bleeding (n = 1). Six patients underwent reoperation because of enetric leak (n = 3) or bowel obstruction (n = 3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12-54 months). CONCLUSIONS: Laparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.

Fibroadenoma of the breast: analysis of associated pathological entities--a different risk marker in different age groups for concurrent breast cancer.

BACKGROUND: Fibroadenoma, one of the most common benign breast lesions, has a characteristic age-specific incidence and is associated with other pathological entities in 50% of cases. The clinical or imaging diagnosis of fibroadenoma may be erroneous, and in some cases is found to be invasive cancer. The clustering of such entities, their correlation with age, and the risk of synchronous breast malignancy are uncertain. OBJECTIVE: To explore the possibility of any significant clustering of fibroadenoma-associated benign breast diseases and to assess the possible risk of concomitant breast cancer. METHODS: We analyzed the pathological results of 147 women undergoing excisional biopsies for fibroadenoma diagnosed pre-operatively either by clinical examination and imaging (n = 17) or by radiology alone (n = 30). The inter-relationships among all entities associated with fibroadenoma were studied by hierarchical cluster analysis. The correlation of the various pathologies with the risk of invasive breast cancer in relation to the patient's age was also evaluated. RESULTS: Fibroadenoma-associated pathologies were found in 48% of the cases: sclerosing adenosis (23%), duct ectasia (17.7%), apocrine metaplasia (15.6%), florid fibrocystic disease (12.9%), duct papillomatosis (11.6%), infiltrating duct carcinoma (5.4%), duct carcinoma in situ (3.4%), and 1 case of lobular carcinoma in situ (0.6%). An orderly internal hierarchy and three significant clusters emerged: a) epithelial apocrine metaplasia, duct ectasia and sclerosing adenosis (similarity coefficients 16.0, 11.0 and 8.0 respectively); b) papillomatosis, florid fibrocystic disease and calcifications (similarity coefficients of 6.0, 4.0 and 2.0 respectively); and c) infiltrating duct carcinoma and duct carcinoma in situ (similarity coefficients of 1.8 and 1.6 respectively). Seven of the eight patients with breast cancer were older than 40 years. CONCLUSIONS: In about half of the cases fibroadenoma was associated with other pathological entities clustered in an orderly hierarchy. The rarity of synchronous breast cancer in the younger age group and its more common association with fibroadenoma in the older age groups dictate a different approach to each. The finding of fibroadenoma in women older than 40 indicates the need for surgical excision.

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND: Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS: We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS: The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION: Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

Laparoscopic transabdominal suspension sutures.

A limited number of access ports used in laparoscopic surgery may impair the ability of the surgeon to achieve adequate retraction and exposure, or to stabilize "moving targets" while operating on nonfixed organs. Solutions such as adding more ports or using a hand-assisted technique have the disadvantages of being more invasive, possibly creating a cumbersome situation of multiple instruments in a limited working space. We describe a useful technique for retraction and stabilization with the use of temporary sutures that pass through the abdominal wall. Although not new, this technique is not widely known or used, and laparoscopic surgeons may find it useful for a variety of applications.

Closure of laparoscopic trocar site wounds with cyanoacrylate tissue glue: a simple technical solution.

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

[Laparoscopic adrenalectomy for pheochromocytoma].

Laparoscopic adrenalectomy has recently been shown to be a safe and effective strategy of treating a variety of benign adrenal tumors. The ability to reduce hypertensive crisis during surgery for pheochromocytoma by adequate preoperative alpha- and beta-blockade and early intraoperative venous ligation have reached a level sufficient to permit a safe laparoscopic approach. During the period January 1995 to December 1999, laparoscopic adrenalectomy was attempted in twelve patients with unilateral pheochromocytoma and in 2 patients with multiple endocrine neoplasia type II. All procedures were completed laparoscopically. The mean operative time was 90 minutes (45-120). Blood transfusion was not required and there were no postoperative complications. The median hospital stay was 3 days.

The use of magnetic resonance imaging in the differential diagnosis between starch and fecal peritonitis.

Granulomatous peritonitis, caused by the starch from the surgeons' gloves, is a hypersensitivity reaction that can complicate abdominal surgery and mimic other causes of peritonitis. The diagnosis of this entity is difficult to make, and relies on a high index of suspicion. We suggest the use of magnetic resonance imaging to facilitate the diagnosis of this condition, based on an experimental animal model. 84 rats were subjected to laparotomy, and the abdominal cavity was exposed to either saline solution, talc solution, starch solution or fecal material by creating a cecal perforation. TI-weighted magnetic resonance images, with and without gadolinum enhancement, were taken after 3, 5 and 10 days. The animals were then sacrificed and the abdominal contents were evaluated both macroscopically and microscopically. Both talc and starch caused gross adhesions involving the entire abdominal viscera, and microscopy revealed signs of inflammation and fibrosis. Starch induced reactive granulomas. The adhesions in the cases of fecal peritonitis were confined to the area of the perforation. MR images of the starch peritonitis group was remarkable for a diffuse pathological process with enhancement of the omentum and the peritoneum after gadolinum injection. The MR readings of the fecal peritonitis group showed a localized process with no diffuse enhancement of the peritoneum. The striking differences between the magnetic resonance images of starch and fecal peritonitis in rats suggest that this modality is both sensitive and specific in diagnosing starch peritonitis in a rat model. Early non-invasive diagnosis of these separate entities would ease the establishment of the appropriate treatment. We are currently investigating the use of MRI imaging in suspected starch peritonitis in humans.

Doble derivación, gástrica y biliar, por laparoscopia en pacientes con carcinoma de cabeza de páncreas irresecable / Laparoscopic gastric and biliary bypass in patients with unresectable pancreatic head carcinoma

Antecedentes. Un elevado número de pacientes con cáncer de páncreas irresecable presentan dificultades del vaciamiento gástrico y obstrucción biliar; en esta situación clínica debe ser planteada una intervención paliativa. El propósito de este estudio en pacientes con cáncer de páncreas irresecable fue la valoración de la seguridad y de la eficacia de la doble derivación biliar y gástrica al intestino delgado mediante el abordaje laparoscópico. Pacientes y método. Entre agosto de 1995 y julio de 1998 fueron intervenidos 12 pacientes consecutivos con carcinoma irresecable de páncreas mediante una derivación biliar (colecistoyeyunostomía) y gástrica (gastroyeyunostomía) transmesocólica simultáneas por laparoscopia. Se realizó en 8 varones y 4 mujeres, con una edad media de 72 años (rango, 50-82 años). En todos los pacientes la indicación de las derivaciones fueron ictericia obstructiva y obstrucción del vaciamiento gástrico. Se valoró la morbilidad relacionada con el procedimiento, la mortalidad, el tiempo operatorio, la estancia intrahospitalaria, la supervivencia y la capacidad de mantener la alimentación oral durante el período de supervivencia. Resultados. Todos los procedimientos fueron completa dos por abordaje laparoscópico, y el tiempo operatorio fue de 89 ñ 29,56 min (rango, 35-150 min). No hubo complicaciones intraoperatorias. La morbilidad postoperatoria consistió en infección de la herida en 2 pacientes y neumonía en otro enfermo. Un paciente con cirrosis falleció por fallo multiorgánico al segundo día del postoperatorio. La estancia hospitalaria promedio fue de 6,4 ñ 1,5 días (rango, 5-17 días). El tiempo de supervivencia hasta la muerte por la enfermedad subyacente fue de 85 ñ 32,46 días. Durante este período, la tolerancia a la alimentación oral fue adecuada y en ningún caso reapareció la ictericia. Conclusión. La doble derivación, biliar y gástrica, simultáneas, por vía laparoscópica son técnicas seguras y eficaces para el tratamiento de la obstrucción biliar y gástrica en pacientes con cáncer de páncreas irresecable (AU)

Laparoscopic approach to small-bowel obstruction.

BACKGROUND: Small-bowel obstruction poses both a diagnostic and a therapeutic challenge. The laparoscopic approach may assist in determining the cause of the obstruction and in many cases to treat the obstructing lesion. METHODS: For the last 2 years, we have been approaching patients with small-bowel obstruction laparoscopically. RESULTS: We have found this technique to be successful as the definitive treatment in more than half of the cases. CONCLUSION: The laparoscopic approach should be the modality of choice for most, if not all, cases of small-bowel obstruction in which there is an indication for exploration.

Laparoscopic resection of huge omental cyst.

Mesenteric cysts are uncommon, and their pathological type includes pseudocyst, mesothelial cyst, lymphangioma, and omental cyst. We describe a case of a giant omental cyst treated successfully by a minimally invasive approach.

Intraperitoneal bupivacaine does not attenuate pain following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is characterized by a short hospital stay. Hence, pain control on the day of surgery is increasingly important. The aim of this study was to evaluate the effect of intraperitoneal bupivacaine on pain relief following laparoscopic cholecystectomy. METHODS: Sixty patients undergoing elective laparoscopic cholecystectomy were prospectively randomized into 2 groups. Following removal of the gallbladder, group A received 100 mg of bupivacaine in 50 cc of saline, installed into the gallbladder bed and right subphrenic space. Group B received saline without bupivacaine. Pain was assessed using a visual/analog scale at fixed-time intervals. RESULTS: No significant difference occurred in the average pain levels between the groups at 1, 2, 4, and 14 hours postsurgery. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance. CONCLUSION: Application of intraperitoneal bupivacaine did not attenuate pain following laparoscopic cholecystectomy, and no role exists for its routine use.

Esplacnicectomía toracoscópica en el tratamiento del dolor en pacientes con cáncer de páncreas irresecable / Thoracoscopic splanchnicectomy in the treatment of pain in patients with irresectable pancreatic cancer

Introducción. En los pacientes con una neoplasia de páncreas irresecable el dolor es uno de los síntomas de más difícil control, produciendo limitaciones en la actividad de los enfermos y empeorando claramente su calidad de vida. Las intervenciones que se realizan en estos pacientes son paliativas, con el único objetivo de aliviar los síntomas de su enfermedad. El objetivo de este estudio es determinar la eficacia y seguridad de la esplacnicectomía toracoscópica, para el control del dolor en pacientes con cáncer de páncreas irresecable. Pacientes y métodos. Desde mayo de 1995 a abril de 1998 hemos realizado 35 esplacnicectomías toracoscópicas en 24 pacientes consecutivos (14 varones y 10 mujeres), diagnosticados de cáncer de páncreas irresecable. Todos los pacientes eran dependientes de opiáceos para controlar su dolor e incapaces de realizar una actividad diaria normal. Se ha utilizado la escala visual analógica (EVA) como parámetro subjetivo de medida del dolor en estos pacientes. Además, se han evaluado el tiempo operatorio, la morbilidad y mortalidad relacionada con el procedimiento y la estancia hospitalaria. Resultados. Todas las esplacnicectomías se han completa do por toracoscopia, sin complicaciones intraoperatorias. El tiempo operatorio fue de 58 ñ 22 min en la esplacnicectomía izquierda y de 93,5 ñ 15,6 min en la esplacnicectomía bilateral. La determinación del dolor por la EVA en estos pacientes era de 8,5 (8-10) como valor medio preoperatorio. El dolor desapareció o mejoró durante el postoperatorio, consiguiendo en todos los pacientes una disminución de las necesidades de analgésicos, abandonando en todos los casos los opiáceos. Cuatro pacientes a quienes se les realizó la esplacnicectomía bilateral presentaron dolor intercostal relacionado con los orificios de los trocares, mientras que el dolor abdominal había desaparecido. Dos pacientes presentaron complicaciones relacionadas con la técnica quirúrgica, uno un derrame pleural y otro un neumotórax residual, que se resolvieron con tratamiento médico. La estancia media hospitalaria fue de 3 días (2-5). En 20 pacientes (84 por ciento) el dolor fue controlado con dosis bajas de analgésicos no opiáceos hasta el momento de su fallecimiento. Conclusión. En nuestra experiencia, la esplacnicectomía toracoscópica es un método seguro y eficaz para el tratamiento del dolor en pacientes afectados de cáncer de páncreas irresecable. Entre las ventajas, permite eliminar la necesidad de dosis de analgésicos cada vez mayores, evita los efectos colaterales de esta medicación y ofrece una mejora importante de la calidad de vida en estos pacientes con una corta esperanza de vida (AU)

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas.

BACKGROUND: Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. METHODS: Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30-85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. RESULTS: All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58+/-22 min for unilateral left splanchnicectomy and 93.5+/-15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8-10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2-5). CONCLUSIONS: We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short.

Laparoscopic interval appendectomy for periappendicular abscess.

BACKGROUND: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. METHODS: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. RESULTS: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. CONCLUSION: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.

[Preliminary experiences with endoscopic parathyroidectomy].

Since the advent of extraperitoneal approaches for laparoscopic surgery, the creation of extraperitoneal virtual spaces has spread rapidly. We describe our preliminary experience with selective neck exploration and endoscopic parathyroidectomy in 4 women, aged 57-74, with primary hyperparathyroidism. Preoperative localization of parathyroid adenoma was assessed by technetium-sestamibi scanning and cervical ultrasonography. A cervical work space was created by the introduction of a trocar with an inflatable balloon-tip and maintained with low-pressure CO2 insufflation. All procedures were completed endoscopically. There were no intraoperative complications. Mean operative time was 40 minutes and cosmetic results were very satisfactory. We found endoscopic parathyroidectomy a feasible and safe option and particularly appropriate for the surgical treatment of primary hyperparathyroidism. Further refinements in technique will enhance its practicability in exploring the mediastinum for ectopic parathyroid glands and in those with secondary hyperparathyroidism.

Simultaneous laparoscopic biliary and retrocolic gastric bypass in patients with unresectable carcinoma of the pancreas.

BACKGROUND: A substantial number of patients with unresectable pancreatic cancer eventually develop biliary or gastric outlet obstruction. In some cases, they present initially with both complications. These conditions contribute markedly to their discomfort and certainly justify palliative intervention. The purpose of this study was to examine the feasibility and safety of simultaneous laparoscopic biliary and gastric bypass in patients with unresectable carcinoma of the pancreas. METHODS: Between August 1995 and July 1998, simultaneous laparoscopic biliary and retrocolic gastric bypass was performed successfully in 12 consecutive patients with unresectable carcinoma of the pancreas. There were eight men and four women. Their median age was 72 years (range, 50-82). In all patients, the indications for gastrointestinal bypass were gastric outlet obstruction and obstructive jaundice. The following parameters were evaluated for each patient: procedure-related morbidity and mortality, operative time, length of hospital stay, overall survival, and ability to sustain oral nutrition during the survival period. RESULTS: All procedures were completed laparoscopically. The mean operative time was 89 +/- 29.56 min. There were no intraoperative complications. Postoperative morbidity consisted of wound infection in two patients and pneumonia in one patient. One patient died of multiorgan failure on postoperative day 2. The mean hospital stay was 6.4 +/- 1.5 days (range, 5-17). The mean survival time until death from underlying disease was 85 +/- 32. 46 days (range, 31-260). None of the patients had recurrent jaundice, and all of them were able to maintain oral nutrition. CONCLUSION: Simultaneous laparoscopic biliary and retrocolic gastric bypass is a safe and effective technique for the treatment of biliary and gastroduodenal obstruction in patients with unresectable pancreatic cancer.

Laparoscopic adrenalectomy in the elderly.

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.