Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.

Three-dimensional ultrasound.

Laparoendoscopic surgery is fueled by technology, and advances in medical imaging may bring about further progress. The application of three-dimensional ultrasound to minimally invasive surgery represents technology "just over the horizon." This article describes the scientific basis of three-dimensional ultrasound and its ability "to see" anatomy not readily visualized laparoscopically. Three-dimensional ultrasound may offer a more intuitive, accurate assessment of hidden anatomic structures in real time, using a safe, non-ionizing and cost-effective technology.

Laparoscopic hernia repair. Three-year experience.

The basis of laparoscopic transabdominal preperitoneal repair (LTPR) of herniae rests upon the utilization of a prosthetic screen to cover hernia defects. Preperitoneal prosthetic screen interposition reproduces the effect of the inguinal shutter mechanism. In this 3-year longitudinal study, one surgeon performed 224 laparoscopic hernia repairs (LTPR) on 164 patients. These patients have been examined postoperatively by that surgeon and a trained research assistant according to an established protocol. Patient mean age was 50.6 years; 45 cases involved bilateral inguinal herniae (21.5%); 20 laparoscopic repairs were for failed open repair (9.6%); and 46 herniae were incarcerated (22%) at the time of laparoscopic repairs. There were no intraoperative complications. Two procedures required conversion to open repair, the first because of uncertainty regarding incarcerated bowel viability and the second for massive abdominal-wall adhesions. Two laparoscopic repairs recurred and required subsequent repair.