Occult hernias detected by laparoscopic totally extra-peritoneal inguinal hernia repair: a prospective study.

BACKGROUND: One distinct advantage of laparoscopic inguinal hernia repair is the opportunity for clear visualization of the direct, indirect, femoral, obturator and other groin spaces. The aim of this study was to examine/assess the potential of the laparoscopic totally extraperitoneal (TEP) inguinal hernia repair method in detecting unexpected additional hernias. METHODS: Patients who underwent an elective inguinal hernia repair, in the department of abdominal surgery at the institute of laparoscopic surgery (ILS, Bordeaux, France) between September 2003 and July 2005 were enrolled prospectively in the study. The patients' demographic data, operative, postoperative course and outpatient follow-up were studied. RESULTS: A total of 337 laparoscopic inguinal hernia repairs were performed in 263 patients. Of these, 189 patients had unilateral hernia (109 right and 80 left) and 74 patients had bilateral hernias. Indirect hernias were the most common, followed by direct and then femoral hernias. There were 218 male patients and 45 female patients with a mean age of 60 ± 15 years. There were 44 unexpected hernias: 6 spegilian hernias, 19 obturator hernias and another 19 femoral hernias. Two patients were converted to transabdominal preperitoneal (TAPP) due to surgical difficulties. There were no major intraoperative complications in all patients except for three cases of bleeding arising from the inferior epigastric artery. Only one patient had postoperative bleeding and was re-operated on several hours after the hernia repair. No recurrence occurred in the present series. CONCLUSIONS: The laparoscopic inguinal hernia repair approach allows viewing of the entire myopectineal orifice, facilitating repair of any unexpected hernias and thereby reducing the chance of recurrence.

Laparoscopic pancreaticoduodenectomy for benign and malignant diseases.

BACKGROUND: Laparoscopy still is not universally accepted as an alternative approach for pancreatoduodenectomy. This study aimed to assess the feasibility and safety of laparoscopic pancreatoduodenectomy for benign and malignant lesions of the pancreas, and to examine whether this procedure obtains adequate margins and follows oncologic principles. To the best of the authors' knowledge, their series of laparoscopic pancreatoduodenectomies is the largest reported to date. METHODS: A prospective study of laparoscopic pancreatoduodenectomy was undertaken between March 1999 and June 2005. The study enrolled 25 patients (16 women and 9 men) with a mean age of 62 +/- 14 years. All the operations were performed in a single institution. RESULTS: The operations were performed without serious complications. Three patients underwent conversion to open surgery. For 13 patients, the anastomosis was performed intracorporeally. For the remaining 9 patients, the resection was performed laparoscopically, with the reconstruction performed through a small midline incision. There was no intraoperative mortality. The mean operating time was 287 +/- 39 min, and the mean blood loss was 107 +/- 48 ml. The mean time to the first bowel movement was 6 +/- 1.5 days, and the mean time to independent self-care was 4.8 +/- 0.8 days. Seven patients experienced postoperative complications. One patient died of a cardiac event 3 days after uncomplicated surgery. The mean hospital stay was 16.2 +/- 2.7 days. All resected margins were tumor free. The mean number of retrieved lymph nodes for the malignant lesions was 18 +/- 5. CONCLUSION: Laparoscopic pancreatoduodenectomy for selected cases of benign and malignant lesions performed by highly skilled laparoscopic surgeons is feasible and safe. This method can obtain adequate margins and follow oncological principles. Larger series and longer follow-up periods are needed to establish the current results.

Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery: is it safe? A prospective study.

BACKGROUND: Many practicing surgeons claim that hernias after previous lower abdominal surgery should be treated by transabdominal preperitoneal repair (TAPP). Moreover, previous radical prostatectomy contraindicates the laparoscopic approach for hernia repair. This prospective study was designed to examine the feasibility and to evaluate the surgical outcome of laparoscopic totally extraperitoneal (TEP) hernia repair in patients who had undergone previous lower abdominal surgery or radical prostatectomy, and to compare this group to all patients who underwent laparoscopic TEP without previous surgery during the study period. METHODS: Patients undergoing elective inguinal hernia repair, by one staff surgeon, in the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS, Bordeaux) between September 2003 and December 2004 were prospectively enrolled to this study. Three groups were defined--patients with previous radical prostatectomy, patients with previous lower abdominal surgery, and patients without previous surgery--and their data were analyzed and compared. RESULTS: A total of 256 laparoscopic inguinal hernia repairs were performed in 202 patients. Of these, 148 patients had unilateral hernia (143 right and 113 left) and 54 patients had bilateral hernias. There were 166 male patients and 36 female patients with a mean age of 61 +/- 16 years. Of these, 10 patients had inguinal hernia after prostatectomy and 15 patients had inguinal hernia after previous lower abdominal surgery. The mean operative time was significantly longer in the patients with previous prostatectomy than in the two other groups. Two patients after prostatectomy were converted to TAPP due to surgical difficulties. There were no major intraoperative complications in all patients except for three cases of bleeding arising from the inferior epigastric artery: two in the postprostatectomy group and one in a patient without previous surgery. Both ambulation and hospital stay were similar for all groups. Only one patient without previous surgery had postoperative bleeding and was reoperated on several hours after the hernia repair. During the follow-up period of 8 +/- 4 months, there was no recurrence of the hernia in any group. CONCLUSIONS: Laparoscopic TEP for inguinal hernia repair in patients after previous low abdominal surgery has good results, similar to those in patients without previous surgery. Despite a longer operative time, TEP repairs can be performed efficiently and safely in patients after prostatectomy by skilled and experienced laparoscopic surgeons.

Laparoscopic repair of postoperative perineal hernia.

BACKGROUND: Perineal hernia is an uncommon complication following abdominoperineal resection of the rectum. There are only a few reports concerning the management of this unusual problem. Various methods of repair have been described, but none of them is well established. The purpose of our study is to present our experience and to discuss the pathogenesis and the different surgical repair techniques of these hernias. METHODS: Between September 2003 and December 2004, four patients with perineal hernia observed several months following laparoscopic abdominoperineal resection for adenocarcinoma of the lower rectum were treated. All patients underwent the transabdominal laparoscopic approach using synthetic mesh for repair. RESULTS: In all patients, the hernia was repaired by the laparoscopic transabdominal approach using synthetic mesh. The blood loss was minimal and mean operating time was 54 +/- 10 min. There were no cases that required conversion to laparotomy and there were no intraoperative or postoperative complications. Beginning of soft diet intake and ambulation times were on the second day following surgery. The average length of hospital stay was 4 +/- 1 days. During 8.3 +/- 6 months of follow-up, there was no recurrence of the hernia. CONCLUSION: Perineal hernias are rare complications of major pelvic surgeries. Symptomatic hernias should be repaired surgically. The transabdominal laparoscopic approach using synthetic mesh provides an appropriate solution for these hernias.

Laparoscopic rectal resection with anal sphincter preservation for rectal cancer: long-term outcome.

BACKGROUND: Total mesorectal excision (TME) is the surgical gold standard treatment for middle and low third rectal carcinoma. Laparoscopy has gradually become accepted for the treatment of colorectal malignancy after a long period of questions regarding its safety. The purposes of this study were to examine prospectively our experience with laparoscopic TME and high rectal resections, to evaluate the surgical outcomes and oncologic adequacy, and to discuss the role of this procedure in the treatment of rectal cancer. METHODS: Between December 1992 and December 2004, all patients who underwent elective laparoscopic sphincter preserving rectal resection for rectal cancer were enrolled prospectively in this study. Data collection included preoperative, operative, postoperative and oncologic results with long-term follow-up. RESULTS: A total of 218 patients were operated on during the study period: 142 patients underwent laparoscopic TME and 76 patients underwent anterior resection. Of the TME patients, 122 patients were operated using the double-stapling technique, and 20 patients underwent colo-anal anastomosis with hand-sewn sutures. Mean operative time was 138 min (range, 107-205), and mean blood loss was 120 ml (range, 30-350). Conversion to open surgery occurred in 26 cases (12%). Mortality rate during the first 30 days was 1%. Anastomotic leaks were observed in 10.5% of the patients. Of these, 61.9% needed reoperation and diverting stoma, and the rest were treated conservatively. Three patients had postoperative bleeding requiring relaparoscopy. Other minor complications (infection and urinary retention) occurred in 9.1% of patients. Mean ambulation time and mean hospital stay were 1.6 days (range, 1-5) and 6.4 days (range, 3-28) , respectively. Patients were followed for a mean period of 57 months. No port site metastases were observed during follow-up. The recurrence rate was 6.8 %. Overall survival rate was 67% after 5 years and 53.5% after 10 years. CONCLUSION: Laparoscopic anterior resection and TME with anal sphincter preservation for rectal cancer is feasible and safe. The short- and long-term outcomes reported in this series are comparable with those of conventional surgery.

Are major laparoscopic pancreatic resections worthwhile? A prospective study of 32 patients in a single institution.

BACKGROUND: Laparoscopic surgery has been used increasingly as a less invasive alternative to conventional open surgery. Recently, laparoscopic therapy for pancreatic diseases has made significant strides. The current investigation studied pancreatic resection by laparoscopy. The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic pancreatic major resection for benign and malignant lesions of the pancreas. METHODS: A prospective study of laparoscopic pancreatic resections was undertaken in patients with benign and malignant lesions of the pancreas. Over an 8-year period, 32 patients underwent laparoscopic pancreatic major resection: 21 left pancreatectomies (1 performed using a retroperitoneal approach), and 11 pancreatoduodenectomies (10 Whipple procedures and 1 total pancreatectomy). All the operations were performed in a single institution. RESULTS: The operations were performed without serious complications. Only one left pancreatectomy was converted to laparotomy because of massive splenic bleeding, and one Whipple procedure was converted because of adhesion to the portal vein. In four of the Whipple operations, the resection was performed completely laparoscopically, and the reconstruction was done via a small midline incision. There was no operative mortality. In 16 patients of the left pancreatectomy group, the spleen was preserved. The mean blood loss was 150 and 162 ml; and the mean operating time was 154 and 284 min, respectively, for the left pancreatectomy and the Whipple procedure. Postoperative complications occurred for five patients after left pancreatectomy and for three patients after the Whipple procedure. Two patients needed surgical reexploration after left pancreatectomy because of intraperitoneal haemorrhage and eventration of the extraction site. Two patients underwent reoperation after the Whipple procedure: one because of intraabdominal bleeding and the other because of small bowel obstruction. The mean hospital stay was 10.8 days after left the pancreatectomy and 13.6 days after the whipple procedure. CONCLUSION: Laparoscopic left pancreatectomy for benign and malignant lesions is feasible, safe, and beneficial. We believe that pancreatoduodenectomy should be performed only in selected cases and by a highly skilled laparoscopic surgeon. If there is any doubt, an open resection should be performed.

Laparoscopic and open gastric resections for malignant lesions: a prospective comparative study.

BACKGROUND: Whereas laparoscopy for benign diseases provides clear advantages over traditional surgery, the benefits of laparoscopic gastric resection for malignant diseases are less clear. The objectives of this study were to compare prospectively the clinical outcomes between completely laparoscopic and open total and partial gastrectomies for malignant diseases and to assess whether laparoscopic gastrectomies obtain adequate margins and follow oncologic principles. METHODS: Between April 1995 and March 2004, a prospective comparative study was performed comparing eight patients who underwent laparoscopic total gastrectomy with 11 patients who underwent open total gastrectomy, and 16 patients who underwent laparoscopic partial gastrectomy with 17 who patients underwent open partial gastrectomy. Stage, extent of lymphadenectomy, and long-term follow-up were examined. The intraoperative and postoperative details of the two groups were compared. RESULTS: The laparoscopic group patients had fewer intraoperative complications while the operative time was similar to that of the open group. Both ambulation and hospital stay were significantly shorter in the laparoscopic groups than in the open groups. The short-term morbidity was lower in the laparoscopic groups and there were no cases of death, whereas one case of postoperative death occurred after an open total gastrectomy. There was no need to convert to open surgery. The number of lymph nodes obtained in the laparoscopic and open procedures was not significantly different. In addition, all resected margins were tumor free in the laparoscopic group, whereas tumor involvement was presented in the margin of one specimen in the open group. CONCLUSIONS: The totally laparoscopic approach to total and partial gastrectomies had good results and was proven to be a feasible and safe procedure. In addition, the laparoscopic procedures are superior to open surgeries in terms of faster postoperative recovery, shorter hospital stay, and better cosmetic outcomes. A totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.

Laparoscopic liver resections: a single center experience.

BACKGROUND: Since the first report of laparoscopic liver resection, by Gagner et al. 1992, an increasing number of small prospective studies have been published. They have shown encouraging results for the feasibility and safety of the procedure. This paper prospectively evaluated the results of a single center's experience with elective liver resections. METHODS: From January 1995 to January 2004 a prospective study of laparoscopic liver resections was undertaken in 31 patients with preoperative diagnosis of benign lesions (13 cases, 42.4%), hepatocellular carcinoma in absence of complicated cirrhosis (three cases, 9.1%), and liver metastases (15 cases, 45.5%). Mean tumor size was 34.9 mm (range 10-100 mm). RESULTS: The procedures included 11 (37.9%) major hepatectomies and 21 (62.1%) minor resections (one patient was submitted to repeat laparoscopic liver resection) . There were three conversions to open. Mean blood loss was 210 ml (range 0-700 ml). Mean operative time was 115 min (range 45-210 min). There were no deaths and no reoperations for complications. No port-site metastases occurred in patients with malignant lesions. CONCLUSIONS: Laparoscopic liver resections, including major hepatectomies, are feasible and safe. Major and posterior resections are difficult, though, and conventional surgery remains an option.

Is laparoscopic left pancreatic resection justified?

BACKGROUND: We reviewed our experience of laparoscopic left pancreatectomy to establish the feasibility of this approach and the characteristics of the operating procedure. METHODS: Thirteen patients with a mean age of 60 years were deemed for a left pancreatectomy. Preoperative diagnoses were: nine mucinous cystadenoma and one insulinoma, intraductal mucinous ectasia, chronic pancreatitis with ductal stenosis, and distal pancreatic tumor. RESULTS: Operative mortality was nil. Two patients required conversion for bleeding from splenic vein injuries leading to a splenectomy in one case. The spleen was preserved in 10 cases. Postoperative course was uneventful in nine cases. Four patients experienced postoperative complications: one pancreatic fistula, two liquid cysts on the pancreatic margin, and one reoperation for bleeding from a trocar port. Length of stay ranged from 5 to 22 days. CONCLUSION: These preliminary results confirm that in selected cases laparoscopic resection of the left pancreas is feasible and safe.

[Intra-arterial thrombolysis of acute mesenteric ischemia]. / Thrombolyse intra-artérielle d'une ischémie aiguë mésentérique.

A 73-year-old man with pre-existing cardiac failure, coronary artery and chronic obstructive pulmonary disease was presented for an acute mesenteric ischaemia, resulting from an embolic obstruction of the superior mesenteric artery. An intra-arterial fibrinolysis with a bolus of 250 000 units of streptokinase, followed by an infusion of 150 mg rtPA with adequate heparin dosage was performed 10 hours after the first symptoms. An abdominal guarding occurred 24 hours later, despite radiological improvement, justifying emergency surgery which confirmed the partial efficiency of the medical therapy. Unfortunately, a cardiogenic shock occurred preoperatively and the patient died five days later from intractable cardiovascular failure.

[Prognosis in surgical treatment of cancer of extra-hepatic biliary ducts]. / Pronostic du traitement chirurgical des cancers des voies biliaires extra-hépatiques.

This work reports a retrospective multicenter study of the treatment and prognosis of 746 patients with gall bladder cancers and 684 patients with extrahepatic biliary duct cancers. Gallbladder cancers: Adenocarcinoma was encountered in 92.6% of cases, 107 were limited to the gallbladder. Removal was possible in 27% of the patients. Overall operative mortality was 21%. Overall survival at one year was 14%. The projected five-year survival for cancers limited to the gall bladder treated by simple cholecystectomy was 93% for noninvasive, "in situ" cancers. The survival was 18% with mucosal involvement, and 10% with extension to the gall bladder wall. Extrahepatic biliary duct cancers: Adenocarcinoma was encountered in 99.7% of assess; 40 were limited exclusively to the biliary ducts. 384 involved the upper 1/3 segment of the biliary duct, 86 the middle 1/3, and 121 for the lower 1/3. Cancers involving two or more of these segments were encountered in 93 cases. Removal of the cancer from these four locations was possible in respectively 30%, 50%, 50% and 7% of cases. Overall operative mortality was 27.7% and after removal: 13.5% for the upper biliary duct segment, 18.1% for the middle 1/3, and 20% for the lower 1/3. The mortality was 25% for cancer that involved two or more of these segments. Analysis related to age demonstrated a postoperative mortality of 16% in patients less than 70 years of age and 59.1% after 70 years. The five-year survival after surgery was projected to be 12% for cancers of the upper 1/3 segment, 15% in middle and 30% in the lower 1/3.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of 64 second primary cancers of the bronchi]. / Analyse de soixante-quatre cancers métachrones des bronches.

Sixty-four primary lung carcinomas were observed among 1,039 patients operated for bronchial carcinoma between 1975 and 1984. (Statement: July 1987). The second tumor tended to develop at a distance from the first resection performed for a lesion with good prognostic factors. Their site and histology present no unusual features. 64% appeared in the contralateral lung; 78% had the same histological type as the first cancer. Among 28 patients treated by surgery, 26 had a second resection: there were two peri-operative deaths and 4 major complications. Among the 36 patients rejected for surgery, 21 had excessively altered lung function tests. 30 patients were treated with radiotherapy, 7 with chemotherapy first; one had no treatment. The survival rate for the whole group was quite good: 26% at three years; it was significantly better after a second resection: 41% at three years. Overall survival seems comparable with that of the patients operated upon for a single carcinoma.