A 14-year analysis of laparoscopic cholecystectomy: conversion--when and why?

BACKGROUND: Contraindications to laparoscopic cholecystectomy diminished over the last decade but still conversion is about 5% to 6% in elective cases and higher in acute cholecystitis. The aim of this study was to analyze the reason for conversion in all patients operated on in our department and to create strategies for critical moments, which may need conversion. METHODS: From 1990 to 2004, operations have been divided in 3 groups: primary open cholecystectomy (OC), laparoscopic cholecystectomy, and conversion. These groups were analyzed regarding the reason for conversion and postoperative complications. RESULTS: Of the 5376 patients who underwent cholecystectomy, 327 had concomitant OC without further evaluation and 544 OC (11%). Of the 4505 patients (3159 women, 1346 men) who were all started by laparoscopy 5.4% [245 patients (123 women, 3.9%; 122 men, 9.1%; P<0.05)] were converted to OC. Acute cholecystitis (29.4%), difficulties with the anatomy in Calot's triangle (17.1%), and adhesions (14.3%) have been the main reasons for conversion beside difficulties in establishing pneumoperitoneum (3.7%). CONCLUSIONS: The key scenes for conversion are the creation of the pneumoperitoneum, intra-abdominal adhesions, and difficulties in Calot's triangle, especially in acute cholecystitis. Conversion should not be seen as a complication.

[Laparoscopic devascularization of the stomach and the abdominal esophagus with the LigaSure instrument in a porcine model]. / A gyomor és az abdominális nyelocsosza- kasz laparoszkópos devaszkularizációja LigaSure eszközzel sertés modellen.

OBJECTIVES: In this study we proved the feasibility of a new minimally invasive procedure for the devascularisation of the proximal stomach and the abdominal esophagus to prevent recurrent variceal bleeding in portal hypertension in a new animal model. MATERIALS AND METHODS: Experiments were performed on 12 female pigs, in two animal groups. In the first step (I. group n=6) portal hypertension was created by controlled laparoscopic clip ligation of the portal vein. The increased portal pressure was established by the needle puncture of the portal vein and the spleen. Two weeks later, the dilated veins were sealed along the lesser and greater curvature and the transhiatal esophagus with the 10 mm LigaSure instrument. Successful of the experimental model had encouraged us to perform this method on other animals (II. group, n=6), using the 5 mm instrument. RESULTS: There was no intraoperative bleeding after using both LigaSure instruments. Autopsy (2 weeks later) showed correct placed clips with partial occlusion of the portal vein without portal vein thrombosis. There was no evidence of postoperative bleeding. Histological investigation of the gastric surface confirmed complete sealing of the extended varices. CONCLUSION: The laparoscopic LigaSure instrument was found to be safe and suitable equipment for the ligation of the dilated veins along the gastric surface and the abdominal esophagus, and this method could be an alternate choice for the patients with recurrent variceal bleeding.

Transilluminated powered phlebectomy: advantages and disadvantages of a new technique.

BACKGROUND: Transilluminated powered phlebectomy is a new procedure for minimal invasive varicose vein surgery. OBJECTIVE: To evaluate this technique for its benefit and the technique-related risks and complications. METHODS: Thirty patients were prospectively operated with this new technique by the same surgeon (11 of them bilaterally [41 legs in all]). According to the sonography, sapheno-femoral-junction ligation and stripping of the long saphenous vein were done if necessary. The phlebectomy of the side branches was done with the new system (Trivex System/Smith and Nephew). The postoperative follow-up was at 10 days and 6 weeks. RESULTS: There was no intraoperative complication. The mean operation time per leg was 40 minutes. Twenty-five patients had an uneventful postoperative course. Twenty two have been very satisfied with the cosmetically result. Two patients required reoperation because of postoperative hematoma. One patient developed a seroma, which could be managed via puncture. One patient developed persistent brown scar. The overall morbidity was 12.2%. CONCLUSION: Using transilluminated powered phlebectomy, multiple and large incisions could be reduced. A perfect cosmetic outcome might be reached if the surgeon is aware of technique-related complications. To evaluate the real value of this technique, further randomized trials are necessary.