Background Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are ...exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. Study Design All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. Results Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. Conclusions This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.
Introduction
Single-incision laparoscopic cholecystectomy (SILC) may increase the risk of bile duct injury due to compromised operative exposure. Dome-down laparoscopic cholecystectomy provides the ...ability to evaluate the cystic duct circumferentially prior to its division, thus minimizing the risks of bile duct injury. This study assesses the feasibility and safety of SILC using a modified dome-down approach with all conventional laparoscopic instruments.
Methods
Three low-profile 5-mm trocars are placed via a single transumbilical incision. The two working trocars are aimed laterally via the rectus to achieve adequate triangulation. An extralong 5-mm 30º laparoscope with an L-shaped light-cord adaptor is used to yield more external working space. Cephalic liver retraction is achieved with one transabdominal suture through the gallbladder fundus. Leaving the gallbladder fundus attached to the liver bed, a window is first created between the gallbladder body and the liver. The dissection is then carried down retrograde toward the porta hepatis. A 360º view of the gallbladder–cystic duct junction is achieved prior to transecting the cystic duct. The gallbladder is then freed by separation of the fundal attachments. The specimen is retrieved by enlarging the fascial incision. All fascial defects are then primarily closed.
Results
Sixteen patients (mean age 31 years, mean BMI 26.3 kg/m
2
) were enrolled in this study. Thirteen had elective surgery for symptomatic cholelithiasis, and three had emergency surgery for acute cholecystitis. Mean operating time was 80.3 min, and blood loss was minimal. All patients were discharged within 24 h without complications. Follow-up at 1 month revealed a barely visible scar within the umbilicus.
Conclusions
SILC using a modified dome-down approach is technically feasible with all straight instruments, and it is safe because of good delineation of ductal anatomy. Adoption of this approach may minimize the risk of bile duct injury during early experience of SILC.
Athletic pubalgia (sports hernia) Litwin, Demetrius E M; Sneider, Erica B; McEnaney, Patrick M ...
Clinics in sports medicine,
04/2011, Volume:
30, Issue:
2
Journal Article
Peer reviewed
Athletic pubalgia or sports hernia is a syndrome of chronic lower abdomen and groin pain that may occur in athletes and nonathletes. Because the differential diagnosis of chronic lower abdomen and ...groin pain is so broad, only a small number of patients with chronic lower abdomen and groin pain fulfill the diagnostic criteria of athletic pubalgia (sports hernia). The literature published to date regarding the cause, pathogenesis, diagnosis, and treatment of sports hernias is confusing. This article summarizes the current information and our present approach to this chronic lower abdomen and groin pain syndrome.
Laparoscopic cholecystectomy Litwin, Demetrius E M; Cahan, Mitchell A
The Surgical clinics of North America,
12/2008, Volume:
88, Issue:
6
Journal Article
Peer reviewed
Laparoscopic cholecystectomy (LC) has supplanted open cholecystectomy for most gallbladder pathology. Experience has allowed the development of now well-established technical nuances, and training ...has raised the level of performance so that safe LC is possible. If safe cholecystectomy cannot be performed because of acute inflammation, LC tube placement should occur. A systematic approach in every case to open a window beyond the triangle of Calot, well up onto the liver bed, is essential for the safe completion of the operation.
Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural ...complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients.
We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered.
A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes.
Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.
Pheochromocytomas are relatively uncommon tumors whose operative resection has clear medical and technical challenges. While the safety and efficacy of laparoscopic adrenalectomy are relatively well ...documented, few studies with extended follow-up have been conducted to measure the success of the procedure for the most challenging of the adrenal tumors. In addition, several reports question the applicability of a minimally invasive approach for sizeable pheochromocytomas. The purpose of our investigation was to assess the outcomes of laparoscopic adrenalectomy for pheochromocytomas in the largest study to date when performed by experienced laparoscopic surgeons.
All pheochromocytomas removed by the authors from January 1995 to October 2004 were reviewed under an Institutional Review Board approved protocol. Eighty-five percent were documented in a prospective fashion.
Eighty consecutive patients underwent laparoscopic resection of 81 pheochromocytomas. Seventy-nine were found in the adrenal (42 left, 35 right, 1 bilateral); 2 were extra-adrenal paragangliomas. Eight patients had multiple endocrine neoplasia syndrome. Two lesions were malignant. There were 48 females and 32 males with a mean age of 45 years (range, 15-79 years). Mean tumor size was 5.0 cm (range, 2-12.1 cm); 41 of these lesions were 5 cm in size or larger. Average operative time and blood loss were 169 minutes (range, 69-375 minutes) and 97 mL (range, 20-500 mL), respectively. Intraoperative hypertension (systolic blood pressure, >170 mm Hg) was reported in 53% of patients and hypotension (systolic blood pressure, <90 mm Hg) in 28% of patients. There were no conversions to open surgery. Mean length of stay was 2.3 days (range, 1-10 days). There were 6 perioperative morbidities (7.5%) and no mortalities. No patient required a blood transfusion. No recurrence of endocrinopathy has been documented at a mean follow-up of 21.4 months.
Laparoscopic resection of pheochromocytomas, including large lesions, can be accomplished safely by experienced surgeons. A short hospital stay with minimal operative morbidity and eradication of endocrinopathy support the minimally invasive approach for adrenalectomy in the setting of pheochromocytoma.
Alterations of video monitor and laparoscopic camera position may create perceptual distortion of the operative field, possibly leading to decreased laparoscopic efficiency. We aimed to determine the ...influence of monitor/camera position on the laparoscopic performance of surgeons of varying skill levels.
Twelve experienced and 12 novice participants performed a one-handed task with their dominant hand in a modified laparoscopic trainer. Initially, the camera was fixed directly in front of the participant (0 degrees) and the monitor location was varied between three positions, to the left of midline (120 degrees), directly across from the participant (180 degrees), and to the right of the midline (240 degrees). In the second experiment monitor position was constant straight across from the participant (180 degrees) while the camera position was adjusted between the center position (0 degrees), to the left of midline (60 degrees), and to the right of midline (300 degrees). Participants completed five trials in each monitor/camera setting. The significance of the effects of skill level and combinations of camera and monitor angle were evaluated by analysis of variance (ANOVA) for repeated measures using restricted maximum likelihood estimation.
Experienced surgeons completed the task significantly faster at all monitor/camera positions. The best performance in both groups was observed when the monitor and camera were located at 180 degrees and 0 degrees, respectively. Monitor positioning to the right of midline (240 degrees) resulted in significantly worse performance compared to 180 degrees for both experienced and novice surgeons. Compared to 0 degrees (center), camera position to the left or the right resulted in significantly prolonged task times for both groups. Novice subjects also demonstrated a significantly lower ability to adjust to suboptimal camera/monitor positions.
Experienced subjects demonstrated superior performance under all study conditions. Optimally, the camera should be directly in front and the monitor should be directly across from a surgeon. Alternatively, the monitor/camera could be placed opposite to the surgeon's non-dominant hand. The suboptimal camera/monitor conditions are especially difficult to overcome for inexperienced subjects. Monitor and camera positioning must be emphasized to ensure optimal laparoscopic performance.
Abstract Background Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy provides an opportunity to definitively evaluate both inguinal areas without the need for additional dissection. We ...aimed to establish the rates and contributing patient factors to errors in the preoperative assessment. Methods A retrospective review of consecutive patients undergoing laparoscopic TAPP herniorrhaphy at 2 tertiary-care centers. Preoperative history and physical examination were used to classify the presence of hernia as “definite,” “questionable,” or “negative.” Any discrepancies between preoperative and intraoperative findings were viewed as errors in preoperative assessment. Results Two hundred sixty-two patients underwent 328 laparoscopic TAPP hernia repairs. Of the 283 hernias diagnosed as “definite” preoperatively, 276 were confirmed at operation (97.8%). An additional 19 of 173 (11.0%) clinically unrecognized hernias were repaired at the time of surgery. Overall, our approach avoided unnecessary groin explorations and/or repairs in up to 16.4% patients and may have prevented inappropriate delays of herniorrhaphy in up to 19.8% of patients. The sensitivity, specificity, and positive predictive value of the clinical assessment of inguinal hernia were 94.5%, 80%, and 88.9%, respectively. Symptom and/or examination findings of inguinal mass were the only significant independent predictor of accuracy ( P < .001). Conclusion A high rate of discordance exists between the preoperative clinical assessment and true presence of inguinal hernias. Given the unique ability of laparoscopy to accurately evaluate the contralateral side and the limited added morbidity of bilateral repair, TAPP herniorrhaphy is beneficial in avoiding unnecessary explorations and allowing timely repairs in patients with occult inguinal hernias.
Determine which management strategy is ideal for patients with acute cholecystitis.
Prospective enrollment between August 2009 and March 2011. Large academic center. Patients with acute ...cholecystitis. Laparoscopic cholecystectomy, intravenous antibiotics followed by laparoscopic cholecystectomy or percutaneous cholecystostomy. Primary endpoints were postoperative complications and 30-day mortality.
A total of 162 patients were enrolled, 53 (33%) with simple acute cholecystitis and 109 (67%) with complex acute cholecystitis. Of the 109 patients with complex cholecystitis, 77 (70.6%) underwent successful laparoscopic cholecystectomy during the same hospital admission and 6 patients (5.5%) had an unsuccessful laparoscopic cholecystectomy requiring conversion to cholecystostomy. Radiology performed cholecystostomy in 19 (11.7%) patients with complex acute cholecystitis and 4 (2.5%) patients with simple acute cholecystitis for a total 23 patients of the 162 patients in the study. Nine of the 23 patients had dislodged tubes (39.1%). Two of the 23 patients (8.7%) had significant bile leaks resulting in either sepsis or emergency surgery. One patient (4.3%) had a wound infection. Overall, patients with complex acute cholecystitis had a higher morbidity rate (31.2%) compared with patients with simple acute cholecystitis (26.4%).
A high complication rate seen with radiology placed percutaneous cholecystostomy tubes prompted our center to reevaluate the treatment algorithm used to treat patients with complex acute cholecystitis. Although laparoscopic cholecystectomy is considered to be the gold standard in the treatment of acute cholecystitis, if laparoscopic cholecystectomy is not felt to be safe due to gallbladder wall thickening or symptoms of >72 hours' duration, we now encourage the use of intravenous antibiotics to "cool" patients down followed by interval laparoscopic cholecystectomy approximately 6 to 8 weeks later. Patients who do not respond to antibiotics should undergo attempted laparoscopic cholecystectomy and if unable to be performed safely, a laparoscopic cholecystostomy tube can be placed under direct visualization for decompression followed by interval laparoscopic cholecystectomy at a later date.
Watermelon Stomach (WS) has been increasingly recognized as an important cause of occult gastrointestinal blood loss. Clinically, patients develop significant iron deficiency anemia and are ...frequently transfusion dependent. The histologic hallmark of WS is superficial fibromuscular hyperplasia of gastric antral mucosa with capillary ectasia and microvascular thrombosis in the lamina propria. Endoscopic findings of the longitudinal antral folds containing visible columns of tortuous red ectatic vessels (watermelon stripes) are pathognomonic for WS. Trauma to the mucosal epithelium overlying engorged vessels by gastric acid or intraluminal food results in bleeding. Treatment options for WS include endoscopic, pharmacologic, and surgical approaches. Endoscopic therapy, including contact and non-contact thermal ablations of the angiodysplastic lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature we recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy. (
J Gastrointest Surg 2003;7:652-661.)
PDF
