Cholangiography is not routinely performed in open surgery, but there are reasons why it should be in laparoscopic cholecystectomy. These include finding common duct stones, identifying the cystic-common duct junction, and noting an inadvertent injury. Thirty-six (7.0%) of 516 laparoscopic cholecystectomies were converted to open surgery; 24 before attempting cholangiography and 12 based on roentgenographic findings. In 73 patients (14.1%), cholangiography showed abnormal findings. Common duct injury was identified in one patient and common duct stones were found in 35. Twenty-one patients were treated laparoscopically and eight underwent open choledocholithotomy. In 22 patients, a short cystic duct was seen that might otherwise have been overlooked, and possible injury was avoided. Cholangiography should be attempted routinely, so that in cases with abnormal findings, open cholecystectomy may be considered.

Catheterization↗

PubMed1991

New ideas and improved instrumentation for laparoscopic cholecystectomy.

A new cholangiograsper cannula was developed through which a Fr 4 or 5 ureteric cannula can be advanced into the incised cystic duct and held in a water-tight position. This instrument facilitates intraoperative cholangiography. A plastic trocar stylet eliminates the metal shadow of the trocar during cholangiography. A new "laparocamera" is described where camera and telescope are built together in one unit decreasing the need for additional manipulation during the procedure. A camera holder driven by air helps the operator to keep his/her hands free. The need for a third assistant is avoided by inserting the camera into a (presterilized) holder, the position of which is controlled by press buttons.

Catheterization↗

PubMed1991

Pouch-anal anastomosis without diverting ileostomy.

Ileal diversion is an important adjunct to restorative proctocolectomy but may produce increased morbidity and requires a second-stage closure. This study reports results utilizing a one-stage procedure designed to retain the benefits of proximal decompression without the liabilities of additional surgical procedures. Eight patients, three men (with ulcerative colitis) and five women (one with familial polyposis coli and four with ulcerative colitis), were selected for the single-stage restorative proctocolectomy with intraluminal decompression in lieu of diverting loop ileostomy. The abdominal proctocolectomy was performed to the level of the anorectal junction. In five patients, the rectum was closed using the TA 55 (U.S. Surgical Corporation, Norwalk, CT), 4.8-mm stapler. AJ-pouch was constructed with multiple firings of the GIA90 (U.S. Surgical Corporation) stapler. These patients had continuity restored utilizing a transanal, circular stapler. Three patients had an S-pouch constructed by suture technique. Fecal diversion was accomplished with a 25-mm intraluminal bypass tube (Coloshield; Deknetel, Fall River, MA) in all cases. There was no mortality. There were no anastomotic complications or morbidity related to the bypass tube. The tube dislodged and passed between days 18 and 26 (mean, 22.1 days). All patients had three to six bowel movements per 24 hours, and all are continent day and night. This experience suggests that, in selected patients, the intraluminal bypass tube may be an excellent alternative to diverting ileostomy.

Adenomatous Polyposis Coli↗

PubMed1991

A new training device for laparoscopic cholecystectomy.

Laparoscopic cholecystectomy provides a new approach for gallbladder removal with which most general surgeons are not familiar. Requisites for the safe performance of this procedure are good hand-eye coordination, depth perception, and team cooperation. To aid with problems in depth perception and in the opposing movements caused by the lever principle, a training model was designed in which surgeons may execute a variety of exercises to enhance their motor skills and learn to work cooperatively with two other surgeons before operating on an experimental animal.

Cholecystectomy↗

PubMed1991

Elective diagnostic laparoscopy.

Laparoscopy developed as a science at the turn of the century, and many scientists assisted in the evolution of this technique. However, it was many years before the multiple trocar system was developed that allowed internal organs to be moved and biopsies to be obtained. This has led to the development of numerous indications for elective diagnostic laparoscopy. Adequate preparation and attention to instrumentation ensure the safety of this operation. Elective diagnostic laparoscopy is a useful adjunct to many other diagnostic modalities such as, for instance, the assessment of abdominal pain, abdominal masses, fever of unknown origin, and gastrointestinal bleeding. In many other circumstances, such as the assessment of oncology cases, this modality is superior to conventional radiology because biopsy specimens may be obtained. If the procedure is correctly performed, the diagnostic yield is extremely high and the morbidity and mortality are low. The role of this important technique should not be underestimated by today's practicing surgeon.

Adult↗

PubMed1991

Emergency laparoscopy.

Unnecessary abdominal explorations in severely injured patients can be reduced by employing emergent or urgent laparoscopy in blunt abdominal trauma and the obscured, acute abdominal cases. In 150 blunt abdominal trauma cases, a mini-laparoscopy was used in the emergency room or the intensive care unit without major complications. In 56%, the findings were negative. In 19%, the laparoscopic findings were corroborated by surgery. In 25%, a minimal to moderate hemoperitoneum was found and the laparoscopic impression dictated close observation. Unnecessary exploration was avoided except in one case. In the elderly high-risk patient with a poor history, abdominal examination can be noninformative. Laparoscopy can detect acute appendicitis or organ perforation. In the young female, appendicitis can be differentiated from pelvic inflammatory disease. Laparoscopy is more accurate and gives a larger latitude for decision-making than lavage. It can also be useful in the obscured problematic abdominal case.

Abdomen, Acute↗

PubMed1991

Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy?

Intraoperative cholangiography can be helpful in cases in which the anatomy is obscured, unsuspected stones are discovered, or anatomic anomalies of surgical importance are found. There is a difference between open and closed laparoscopic cholecystectomy. It is more difficult to locate the common bile duct during laparoscopic cholecystectomy. During this procedure, the anatomy is distorted due to the extreme traction at the infundibulum. With a short cystic duct, the common bile duct can become "tented" and simulate the appearance of the cystic duct. Ductal injuries may be avoided by knowing where the clips should be placed in relation to the ductal system and by obtaining information about the intact display of the distal and proximal ductal system. The image can be observed immediately by using a modern fluoroscopic system, and permanent documentation can be obtained. We attempted intraoperative cholangiography in 415 cases and were successful in 90%. We strongly recommend the routine use of intraoperative cholangiography.

Catheterization↗

PubMed1991

The Los Angeles experience with laparoscopic cholecystectomy.

Surgeons should be competent in diagnostic laparoscopy before performing laparoscopic cholecystectomy (LC). Well-structured and endorsed courses with experienced faculty are important. Within 12 months, 418 LCs were performed in our hospital. The number of open cholecystectomies decreased to one third of all cholecystectomies performed. Cholangiography was attempted routinely and the duct was successfully cannulated in 90%. Inquiries were made at 6 other hospitals within a 5-mile radius where a total of 220 LCs were performed. The following gray areas need to be addressed: patients with slightly increased liver function tests but no jaundice, and unsuspected stones discovered by cholangiography. New projects are in progress to explore the common bile duct via the cystic duct or directly through the common bile duct with insertion of a T tube. The authors recommend proper training as well as caution and sound judgment before commencing with LC.

Aged↗

PubMed1991

Laparoscopy in pediatric surgery.

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Child↗

PubMed1991

Small bowel haemorrhage due to cytomegalovirus vasculitis.

A case is described of a life threatening vasculitis of the small bowel leading to massive gastrointestinal haemorrhage which was apparently due to cytomegalovirus inclusion disease. Reactivation of cytomegalovirus probably followed the treatment of Wegener's granulomatosis with corticosteroids and azathioprine. This patient was treated successfully by surgical excision of the affected segment of ileum together with intravenous ganciclovir.

Aged↗

PubMed1991

Laparoscopic trancystic choledocholithotomy as an adjunct to laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is rapidly becoming the standard operation for symptomatic cholelithiasis. Initially, common duct stones presented a barrier to this treatment modality and are said to be unsuspected in 5-9 per cent of patients. A technique is described that removes common bile duct stones through the cystic duct with a flexible nephroureteroscope, thereby extending the range of laparoscopic cholecystectomy.

Adult↗

PubMed1991

Modified Ramstedt's pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis.

Thirty-seven infants with hypertrophic pyloric stenosis had a modified Ramstedt pyloromyotomy performed. The incidence of postoperative vomiting was low (16%), with no infant suffering sustained vomiting requiring re-exploration for incomplete pyloromyotomy. The modified Ramstedt's pyloromyotomy is a simple procedure and may confer an advantage in the postoperative course of the recovering infant.

Female↗

PubMed1990

An unusual angiogram in a patient with gastrointestinal bleeding.

A patient presenting with upper gastrointestinal bleeding had two visceral angiograms, the second of which demonstrated the hepatic veins in the late phase of the hepatic arterial injection. This observation led to the correct diagnosis of hepatic telangiectasia with arteriovenous shunting and the suspicion, subsequently confirmed at endoscopy, of similar-lesions in the gastrointestinal tract. Visualisation of hepatic veins in visceral arteriography is unusual but may, as discussed, be normal.

Adult↗

PubMed1990

Intra-vaginal torsion of the testis occurring in a neonate.

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Humans↗