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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↗

PubMed1986

Endometriosis in diagnostic laparoscopy in Isfahan, Iran.

In 200 consecutive routine diagnostic laparoscopies, 31 cases (15.5%) of endometriosis were found. Of these 200 cases, 131 patients (65.5%) were referred for laparoscopy because of infertility. In 22 (71.0%) out of 31 patients with endometriosis infertility was the indication for laparoscopy. In the remainder of the patients laparoscopy was performed because of other indications. Half of the patients with endometriosis showed moderate or severe degrees of the disease. Seventy-one percent of the patients were below the age of 29. According to our findings, the presumption that endometriosis is a rare disease in Iran is considered to be erroneous.

Adult↗

PubMed1995

Gasless laparoscopy in infants: the rabbit model.

Laparoscopic operations can be performed in neonates and infants, but carbon dioxide pneumoperitoneum may be more dangerous than in adults. Therefore the concept of gasless laparoscopy is especially attractive for small children. The authors have developed an animal training model of gasless infant laparoscopy using the rabbit. Eleven New Zealand white rabbits (mean weight, 2.2 kg) were premedicated with fentanyl (10 micrograms intramuscularly) and maintained under inhalation anesthesia by mask, with halothane (1.0 to 2.5%) in oxygen and nitrous oxide (1:1). The animals were neither intubated nor mechanically ventilated. Heart rate and oxygen saturation were monitored by pulse oximetry. A supraumbilical incision was made through the peritoneum, and an abdominal wall elevator was inserted. A 4-mm-diameter 30 degrees endoscope was introduced at the same site, allowing excellent visualization of the abdominal cavity. Three additional 5-mm cannulas were placed, and a standard Nissen fundoplication was performed in all 11 animals. In seven of these, a left nephrectomy was also performed. Five-millimeter pediatric instruments and 1.7- and 2.7-mm laryngoscopic instruments were used. The rabbit can serve as a training model for laparoscopy in the infant. Gasless laparoscopy, using abdominal wall elevation, may be particularly useful in very small patients.

Abdominal Muscles↗

PubMed1981

Major surgical complications of laparoscopy.

During the 15-yr period from 1965 to 1979, 6 major surgical complications were encountered among 2757 consecutive laparoscopies, yielding a rate of 2.1 per 1000. Five of the complications required exploratory laparotomy (in 2 patients with small bowel perforations, 2 patients with intraabdominal bleeding and 1 patient with severe peritonitis). In the 6th patient perforation of the uterine fundus occurred during laparoscopy performed because the presence of an adnexal mass was suspected at 15 wk gestation. Laparotomy in this patient was not performed since bleeding from the perforation site stopped spontaneously. Exploratory laparotomy rather than laparoscopy should be considered for evaluation of pelvic masses suspected after the first trimester of pregnancy. A small rate of major surgical complications of laparoscopy is to be expected even when accurate technique is used.

Adult↗

PubMed1986

The differences between findings at laparoscopy and at subsequent fertility surgery.

In a series of 42 patients, the findings during fertility microsurgery were compared to the findings at both laparoscopy performed by referring gynaecologists and re-laparoscopy performed in our regimen. Since significantly fewer discrepancies were found in the latter group, this re-laparoscopy may be considered useful and justified. The importance of meticulous laparoscopy is emphasized.

Endometriosis↗

PubMed1996

Diagnosis and management of serious urinary complications after major operative laparoscopy.

OBJECTIVE: To evaluate the incidence, diagnosis, and management of serious urinary complications after major operative laparoscopy. METHODS: For this retrospective study of 953 consecutive cases of major operative laparoscopy from January 1, 1990, to December 31, 1994, we reviewed incidence, method of diagnosis, and management of complications. Urinary complications included bladder injuries, urinary fistulas, and ureteral injuries. Major operative laparoscopic procedures included hysterectomy, adnexectomy, treatment of tubal pregnancy, ovarian cystectomy, and ablation-fulguration of severe endometriosis (stage IV). RESULTS: Serious urinary complications were found during or after operative laparoscopy in 15 of 953 patients (1.6%, 95% confidence interval [CI] 0.8-2.4). Four ureteral injuries, three bladder fistulas, and eight bladder perforations were documented in this series. Eight cases of urinary complications were recognized during the original surgery (one ureteral injury and seven bladder injuries) and repaired at that time. Laparotomy or additional major surgery was performed in seven patients (three ureteral injuries, two bladder fistulas, and two bladder perforations). CONCLUSIONS: Serious urinary complications after major operative laparoscopy were discovered in 1.6% of patients. This incidence compares favorably to serious urinary complications after standard gynecologic surgery. Intraoperative recognition of these complications will likely avoid additional surgery.

Adolescent↗

PubMed1996

Treatment of the small unruptured ectopic pregnancy: a cost analysis of methotrexate versus laparoscopy.

OBJECTIVE: To compare the economic costs between two strategies for management of the small unruptured ectopic pregnancy: initial treatment with methotrexate versus initial treatment with laparoscopic salpingostomy. METHODS: We assumed that both treatment strategies would result in identical clinical outcomes: resolution of the ectopic pregnancy without maternal mortality or long-term morbidity. Based on a literature review, estimates were derived for the likely clinical outcomes of a single injection of methotrexate (50 mg/m2) and for the likely clinical outcomes of the laparoscopy strategy. A range of values was evaluated for the initial success rate of each strategy and varying assumptions made about the type of treatment modality used for initial treatment failures. Direct medical costs of each strategy were estimated based on actual reimbursement rates of a third-party payer for the components of each strategy. The treatment strategies were compared in best-case/worst-case scenarios to determine the potential range of differences in costs between the two strategies. RESULTS: The cost of the methotrexate strategy ranged from $438 to $1390, and the cost of laparoscopic salpingostomy ranged from $2506 to $2974; therefore, the methotrexate strategy was less costly than laparoscopy, with a cost difference ranging from $1124 (best-case laparoscopy-worst-case methotrexate scenario) to $2536 (worst-case laparoscopy-best-case methotrexate scenario). Sensitivity analyses demonstrated that initial therapy with methotrexate was less costly over a wide range of probability and cost estimates. CONCLUSION: Initial methotrexate is a cost-effective alternative to laparoscopic salpingostomy in the treatment of the small unruptured ectopic pregnancy.

Costs and Cost Analysis↗

PubMed2004

Complications of laparoscopy: an inquiry about closed- versus open-entry technique.

OBJECTIVE: The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands. STUDY DESIGN: Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected. RESULTS: Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively (P<.001). Significantly more visceral lesions were found (P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively. CONCLUSION: Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.

Female↗

PubMed2004

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma.

BACKGROUND: Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed. METHODS: Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed. RESULTS: Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days. CONCLUSION: At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.

Adult↗

PubMed2005

The role of laparoscopy to evaluate candidates for complete cytoreduction of peritoneal carcinomatosis and hyperthermic intraperitoneal chemotherapy.

AIM: The aim of this study was to evaluate the role of explorative laparoscopy to evaluate candidates for complete resection of peritoneal carcinomatosis (PC) combined with hyperthermic intraperitoneal chemotherapy (HIPC). METHODS: The database of the surgical department of the Institut Gustave Roussy was used to select 113 patients planned to undergo a maximal cytoreductive surgery combined with HIPC for PC between April 2001 and July 2003. Among them, 11 underwent an explorative laparoscopy because extent of the PC was insufficiently documented to evaluate its resectability. Patient records were retrospectively reviewed. RESULTS: Laparoscopic evaluation was successful in all 11 patients. The median operating time was 38 min (range 23-75 min). The laparoscopic examinations were well tolerated in all cases. The median length of hospital stay was 1.7 days. For three patients, the PC was as judge as unresectable. A complete resection of the PC combined with HIPC was performed in seven out of the eight patients with PC considered resectable at laparoscopy. One patient was diagnosed with more extensive disease than that as assessed by the evaluative laparoscopy. Of note, for 20% of the patients with straight away laparotomy, the complete cytoreduction was not possible. CONCLUSION: Laparoscopic scoring of peritoneal carcinomatosis is accurate to assess the complete resectability of PC in patients for which there is inadequate or contradictory information concerning disease extent.

Adult↗

PubMed2006

Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial.

OBJECTIVE: To evaluate the use of mechanical bowel preparation (MBP) before gynecologic laparoscopy, using as the primary endpoint the appropriateness of the surgical field as judged by the surgeon. DESIGN: Prospective, randomized, single-blind clinical trial. SETTING: Academic department specializing in gynecologic surgery. PATIENT(S): One-hundred sixty-two patients scheduled for laparoscopy. INTERVENTION(S): The evening before laparoscopy, patients were randomized to either MBP with 90 mL of oral sodium phosphate (NaP) or no bowel preparation. MAIN OUTCOME MEASURE(S): Patient discomfort was evaluated with a visual analogue scale. Bowel preparation was evaluated by a surgeon (blind to bowel-preparation status) using a 5-point scale. Surgical difficulty, operating times, and postoperative complications were recorded. RESULT(S): Preoperative discomfort was significantly greater in the MBP group. No significant difference in the evaluation of the surgical field, operative difficulty, operative time, and postoperative complications was present between the two groups. CONCLUSION(S): Bowel preparation with oral NaP does not offer any significant advantage in patients undergoing laparoscopy for benign gynecologic conditions. In addition, MBP significantly increases preoperative discomfort.

Adult↗

PubMed2006

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds.

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

Abdominal Injuries↗

PubMedDate not supplied

Minimizing ancillary ports size in gynecologic laparoscopy: a randomized trial.

STUDY OBJECTIVE: To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm. DESIGN: Randomized, controlled trial (Canadian Task Force classification I). SETTING: Gynecologic department of a university hospital PATIENTS: A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n=52) or 3-mm instruments (n=50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria. INTERVENTIONS: Laparoscopic procedures for the treatment of benign adnexal masses. MEASUREMENTS AND MAIN RESULTS: Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p=.49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15-175 min] vs 50 min [range 20-150 min], p=.89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0-60] vs 32.5 [range 0-80], p=.04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups. CONCLUSION: Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon's ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

Adnexal Diseases↗

PubMedDate not supplied

Laparotomy to laparoscopy: changing trends in the surgical management of ectopic pregnancy in a tertiary care teaching hospital.

STUDY OBJECTIVE: To review the changing trends in the surgical management of ectopic pregnancy and to evaluate the effect of an ongoing training program for resident surgeons on the rate and success of laparoscopic surgery. DESIGN: Retrospective chart review (Canadian Task Force classification II-3). SETTING: University tertiary medical center. PATIENTS: One thousand forty-six patients with ectopic pregnancy treated at Jackson Memorial Hospital from January 1, 1995, through December 31, 2004. INTERVENTION: A formal, ongoing laparoscopic training program was established in 1999. MEASUREMENTS: The rate of laparoscopy, laparotomy, and conversion for each year was compared with the baseline year of 1995 and between the years before and after the establishment of the training program. RESULTS: Four hundred sixty-eight laparotomies and 578 laparoscopies were successfully completed. The laparoscopic approach rate has increased from 40.9% in 1995 to 86.3% in 2004. By year 2000 and thereafter, significantly more ectopic surgeries were approached through the laparoscope compared with in 1995 (p<.01). By 2000 and thereafter, significantly less conversions occurred compared with the baseline year of 1995 (4.0% vs 18.5%; p = .01). CONCLUSION: Laparoscopy became the primary approach for the management of ectopic pregnancy in part because of resident participation in an ongoing laparoscopy training program.

Education, Medical, Graduate↗

PubMedDate not supplied

Partial small bowel obstruction and ileus following gynecologic laparoscopy.

STUDY OBJECTIVE: To assess the incidence and management of partial small bowel obstruction (PSBO) and ileus after gynecologic endoscopy. DESIGN: Internet-based cross-sectional survey (Canadian Task Force classification II-3). MATERIAL AND METHODS: An online survey was distributed to gynecologic surgeons to collect information about frequency and management of ileus and PSBO after gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: Of the 58 physician respondents, 22 had managed at least 1 patient with PSBO or ileus after gynecologic laparoscopy. A total of 12 PSBOs and 14 patients experiencing ileus were identified for an overall incidence of 0.036%. Patients showed symptoms between 1 and 20 days postoperatively and had findings ranging from hypoactive (45%), to normal (30%), to hyperactive (25%) bowel sounds. Plain film radiographs (75%) were the most commonly used diagnostic modality followed by computed tomography (CT) scans of the abdomen. Most patients were initially managed with intestinal rest and nasogastric tube placement for 2 to 16 days. Fifty percent required a second procedure, with reported findings that included intestinal herniation (n = 7), bowel injury (n = 4), volvulus (n = 2), and urinoma (n = 1). CONCLUSION: Ileus and PSBO are rare findings after gynecologic laparoscopy. We identified 26 cases, most of which were initially managed conservatively. The majority of patients ultimately required a second operation. Surgeons should have a high index of suspicion when managing a patient with PSBO or ileus after gynecologic laparoscopy. Given the findings from the second procedures, CT scans would seem to be the diagnostic procedure of choice.

Adult↗

PubMed2006

Laparoscopy for renal cell carcinoma: diffusion versus regionalization?

PURPOSE: Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma. MATERIALS AND METHODS: Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques. RESULTS: Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001). CONCLUSIONS: Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.

Carcinoma, Renal Cell↗

PubMed2004

Laparoscopy in the second trimester of pregnancy.

Advances in laparoscopic surgery have led to the development of methods to perform traditionally major abdominal surgery and reduce morbidity using minimally invasive surgery techniques. Because a growing number of reports in the literature have suggested its safe use, laparoscopy is being performed in pregnancy with increasing frequency in many centers. Any surgeon treating pregnant patients must have a thorough understanding of the physiology of the pregnant patient and risks and benefits of the surgical procedure. This article discusses the use of laparoscopy in pregnancy focusing on the physiologic changes induced by pregnancy relevant to laparoscopy. Strategies to reduce the risk of complications while performing laparoscopy on a pregnant patient are discussed.

Female↗

PubMed2004

Are borderline tumors of the ovary safely treated by laparoscopy?

OBJECTIVES: To evaluate the risk of the laparoscopic approach to patients with borderline ovarian tumors compared to the laparotomic management. METHODS: We treated or followed in our institution 479 women with borderline ovarian tumor. Sixty-two patients had fertility-sparing surgery followed by restaging or follow-up intervention: 30 operated by laparoscopy, 32 by laparotomy. Restaging surgery was performed in five cases and second-look surgery in 57. RESULTS: The diameter of the cyst is significantly lower in patients treated by laparoscopy, especially in women who underwent cystectomy (4.7 cm) compared to oophorectomy (10 cm, P = 0.008). Rupture of the cyst and stage IC were more frequent in the laparoscopic group. After a median follow-up of 61 months for the laparoscopic group and 77 months for the laparotomic group, we observed 11 patients (37%) with persistent disease after primary laparoscopy (adnexa, five cases; peritoneal implants, three cases; both patterns, three cases). After primary laparotomy, no patients showed early persistence of tumor, and ovarian relapses were diagnosed in seven women (22%) 33-138 months after laparotomy. The univariate analysis for the risk of neoplastic persistence after primary laparoscopy shows that patients with cysts greater than 5 cm have a higher risk (odds ratio 9.7, P = 0.02) compared to smaller cysts. No other factors proved significant, but the odds ratios for patients with serous tumor (5.8), stage IC (2.0), and those undergoing cystectomy (1.9) suggest a relationship to the probability of persistence. CONCLUSION: Laparoscopic treatment in borderline ovarian tumors should be reserved to masses not greater than 5 cm. When conservative therapy is desired, the entire affected ovary should be removed. If the neoplasia is bilateral, cystectomy could be allowed in women who wish to preserve fertility, although they are at high risk of relapse.

Adult↗