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PubMed1993

1000 consecutive laparoscopies in gynaecological practice.

One thousand consecutive laparoscopies were performed by an individual team at University College Hospital, Galway from 1982 to 1990. The mean age of the patients was 34 years (range 15-61). The majority (702) were undertaken for tubal ligation, followed by investigation of infertility (125), pelvic pain (87) and suspected ectopic pregnancy (41). Laparotomies were avoided in 77 patients with pelvic pain and in 26 patients with suspected ectopic pregnancy. A further 73 patients had surgical procedures performed laparoscopically. There were no failed laparoscopies. Minor complications occurred in 1.3% of patients. The commonest difficulty encountered was failed first attempt at pneumoperitoneum (4%). Two patients required laparotomy following laparoscopy, because of intra-abdominal bleeding. Readmissions occurred in 7 patients but again no serious sequelae were recorded. The use of the laparoscope in general gynaecological practice is examined with the safety, diagnostic and therapeutic facilities of the procedure explored.

Adult↗

PubMed1993

Preoperative diclofenac sodium reduces post-laparoscopy pain.

Post-laparoscopy pain can increase recovery time and delay patient discharge. While previous studies have focused on the problems of nausea and vomiting, the purpose of this study was to assess the effect of diclofenac (a non-steroidal antiinflammatory drug) in the treatment of post-laparoscopy pain. Diclofenac (50 mg) or placebo was administered pr randomly and double-blind, prior to induction of anaesthesia, to 46 women. Pain intensity was assessed by the patient using a visual analogue scale 1, 12 and 24 hr after surgery. Postoperative analgesic requirements and side effects were also studied. Diclofenac resulted in better pain relief at 24 hr (1.0 vs 2.5, P < 0.05) and reduced the number of patients who needed additional postoperative analgesics (7 vs 15, P < 0.05). There was no difference in the incidence of side effects. These data suggest that diclofenac reduces post-laparoscopy pain and postoperative analgesic requirements.

Acetaminophen↗

PubMed2001

Selective spinal anesthesia for outpatient laparoscopy. II: epinephrine and spinal cord function.

PURPOSE: To compare two small-dose solutions (with and without epinephrine) for spinal anesthesia during outpatient laparoscopy and to determine spinal cord function with these low-dose solutions. METHOD: Twenty outpatients undergoing gynecological laparoscopy were randomly assigned to receive spinal anesthesia with one of two low dose solutions. Group LS-10 mg lidocaine plus 10 microg sufentanil; Group LSE-10 mg lidocaine plus 10 microg sufentanil plus epinephrine 50 microg. Solutions were diluted to three millilitres with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Operating conditions and spinal cord function (spinothalamic, dorsal column and motor) were assessed. RESULTS: Operating conditions were good-excellent in both groups. The incidence of shoulder tip discomfort, pruritus and nausea, and the amount of supplementation with alfentanil and midazolam was not different between groups. Most patients in both groups had preserved dorsal column function and normal motor power on arrival in PACU and were able to satisfy 'walk out' criteria. Recovery of pinprick sensation and discharge times were not different. Mild pruritus (VAS score < or = 5) was present in both groups. CONCLUSION: For short duration laparoscopy, addition of 50 microg epinephrine to a small dose of spinal 10 mg lidocaine with 10 microg sufentanil did not provide additional benefit in terms of intraoperative analgesia or operating conditions. Spinal cord function was preserved with small-dose techniques.

Adult↗

PubMed2001

Selective spinal anesthesia for outpatient laparoscopy. III: sufentanil vs lidocaine-sufentanil.

PURPOSE: The efficacy of low dose intrathecal lidocaine-sufentanil was compared with intrathecal sufentanil for short duration outpatient gynecological laparoscopy. METHODS: Thirteen ASA I and II patients undergoing gynecological laparoscopy were studied in a randomized double-blind trial. Patients received either intrathecal 10 mg lidocaine plus 10 microg sufentanil (Group LS) or intrathecal 20 microg sufentanil (Group S), each diluted to 3 mL with sterile water through a 27g Whitacre needle in the sitting position. Sensory and motor recovery were assessed with pinprick and a modified Bromage scale. RESULTS: One of seven Group LS patients and two of five Group S patients required conversion to general anesthesia for failed skin test with forceps. Two of the remaining three Group S patients felt sharpness with skin incision. The study was terminated early because of inadequate anesthesia in Group S. The small sample size (n = 9) made statistical analysis uninformative. CONCLUSION: Intrathecal 20 microg sufentanil is unsuitable as a sole agent for gynecological laparoscopy.

Adult↗

PubMed2003

Intravenous fluid loading with or without supplementary dextrose does not prevent nausea, vomiting and pain after laparoscopy.

PURPOSE: To examine the effects of iv compound sodium lactate (CSL) with and without caloric supplementation with dextrose on nausea, vomiting and pain following general anesthesia for laparoscopy. METHODS: We compared iv fluid loading with and without supplementary dextrose for the prevention of postoperative nausea and vomiting (PONV). In a prospective double-blinded controlled trial, 120 ASA I female patients undergoing elective gynecological laparoscopy were randomized to one of three groups, and received either: (a) CSL 1.5 mL.kg(-1) per hour fasting duration; (b) CSL, 1.5 mL.kg(-1) per hour fasting duration with 0.5 g.kg(-1) dextrose added in 50% formulation (CSL/dextrose); or (c) no iv fluid (control). RESULTS: Compared with control the percentage of patients who had no PONV within 24 hr of anesthesia in the CSL and CSL/dextrose groups was 78% vs 83% and 71%, P = 0.81 and P = 0.683 respectively. The numbers needed-to-harm for causing PONV episodes in CSL/dextrose vs CSL or control groups were 5.7 [95% confidence interval (CI), 5.57-5.91] and 8.2 (95% CI, 8.01-8.37) respectively. The number needed-to-treat for prevention of PONV episodes in CSL vs control was 19.2 (95% CI, 19.08-19.37). A greater proportion of patients in the CSL/dextrose group required narcotic analgesia in the postanesthetic care unit compared to those in the control group (16/35 vs 7/37, P = 0.03). The CSL/dextrose group also demonstrated hyperglycemia (serum glucose 14.0 +/- 3.94 vs 5.0 +/- 1.01 vs 5.2 +/- 0.9 mmol.L(-1), P < 0.0001) in the postanesthetic care unit compared to the CSL and control groups. The CSL/dextrose group also reported increased thirst at 24 hr compared to control (20/35 vs 11/37, P = 0.035). CONCLUSION: These findings suggest that: 1) administration of dextrose is associated with nausea, increased opioid requirement and late thirst after elective gynecological laparoscopy; 2) iv fluids did not decrease PONV.

Adult↗

PubMed2000

[Laparoscopy in small bowel ileus].

Today laparoscopic procedures are routinely performed in patients with intestinal adhesions from previous abdominal surgery. Does laparoscopy have a potential benefit in acute small-bowel obstruction? Theoretically, a lower rate of wound complications and incisional hernias, as well as less subsequent adhesions with a lower incidence of recurrent intestinal obstruction, can be expected. However, laparoscopy is successful in only 50-70% of selected patients, thereby representing the highest rate of conversion in minimally invasive surgery. Laparoscopic management of severe abdominal distension with massively dilated and fragile small-bowel or dense adhesions is extremely difficult even when performed by experienced surgeons. Significantly prolonged operating time, the high risk of bowel injury (> 6-10%) and an increased frequency of early reoperations jeopardize the patient's safe outcome. However, in strictly selected patients the laparoscopic approach may be promising. In acute intestinal obstruction without a history of previous abdominal surgery, laparoscopy is--in the absence of adhesions--an excellent diagnostic tool and may also be a successful therapeutic modality in a variety of bowel-obstruction etiologies. Furthermore, the laparoscopic option should be considered in patients who previously had undergone small laparotomies (e.g., appendectomy) or laparoscopic surgery. We recommend "postlaparoscopic" intestinal obstruction as the ideal case for laparoscopic reexploration. Incarcerated hernias at the site of trocar insertion or adhesions due to peritoneal tears are easily identified as the cause of obstruction and successfully cured with the laparoscope. In conclusion, we advocate the laparoscopic approach in acute small-bowel obstruction exclusively for selected patients. Clinical studies are required to define appropriate surgical indications objectively.

Contraindications↗

PubMed2002

[Urologic laparoscopy in marginal patients].

This paper describes the use of urological laparoscopy in borderline patients, focussing on geriatric patients and those with renal failure. Laparoscopy must not only be feasible but also at least as effective concerning operative and postoperative parameters when compared to standard open surgery. For laparoscopic nephrectomy most of these factors have tested positive. However, only a few papers have been published concerning borderline patients. In some cases the pneumoperitoneum may not be suitable for borderline patients and open operative techniques are preferred. Apart from this, the current literature supports the effectiveness of laparoscopy even when certain risk factors are present. Especially borderline patients can benefit from the laparoscopic approach for nephrectomy. Although data are scarce concerning other laparoscopic procedures in borderline patients, the results of laparoscopic nephrectomy should probably apply to other laparoscopic procedures.

Aged↗

PubMed1999

Laparoscopy with laparoscopic ultrasonography in the TNM staging of pancreatic carcinoma.

A prospective study was performed comparing laparoscopy with laparoscopic ultrasonography (LapUS), transabdominal ultrasonography (USS), computed tomography (CT), and selective visceral angiography with portal phase venography (SVA) for the assessment of resectability in 50 patients with pancreatic or periampullary cancer. The results were stratified by TNM stages. Tumor unresectability was demonstrated in 36 patients (72%). The sensitivity of LapUS for demonstrating the index lesion was 96%. Laparoscopic ultrasonography failed to predict factors precluding resection by T stage in six patients, and there were no significant differences in the ability of any modality to predict local resectability (predictive value 58-73%). Laparoscopic ultrasonography did not overestimate T stage and was significantly more specific for assessing unresectability compared with USS (100% vs. 64%, p<0.05) and CT (100% vs. 47%, p<0.005). No imaging investigation was able to assess the N stage accurately. Metastases were confirmed in 16 patients (32%), with LapUS proving significantly more sensitive than USS (94% vs. 29%, p<0.001) and CT (94% vs. 33%, p<0.005). The addition of LapUS to the laparoscopic examination did not change the M stage in any patient, as all metastases were superficially located. Laparoscopy with LapUS was the most reliable method for assessing overall tumour resectability and was significantly more predictive than CT (97% vs. 79%, p<0.005). These results confirm that laparoscopy is indispensable for detecting occult intraabdominal metastases. LapUS reliably predicts tumor unresectability, offsetting the tendency of USS and CT to overestimate T stage. Methods of accurate N staging remain elusive, and the use of routine SVA is not justified.

Adult↗

PubMed2001

The poor quality of information about laparoscopy on the World Wide Web as indexed by popular search engines.

BACKGROUND: This study was undertaken to determine the quality of information on the Internet regarding laparoscopy. METHODS: Four popular World Wide Web search engines were used with the key word "laparoscopy." Advertisements, patient- or physician-directed information, and controversial material were noted. RESULTS: A total of 14,030 Web pages were found, but only 104 were unique Web sites. The majority of the sites were duplicate pages, subpages within a main Web page, or dead links. Twenty-eight of the 104 pages had a medical product for sale, 26 were patient-directed, 23 were written by a physician or group of physicians, and six represented corporations. The remaining 21 were "miscellaneous." The 46 pages containing educational material were critically reviewed. At least one of the senior authors found that 32 of the pages contained controversial or misleading statements. All of the three senior authors (LKN, NAO, GAF) independently agreed that 17 of the 46 pages contained controversial information. CONCLUSION: The World Wide Web is not a reliable source for patient or physician information about laparoscopy. Authenticating medical information on the World Wide Web is a difficult task, and no government or surgical society has taken the lead in regulating what is presented as fact on the World Wide Web.

Abstracting and Indexing↗

PubMed2002

Vaginal extraction of pelvic masses following operative laparoscopy.

OBJECTIVE: To investigate the clinical outcome of patients undergoing operative laparoscopy for a benign pelvic mass followed by vaginal extraction of the surgical specimen. METHODS: Patients presenting with a suspected benign mass greater than 5 cm or an extrauterine pregnancy undergoing operative laparoscopy were considered eligible. Patients with endometriosis, pelvic inflammatory disease, and previous hysterectomy were excluded. In all cases the surgical specimen was removed through a colpotomy performed in laparoscopy at the level of the posterior vaginal fornix. Additionally, a review of the literature has been conducted to specifically address the incidence of colpotomy-related complications. RESULTS: Sixty-three patients were included in the study. The median (range) time required to extract the freed mass to the complete suture of the colpotomy was 15 min (5-31). This time was significantly longer in patients with myomas than for others [median 21 min (range: 10-31) vs median 10 min (5-13), p<0.05]. No intra- and postoperative colpotomy related complications occurred. No patients complained dyspareunia at follow-up visits. A total of 23 studies were reviewed for a total of 501 patients and only one (0.2%) complication (severe vaginal bleeding) was directly attributable to the colpotomy. CONCLUSION: Removal of a pelvic mass through a laparoscopic colpotomy is feasible, safe, and offers better cosmetic results than transabdominal extraction of the surgical specimen.

Adolescent↗

PubMed2002

Laser laparoscopy for endometriosis and endometriotic cysts.

BACKGROUND: Endometriosis is a common and debilitating condition involving women during their reproductive years. It is characterized by the occurrence of endometrial glands and stroma outside the uterine cavity. Presenting symptoms include chronic nonmenstrual pelvic pain, dysmenorrhea, dyspareunia, and subfertility. The condition is diagnosed at laparoscopy, and operative laparoscopic surgery for endometriosis is also possible. METHODS: This article critically evaluates the evidence for the laparoscopic management of endometriosis and endometriotic cysts. It focuses on laser laparoscopy and reviews the contribution made by the Minimal Access Therapy Training Unit, Guildford, UK, to the treatment of this condition. RESULTS: Few randomized controlled trials have been undertaken to evaluate the surgical management of endometriosis. The studies that have been done show that laparoscopic surgery, including laser laparoscopy, is effective in the management of painful symptoms and subfertility and preventing cyst recurrence. Several of the landmark studies in this area have been carried out in Guildford. CONCLUSION: Laparoscopic surgery is the treatment of choice for patients with endometriosis and endometriotic cysts.

Endometriosis↗

PubMed2003

One-trocar laparoscopy: a valid procedure to treat abdominal complications in children with peritoneal shunt for hydrocephalus.

BACKGROUND: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). MATERIALS AND METHODS: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. RESULTS: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. CONCLUSIONS: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

Abdominal Cavity↗

PubMed2003

The use of laparoscopy in abdominal emergencies.

BACKGROUND: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. METHODS: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). RESULTS: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. CONCLUSIONS: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

Abdomen↗

PubMed2004

Laparoscopy as a prognostic factor in curative resection for node positive colorectal cancer: results for a single-institution nonrandomized prospective trial.

BACKGROUND: Several studies reporting preliminary long-term survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy. METHODS: A single-institution prospective nonrandomized trial compared short- and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000. RESULTS: In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid-low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 +/- 5.7 for OR and 12.7 +/- 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid-low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancer-related survival was identified in stage III patients undergoing LR. CONCLUSIONS: Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and long-term survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.

Adenocarcinoma↗

PubMed2005

Assessment of cyclin D1 overexpression as a prognostic factor in soft tissue sarcomas: role of laparoscopy and core needle biopsy.

BACKGROUND: This study was designed to test cyclin D1 as a prognostic marker in patients with soft tissue sarcomas (STS), and to evaluate the usefulness of laparoscopy for determining cyclin D1 overexpression. METHODS: The records of 62 patients with STS were collected: 28 with retroperitoneal STS (RSTS) and 34 with extremity STS (ESTS). A total of 51 patients underwent surgical resection, whereas 11 did not undergo surgery because of advanced tumor stage. Preoperative-intraoperative laparoscopic staging was performed for patients judged to be resectable at preoperative imaging. RESULTS: Cyclin D1 was overexpressed in 30 (58.8%) of 51 resected patients and in 10 (90.9%) of 11 nonresected patients. Laparoscopy avoided unnecessary laparotomy in 9 (32.1%) of 28 RSTS patients. CONCLUSIONS: High tumor grade, positive surgical margins, local recurrence, distant metastases, and cyclin D1 overexpression were related to poor survival. Multivariate analysis demonstrated cyclin D1 to be the only independent factor. Laparoscopy was shown to be useful for avoiding useless laparotomies.

Biopsy, Needle↗

PubMed2005

Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography.

BACKGROUND: Computed tomography (CT) is insensitive to small metastatic deposits in patients with pancreatic cancer. This study aimed to evaluate additional staging information obtained by laparoscopy in the subset of patients with locally extending pancreatic cancer but no evidence of distant disease using computed tomography. METHODS: Between April 2000 and February 2004, 74 patients with locally unresectable pancreatic cancer and no evidence of metastasis detected by high-quality pancreas protocol computed tomography underwent outpatient staging laparoscopy and peritoneal lavage cytology. RESULTS: Occult tumor was found during staging laparoscopy in 25 of the 74 patients (34%). The results were positive for peritoneal lavage cytology in 27% (20/74), for liver lesions in 16% (12/74), and for peritoneal implants in 7% (5/74) of the patients. Body and tail tumors were twice as likely as pancreatic head tumors to have unsuspected metastasis (53% vs 28%). CONCLUSIONS: Even the best computed tomography scan is not adequate for accurate staging of locally extended pancreatic cancer because occult distant disease will be found in half of the patients with left-sided disease and one-fourth of those with right-sided pancreatic cancer.

Adenocarcinoma↗

PubMed2004

A comparative study of skills in virtual laparoscopy and endoscopy.

BACKGROUND: The present study was designed to investigate whether there is a correlation between manual skills in laparoscopic procedures and manual skills in flexible endoscopy. METHODS: In a prospective study using laparoscopy and endoscopy simulators (MIST-VR, and GI-Mentor II), 24 consecutive subjects (gastrointestinal surgeons, novice and experienced gastroenterologists, and untrained subjects) were asked to perform laparoscopic and endoscopic tasks. Their performance was assessed by the simulators' software and by observers blinded to the levels of subjects' experience. Performance in experienced vs inexperienced subjects was compared. Score pairs of three parameters--time, errors, and economy of movement--were also compared. RESULTS: Experienced subjects performed significantly better than inexperienced subjects on both tasks in terms of time, errors, and economy of movement (p < 0.05). All three performance parameters in laparoscopy and endoscopy correlated significantly (p < 0.02). CONCLUSION: Both simulators can distinguish between experienced and inexperienced subjects. Observed skills in simulated laparoscopy correlate with skills in simulated flexible endoscopy. This finding may have an impact on the design of training programs involving both procedures.

Clinical Competence↗

PubMed2006

Does laparoscopy used in open exploration alleviate pain associated with chronic intractable abdominal wall neuralgia?

BACKGROUND: This study aimed to assess the efficacy of diagnostic laparoscopy and open exploration of trigger points (scar revision and neurectomy) in the treatment of intractable chronic abdominal wall pain. METHODS: This prospective nonrandomized study enrolled 24 patients (21 women) with an average age of 59 +/- 11 years. Abdominal wall pain was diagnosed by excluding other causes of pain and using multiple injections of bupivacain. The patients' demographic data and long-term postoperative course (37 +/- 13 months) were carefully recorded. RESULTS: Using laparoscopy, intraabdominal adhesions close to trigger points were found and lysed in 15 patients (63%). Next, a subcutaneous nerve resection was performed. After 1 month, 33% of the patients were completely pain free, and 42% reported alleviation of pain. After 3 years, chronic abdominal pain was totally healed in 25%, diminished in 50%, and unchanged or increased in 25% of the patients. A total of 23 patients (96%) reported that surgery was beneficial for their intractable pain. CONCLUSIONS: Laparoscopy used in open exploration is beneficial for 75% of carefully selected patients with chronic abdominal wall pain.

Abdominal Pain↗