surgical endoscopy journal

7/27/2019 surgical endoscopy journal

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Erratum

The following four articles were inadvertently printed in Surgical Endoscopy, vol. 14, no. 3, March 2000, with incorrect DOInumbers. Their correct DOI numbers are: F.L. Greene, The impact of laparoscopy on cancer management (pages217218), DOI: 10.1007/s004640030045; Vitale et al., Endoscopic treatment of distal bile duct stricture from chronicpancreatitis (pages 227231), DOI: 10.1007/s004640030046; Ishida et al., Pneumoperitoneum with carbon dioxide en-hances liver metastases of cancer cells implanted into the portal vein in rabbits (pages 239242), DOI: 10.1007/ s004640030047; and Lichtenbaum et al., Preoperative abdominal ultrasound may be misleading in risk stratification forpresence of common bile duct abnormalities (pages 254257), DOI: 10.1007/s004640030049.

Springer-Verlag New York Inc. 2000Surg Endosc (2000) 14: 411DOI: 10.1007/s004640030001


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Erratum

The following four articles were inadvertently printed in Surgical Endoscopy, vol. 14, no. 3, March 2000, with incorrect DOInumbers. Their correct DOI numbers are: F.L. Greene, The impact of laparoscopy on cancer management (pages217218), DOI: 10.1007/s004640030045; Vitale et al., Endoscopic treatment of distal bile duct stricture from chronicpancreatitis (pages 227231), DOI: 10.1007/s004640030046; Ishida et al., Pneumoperitoneum with carbon dioxide en-hances liver metastases of cancer cells implanted into the portal vein in rabbits (pages 239242), DOI: 10.1007/ s004640030047; and Lichtenbaum et al., Preoperative abdominal ultrasound may be misleading in risk stratification forpresence of common bile duct abnormalities (pages 254257), DOI: 10.1007/s004640030049.



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Minimally invasive surgery for posterior gastric stromal tumorsC. C. Hepworth, D. Menzies, R. W. Motson

Colchester General Hospital, Turner Road, Colchester, Essex CO4 5JL, UK

Received: 30 April 1999/Accepted: 12 July 1999

Abstract Background: Because involvement is extremely rare, sur-gery for gastric stromal tumors consists of local excisionwith clear resection margins. The aim of this study was toreport the results of a consecutive series of nine patientswith posterior gastric stromal tumors that were excised us-ing a minimally invasive method. Methods: Patients received a general anesthetic beforeplacement of three laparoscopic ports a 10-mm (umbili-cal) port for the telescope and two working ports, a 12-mmport (left upper quadrant) and a 10-mm port (right upperquadrant). Grasping forceps were placed through an anteri-orly placed gastrotomy to deliver the tumor through thegastrotomy into the abdominal cavity, thus allowing an en-doscopic linear cutter to excise the tumor with a cuff of normal gastric tissue. Results: Nine consecutive patients with a median age of 73years (range, 4783) were treated. In seven patients, lapa-roscopic removal of the tumor was achieved. Two patientsrequired conversion to an open operation because the tumorcould not be delivered into the abdominal cavity. The me-dian length of postoperative stay for the seven patients inwhom the procedure was completed laparoscopically was 3days (range, 26).Conclusions: Posterior gastric stromal tumors can be re-moved safely using this minimally invasive method. Deliv-ery of the tumor through the gastrotomy is essential forsuccess.

Key words: Gastric stromal tumors Minimally invasivesurgery Stomach

Smooth muscle tumors (leiomyomas, leiomyosarcomas, andleiomyoblastomas) arising in gastric tissue are now calledgastric stromal tumors. They were formerly distinguishedas leiomyomas and leiomyosarcomas when composed of spindle cells and as either benign leiomyoblastomas (epi-

thelioid leiomyomas) or malignant leiomyoblastomas (epi-thelioid leiomyosarcoma) when composed of epithelioidcells [8]. They are uncommon, and the majority are small(


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lesion be determined with absolute certainty. If the tumor issubsequently found to be malignant, no further treatment[41] is required as long as the resection margins are clear, asthese tumors are usually radio-resistant and not responsiveto chemotherapy [6]. Both wedge resection and gastrectomyhave been performed [6, 7, 12, 35] for malignant tumors,but neither method appears to confer a survival advantage

[12, 15]. This may be due in part to the fact that nodalmetastasis is rare [7, 20, 41] and there does not appear to bea need for regional lymph node dissection. If malignancy issuspected or confirmed on subsequent histological grounds,a careful surveillance program for local recurrence and he-patic or peritoneal deposits may be required. Surveillance isnecessary because following complete resection of the ma-lignant tumor, only 10% of patients remain free of the dis-ease [28]. One study showed that the median interval torecurrence was 18 months (range 3232) and that recur-rences arose mainly in the peritoneum (78%) and/or liver(70%) [28]. Resection of recurrences is associated with aprolonged median survival [27, 28, 30]. Extraabdominal

metastases (lung and bone are most common sites) have apoor prognosis.Carneys triad [3, 21] occurs mainly in young women;

the average age of presentation is 16 years. This syndromeincludes epithelioid cell gastric sarcomas, pulmonary chon-dromas, and extraadrenal paragangliomas (which cause hy-pertension). Intraadrenal pheochromocytomas have been re-ported. In Carneys triad, the gastric sarcomas are usuallymultifocal; if locally excised, they recur in the gastric rem-nant. If this syndrome is suspected, a total gastrectomy maybe indicated.

In this paper, we report the results of a consecutiveseries of nine patients with posterior gastric stromal tumors

that were excised using a minimally invasive method.

Materials and methods

Patients

Nine consecutive patients (median age, 73 years; range, 4783) with gas-tric stromal tumors identified at endoscopy on the posterior wall of thestomach underwent minimally invasive surgery for their removal.

Technique

After receiving a general anesthetic, the patient was placed in a supineposition with the legs abducted in Allen supports (CLS Medical Ltd.,Newcastle-upon-Tyne, England). Using a direct puncture technique, a 10-mm laparoscopic port (Eurosurgical Ltd., Guildford, Surrey, England) wasintroduced at the umbilicus [24]. Carbon dioxide was insufflated (Olym-pus, model A5845; Keymed, Southend-on-Sea, England) through this portto create a pneumoperitoneum with an insufflation pressure of 1215mmHg. A 30 telescope (Olympus model A5255), was then placed throughthe 10-mm laparoscopic port to visualize the abdominal contents and toallow placement of the remaining two ports under direct vision. A 12-mmport (Fig. 1) was placed in the left upper quadrant to allow the use of theendoscopic linear cutter (Ethicon, Bracknell, Berkshire, England). Another10-mm port was placed in the right upper quadrant. The camera was heldby an assistant standing on the patients left while the surgeon stood be-tween the patients legs.

An IT 20 gastroscope (Olympus; Keymed) was inserted orally, and thetumor was visualized in the stomach. Two stay sutures (8 cm apart) wereplaced through the anterior abdominal wall into the peritoneal cavity. Theywere passed through the seromuscular layer of the anterior aspect of the

stomach (Fig. 2) and then back through the anterior abdominal wall. Trac-tion on the stay sutures lifted up the anterior wall of the stomach (Fig. 3)so that the anterior wall of the stomach lay in a vertical plane.

The tumor was located by the gastroscope on the posterior part of thestomach. The 30 telescope visualized the anterior part of the stomach. Byturning the laparoscopic light off and rotating the gastroscope to face theanterior wall after it has located the tumor, transillumination of the anteriorwall of the stomach can be achieved.

A gastrotomy was made using cutting diathermy at the point of greatest

transillumination, allowing access directly onto the tumor. The gastroscopewas withdrawn, and the 30 telescope and grasping forceps (Storz, Slough,England) were introduced through the gastrotomy into the gastric cavity.The grasping forceps are placed through the gastrotomy before the 30telescope. The tumor can then be grasped and pulled through the gas-trotomy by withdrawing the grasping forceps. To aid delivery, the staysutures are relaxed so that the stomach again rests in its normal anatomicalposition. Delivery of the tumor everts the posterior wall of the stomachthrough the gastrotomy (Fig. 3), forming a pedicle of normal gastric tissue.If the tumor is too large to be delivered or cannot be delivered with apedicle of normal gastric tissue, conversion to an open operation is re-quired. This problem may arise if the tumor has invaded surroundingorgans.

If the tumor is on the anterior wall [13] of the stomach, transillumina-tion by the gastroscope (viewed by the 30 telescope) will demarcate thetumor clearly. The tumor appears as a dark area surrounded by a halo of

light.For posterior tumors, once the tumor is delivered with its cuff of normal

gastric tissue, sequential application of the endoscopic linear cutter acrossthe pedicle both transects and staples the posterior wall of the stomach (Fig.4). The tumour is then placed into an endoscopic retrieval bag (VernonCarus, Preston, Lancashire, England) and removed through the 12-mmtrocar site. Thereafter, tension on the stay sutures lifts the anterior wall of the stomach into a vertical plane and allows laparoscopic closure of thegastrotomy with a continuous single Vicryl (Ethicon) suture (Fig. 5). Thestay sutures are then cut and the stomach resumes its original position inthe abdomen. Laparoscopic ports are removed with closure of the portsites.

The patient is allowed a normal diet the following day and monitoredcarefully for evidence of upper gastrointestinal bleeding, vomiting, or peri-tonism.

Results

Nine consecutive patients (six female and three male) witha median age of 73 years (range, 4783) were found atgastroscopy to have probable gastric stromal tumors (Table1). Seven of these nine presented acutely because of melenawith a median hemoglobin of 9.1 g/dl (range, 7.513.7).Another patient was being investigated for upper abdominalpain (hemoglobin 14.0 g/dl) due to cholecystitis and had agastric stromal tumor that was found incidentally at gastros-copy. The remaining patient was being investigated for irondeficiency anemia (hemoglobin 8.1 g/dl).

None of the patients required either emergency inter-ventional endoscopy or surgery. All of them underwent gas-troscopy. Although the tumor was visualized in all cases, inonly one case did an endoscopic biopsy yield a specificdiagnosis of gastric stromal tumor. The endoscopic biopsysuggested a malignant gastric stromal tumor, but surgicalhistology identified the lesion as a borderline malignancy.

At operation, seven of our nine patients had a laparo-scopic procedure to remove the tumor. Two of nine patientsrequired conversion to an open operation because a pedicleof gastric tissue could not be formed to allow transectionwith the linear stapler. One of these two patients underwenta partial gastrectomy; surgical histology of the specimen

identified the lesion as a malignant tumor. Twenty-sevenmonths later, this patient developed a recurrence and re-quired total gastrectomy.

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The remaining eight patients histology revealed benigntumors in three cases and a borderline malignancy in fivecases. The most common location was the fundus. An openoperation was required for two tumors that were larger (11 7 cm, 12 12 cm) than those removed laparoscopically

(median, 6.5 4.5 cm; range, 6 39 6).All seven patients who were treated laparoscopicallywere eating, drinking, and ambulant the following day.

There was no postoperative bleeding or leakage, and noneof the patients died.

The overall median length of postoperative stay was 3days (range, 210). For patients in whom the procedure wascompleted laparoscopically, the median length of stay was 3

days (range, 26). The two patients who required conver-sion to an open operation remained in hospital for 6 and 10days, respectively.

Fig. 1. Abdominal placement of laparascopic ports. , 10-mm laparoscopic port; q , 12-mmlaparoscopic port.

Fig. 2. Two stay sutures are placed through the anterior abdominal wall into the peritonealcavity and then through the seromuscular layer of the anterior aspect of the stomach.

Fig. 3. Traction on the two stay sutures lifts up the anterior wall of the stomach.

Fig. 4. Sequential application of the endoscopic linear cutter transects and closes (withstaples) the everted posterior wall of the stomach (pedicle) after delivery of the stromal tumor.

Fig. 5. Closure of the gastrotomy with a single continuous suture.

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Discussion

Our review of the literature revealed case reports of endo-scopic resection [9, 16, 36], laparoscopic resection [2, 39],laparoscopic intragastric resection [37], and endoscopicallyassisted laparoscopic resections [5, 11, 13, 14, 25, 29]. Thispaper describes nine consecutive patients with posteriorgastric stromal tumors that were excised using a minimallyinvasive approach.

Due to difficulties in biopsying subcutaneous tumors atendoscopy, a clear distinction between benign and malig-

nant tumours is rarely made before surgery. In this series,endoscopic biopsies were diagnostic on only one occasion.Surgical histology showed borderline malignancy in fivecases and unequivocal malignancy in one case. Given thatonly three of our nine patients had definitely benign histol-ogy, it is arguable that most gastric stromal tumors shouldbe removed surgically.

Placement of stay sutures through the anterior abdomi-nal wall and the anterior aspect of the stomach facilitatedboth gastrotomy formation and its subsequent closure.Grasping forceps had to be placed through the gastrotomybefore the telescope. If the telescope is placed first, it isdifficult to locate the gastrotomy with the forceps. Everting

the gastric stromal tumor produces a pedicle of normal gas-tric tissue. The laparoscopic linear stapling device facili-tated simultaneous division and closure of the tissues, re-ducing both the spillage of gastric contents and the amountof bleeding. If the tumor was too large to be everted or apedicle of normal gastric tissue could not be formed toallow application of the endoscopic linear cutter, the pro-cedure was converted to an open operation. We encounteredthis problem in two cases; both were converted to an openprocedure. Laparoscopic resection of the stomach [10, 19]has been reported, but it was not performed in this study. Atpresent, the laparoscopic resection of malignant tumors iscontroversial due to the possibility of port site recurrence

[26].The reason for failure to form a pedicle is not clear. Thesource of the problem might be fixation of the tumor to

adjacent structures or the size of the tumor. Preoperativeendoscopic ultrasound may determine which posterior gas-tric tumors would be suitable for this type of removal. Useof the linear cutter across the pedicle does raise the theo-retical possibility that other tissue could be incorporated.There was no clinical evidence of this problem in this study.If unwanted tissue were incorporated, one would expect to

encounter some difficulty in everting the tumor to form thegastric pedicle.Had the tumor been located on the anterior wall of the

stomach, the use of the stay sutures and transilluminationfrom the gastroscope would have identified the outline of the tumor, facilitating its removal [13].

There are several methods (endoscopic and laparoscop-ic) for resecting gastric stromal tumors. Preoperative inves-tigations that best determine the position and size of thetumor should allow the most suitable method to be chosen.

For patients in whom minimally invasive therapy can beperformed, the well-known advantages of a shorter recoveryperiod, reduced pain, and shorter hospital stay may be at-

tained. However, a randomized prospective controlled studyis needed to verify this possibility.

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FeatureNo. of patients

Tumor location a

antrum 1body b 2fundus c 4

cardia 1Histological diagnosisbenign 3borderline b 5malignant c 1

Mode of presentationmelena 7anemia 1incidental finding 1

a Tumor location is shown for only eight of the nine patientsb One patient required conversion to an open procedure for a borderlinemalignant tumorc One patient required conversion to an open procedure. Two years later,the patient developed a recurrence and underwent a total gastrectomy

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38. Welch JP (1975) Smooth muscle tumors of the stomach. Am J Surg130: 279285

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News and notices

The Association of Endoscopic Surgeons of Great Britain and Ireland

The AESGBI office is moving from the Oaks Hospital Colchester. Allcorrespondence should be addressed to:

Association of Endoscopic Surgeons of Great Britain and IrelandThe Royal College of Surgeons35/43 Lincolns Inn FieldsLondon WC2A 3PN, UKTel: 0044 (0)171 973 0305Fax: 0044 (0)171 430 9235E-mail: [email protected]

Volunteer Surgeons NeededNorthwestern Nicaragua LaparoscopicSurgery Teaching Program,Leon, Nicaragua

Volunteer surgeons are needed to tutor laparoscopic cholecystectomy forthis non-profit collaboration between the Nicaraguan Ministry of Health,the National Autonomous University of Nicaragua, and Medical TrainingWorldwide. The program consists of tutoring general surgeons who havealready undergone a basic laparoscopic cholecystectomy course. MedicalTraining Worldwide will provide donated equipment and supplies whenneeded.

For further information please contact:

Medical Training WorldwideRamon Berguer, MD, ChairmanTel: 707-423-5192Fax: 707-423-7578E-mail: [email protected]

Courses at the Washington Institute of Surgical Endoscopy

We are delighted to offer a variety of regular courses in laparoscopictechniques year round. In addition, special arrangements can be made forindividual tuition in all minimally invasive disciplines. CME credit isavailable and course fees depend on the instruction offered.


Debbie MoserWashington Institute of Surgical Endoscopy2150 Pennsylvania Avenue, N.W.Suite 6-BWashington, DC 20037, USATel: 202-994-8425, or 1-888-8WISEDOCFax: 202-994-0567

Courses at the Washington Institute of Surgical Endoscopy

Courses are available in difficult cholecystectomy and common duct ex-ploration, laparoscopic antireflux surgery, laparoscopic colorectal surgery,laparoscopic solid organ surgery, transanal endoscopic microsurgery, andadvanced techniques. Additionally, tailor-made courses are available forsingle surgeons or groups of surgeons to fit their requirements. Coursesconsist of didactic construction, review of videos, and experience in oursuperbly-equipped laboratory. We utilize training boxes, phantom abdo-

mens as well as in vivo animal models. Course fees depend on length andcomplexity of instructions. In addition, attendees may observe live surgeryand attend other educational activities at the George Washington Univer-sity. For further details and brochure please contact:

Debbie MoserWashington Institute of Surgical EndoscopyGeorge Washington UniversityDepartment of Surgery2150 Pennsylvania Avenue, N.W.Suite 6-BWashington, DC 20037, USATel: 202-994-5441Fax: 202-944-0567

Essentials of Laparoscopic SurgerySurgical Skills UnitUniversity of DundeeScotland, UK

Under the direction of Sir A. Cuschieri the Surgical Skills Unit is offeringa three-day practical course designed for surgeons who wish to undertakethe procedures such as laparoscopic cholecystectomy. This intensely prac-tical program develops the necessary operating skills, emphasizes safepractice, and highlights the common pitfalls and difficulties encounteredwhen starting out. Each workshop has a maximum of 18 participants whowill learn both camera and instrument-manipulation skills in a purpose-built skills laboratory. During the course there is a live demonstration of alaparoscopic cholecystectomy. The unit has a large library of operativevideos edited by Sir Cuschieri, and the latest books on endoscopic surgeryare on display in our Resource area. Course fee including lunch and coursematerials is $860.

For further details and a brochure please contact:

Julie Struthers, Unit Co-ordinatorSurgical Skills UnitNinewells Hospital and Medical SchoolDundee DD1 9SY, Scotland, UKTel: +44 382 645857Fax: +44 382 646042

Minimal Access Therapy Training CoursesSurgical Skills Unit

University of Dundee, Scotland, UKUnit Director: Sir Alfred Cuschieri

The Surgical Skills unit offers practical courses in minimal access thera-pies. Each program is organized to have maximum hands on practicesessions in the purpose-built laboratory. Subject experts are available fortuition and personal feedback. Live operative demonstrations on specificprocedures form part of each course; these are backed up by video illus-trations. Each course has a workbook with essential information, clearexplanations, and guidelines. Informal discussion sessions with subjectexperts form part of each program. The courses are run regularly through-out the year.

Essentials of Laparoscopic Surgery, a 3-day course covering the es-sential skills and safety procedures for basic laparoscopic operations.

Foundations of Laparoscopy Surgery, a 5-day course presenting anextensive and detailed introduction to laparoscopic surgery.

Practical Training in Pediatric Endoscopic Surgery, a 5-day coursefor surgeons who wish to perform or refine endoscopic surgical techniquesin children.



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The Advanced Endoscopic Surgical Courses of the Royal College of Surgeons of Edinburgh are held in the Surgical Skills Unit.

These are: Advanced Endoscopic Skills Course, a 5-day endoscopicskills training in advanced surgical tasks common to all specialities, e.g.,intracorporeal and extracorporeal knot tying, internal continuous and in-terrupted suturing, anastomosis of organs, stapling, use of sophisticatedequipment such as ultrasound and harmonic dissections and SpecialistProcedure-related courses, which are 23 days long and concentrate onspecific clinical situations particularly relevant to a speciality and focused

on specific endoscopic operation(s).Ductal Calculi: The Laparoscopic ApproachPractical Aspects of Laparoscopic FundoplicationLaparoscopic Colorectal CourseThoracoscopic SympathectomyOther specialist courses held in the unit include courses in anaesthetic

techniques, arthroscopy, colonoscopy, endoscopy, gynecology, and otolar-yngology.

For further information you can visit our web site or contact:

Julie Struthers, Unit Co-ordinatorSurgical Skills UnitNinewells Hospital and Medical SchoolDundee DD1 9SY, Scotland, UKTel: +44 1382 645857Fax: +44 1382 646042E-mail: [email protected] Web page: http://www.dundee.ac.uk/surgicalskills/

Courses at the Royal Adelaide Centre forEndoscopic Surgery

Basic and Advanced Laparoscopic Skills Courses are conducted by theRoyal Adelaide Centre for Endoscopic Surgery on a regular basis. Thecourses are limited to six places to maximize skill development and tui-tion. Basic courses are conducted over two days for trainees and sur-geons seeking an introduction to laparoscopic cholecystectomy. Animalviscera in simulators is used to develop practical skills. Advanced coursesare conducted over four days for surgeons already experienced in laparo-scopic cholecystectomy who wish to undertake more advanced proce-dures. A wide range of procedures are included, although practical sessionscan be tailored to one or two procedures at the participants request.Practical skills are developed using training simulators and anaesthetisedpigs.

Course fees: $A300 ($US225) for the basic course and $A1,600($US1,200) for the advanced course.

For further details and a brochure please contact:

Dr. D. I. Watson or Professor G. G. JamiesonThe Royal Adelaide Centre for Endoscopic SurgeryDepartment of SurgeryRoyal Adelaide Hospital

Adelaide, SA 5000, AustraliaTel: + 61 8 224 5516Fax: + 61 8 232 3471

Advanced Laparoscopic Suturing and SurgicalSkills Courses

MOET InstituteSan Francisco, CA, USA

Courses are offered year-round by individual arrangement. The MOETInstitute is accredited by the Accreditation Council for Continuing MedicalEducation (ACCME) to provide continuing medical education for physi-cians and designates these CME activities for 2040 credit hours in Cat-egory 1 of the Physicians Recognition Award of the American MedicalAssociation. These programs are also endorsed by the Society of Gastro-intestinal Endoscopic Surgeons (SAGES).


Wanda Toy, Program AdministratorMicrosurgery & Operative Endoscopy Training (MOET) Institute153 States StreetSan Francisco, CA 94114, USATel: (415) 626-3400Fax: (415) 626-3444

Fellowships in Minimally Invasive Thoracic andGeneral Surgery

University of Pittsburgh Medical CenterPittsburgh, PA, USA

One-year fellowships in advanced Minimally Invasive Surgery in Generaland Thoracic Surgery are being offered at the University of PittsburghMedical Center. Requirements include completion of residence trainingprograms in General or Thoracic Surgery. The fellowships will involveextensive clinical exposure as well as clinical and basic science research.These positions include a very competitive salary and travel allowance.Interested candidates are invited to send a letter of inquiry with a curricu-lum vitae to:

Philip R. Schauer, M.D.

Assistant Professor of Surgery and Co-Director for General SurgeryJames Luketich, M.D.Assistant Professor of Surgery and Co-Director for Thoracic SurgeryThe University of Pittsburgh Medical CenterC-800 Presbyterian University Hospital200 Lothrop StreetPittsburgh, PA 15213-3221, USA

Visiting Scholar Opportunities in MinimallyInvasive Surgery

Ohio State University Medical CenterColumbus, OH, USA

A minimum experience of one month and a maximum of six months is

being offered to Visiting Scholars at the Ohio State University MedicalCenter starting immediately. Applicants must have completed a recognizedtraining program in general surgery. The program is designed to exposetrained surgeons to advanced applications of new techniques in minimallyinvasive surgery, prepare individuals to train others in the application of this new technology, to include this individual in the development of thenew application of technology, and to provide the individual with theguidance and the resources to develop independent investigational projectsevaluating treatment modalities in minimally invasive surgery. Interna-tional applicants are encouraged to apply. Interested candidates are invitedto send a letter of inquiry with a curriculum vitae to:

W. Scott Melvin, M.D.Assistant Professor of Surgery and DirectorCenter for Minimally Invasive SurgeryThe Ohio State University

Department of SurgeryN737 Doan Hall410 West Tenth AvenueColumbus, OH 43210, USA

Fellowships in Minimally Invasive Thoracic andGeneral Surgery

Ohio State University Medical CenterColumbus, OH, USAOne-year research or clinical fellowships in Minimally Invasive Surgeryare being offered at the Ohio State University Medical Center starting July1, 2000. Requirements include completion of residence training programsin General or Thoracic Surgery. The clinical fellowship will include ex-tensive clinical exposure to advanced techniques in laparoscopic surgery.The research fellowship will involve both clinical and basic science re-search. The positions offer a competitive salary and travel allowance. In-terested candidates are invited to send a letter of inquiry with a curriculumvitae to:

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W. Scott Melvin, M.D.Assistant Professor of Surgery and DirectorCenter for Minimally Invasive SurgeryRobert E. Michler, M.D.Professor of Surgery and Chief Cardio Thoracic SurgeryThe Ohio State UniversityDepartment of SurgeryN737 Doan Hall

410 West Tenth AvenueColumbus, OH 43210, USA

The Royal Surrey County HospitalMinimal Access Therapy Training UnitCME accredited Laparoscopic Courses 2000Directed by Professor Michael Bailey. The Minimal Access Therapy Train-ing Unit offers a full range of Laparoscopy Courses. All courses includelive demonstrations, interactive presentations and hands-on skills training.Courses on offer include: An Introduction to Laparoscopic Surgery; BasicSurgical Skills; Laparoscopic Cholecystectomy [RCS Certified]; AdvancedLaparoscopic Workshop; Extra Peritoneal Hernia repair; Nissen Fundopli-cation; Upper Gastrointestinal Laparoscopy; Laparoscopic Colorectal Sur-gery; EAES, AESGBI approved.

For further details contact:

Alison Snook MATTUThe Royal Surrey County HospitalEgerton Road, GuildfordSurrey GU2 5XX, UKTel: 00 44 [0] 1483 303053Fax: 00 44 [0] 1483 406636E-mail [email protected] www.mattu.org.uk- online registration.

Carolinas Laparoscopic and Advanced SurgeryProgram (CLASP)A Division of Carolinas Medical CenterCharlotte, NC, USA

Courses offered in 2000Laparoscopic Ventral and Incisional Herniorrhaphy Workshop: Thepurpose of this course is to teach laparoscopic techniques for ventral herniarepair, discuss the different prosthetic materials, their application, and as-sociated healing process, and describing the techniques for minimally in-vasive access in the multiply operated abdomen. Dates offered: April 7,June 9, and September 22, 2000. Course consists of 1 2 -day didactic and1 2 -day hands-on workshops. Course fee: $250.00.

Laparoscopic Solid Organ-Adrenal, Spleen, and Liver Workshop: Thepurpose of this course is to identify the appropriate work-up for adrenalpathology and determine those that require resection, as well as the tech-niques of laparoscopic adrenalectomy. One should be able to determine theappropriate pathology that necessitates splenectomy, and describe tech-niques of laparoscopic splenectomy. Additionally, there will be a detaileddescription of laparoscopic cryoablation of hepatic metastasis. Course con-

sists of 1 2 -day didactic and 1 2 -day hands-on workshops. Course fee:$450.00; workshop date: May 5, 2000.

Hand Assisted Laparoscopic Surgery for General and Colorectal Sur-geons: The purpose of this course is to discuss the use and indications forlaparoscopic hand-assisted surgery in regard to splenectomy, morbid obe-sity surgery, and colon resection. Surgeons will perform splenectomies,nephrectomies, and a bowel resection during the laboratory session. Coursedate: September 23, 2000.

Fundamentals in Critical Care: Course date: April 21, 2000.

Course Directors: B. Todd Heniford, M.D.Chief of Minimal Access SurgeryCodirectorCarolinas Laparoscopic and Advanced Surgery ProgramCarolinas Medical Center

Frederick L. Greene, M.D.Chairman, Department of General SurgeryCodirectorCarolinas Laparoscopic and Advanced Surgery ProgramCarolinas Medical Center

For further information please contact:Judy QuesenberryProgram Service Coordinator704-355-4823

European Course on Laparoscopic Surgeryunder the auspices of E.A.E.S.

April 47, 2000

November 2124, 2000University Hospital Saint-Pierre (U.L.B.)Brussels, BelgiumCourse Director: G. B. Cadiere, M.D.Universit Libre de Bruxelles (U.L.B.)Department of G.I. SurgeryUniversity Hospital Saint-Pierre

Live demonstrations. Interactive dialogue with the operating surgeons;Video forum: videotaped discussions, technical details, pitfalls: Topics:Functional gastric surgery (Nissen-Toupet-Gastroplasty); Colon (colec-tomy-rectopexy); Hernia (trans-/pre-peritoneal approach, balloon); Retro-peritoneoscopy; Splenectomy; Needle surgery; Biliary surgery; New tech-nologies.

Surgeons: J. Bruyns, G. B. Cadiere, J. Himpens, J. Leroy, M. Vertruyen

Official languages: EnglishFrench.Internet site: http://www.LAP-SURGERY.com

For any further information:

Scientific InformationC.H.U. Saint-PierreService de Chirurgie DigestiveRue Haute 322B-1000 Bruxelles, BelgiumTel: 322 535 41 15Fax: 322 535 31 66E-mail: [email protected]

or

Administrative SecretariatConference Services S.A.Avenue de lObservatoire 3, bte 17B-1180 Bruxelles, BelgiumTel: 322 375 16 48Fax: 322 375 32 99E-mail: [email protected]

III International Czech-Polish-SlovakSymposium on Videosurgery

September 2021, 2001Trinec, Czech Republic

The main memory of the traditional surgery (competition miniinvasive vstraditional surgery in the Year 2001).

Stanislav Czudek, M.D., Ph.D.

Center for Miniinvasive SurgeryHospital Podles73961 Tr inecCzech Republic

1st World Congress of Pediatric ThoracicDisciplines

April 2022, 2000Izmir, TurkeyURL: http://www.med.ege.edu.tr/pedsurg/congress.htm

Contact:

Prof. Dr. Oktay Mutaf Department of Pediatric SurgeryEge University Faculty of MedicineBornova 35100 Izmir, TurkeyFax: +90 232 375 12 88E-mail: [email protected]

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Pain after microlaparoscopic cholecystectomy

A randomized double-blind controlled study

T. Bisgaard, B. Klarskov, R. Trap, H. Kehlet, J. Rosenberg

Department of Surgical Gastroenterology 435, University of Copenhagen, Hvidovre Hospital, DK-2650, Hvidovre, Denmark

Received: 12 July 1999/Accepted: 21 October 1999

Abstract Background: Laparoscopic cholecystectomy (LC) is tradi-tionally performed with two 10-mm and two 5-mm trocars.The effect of smaller port incisions on pain has not beenestablished in controlled studies. Methods: In a double-blind controlled study, patients wererandomized to LC or cholecystectomy with three 2-mm tro-cars and one 10-mm trocar (micro-LC). All patients re-ceived a multimodal analgesic regimen, including incisionallocal anesthetics at the beginning of surgery, NSAID, andparacetamol. Pain was registered preoperatively, for the first

3 h postoperatively, and daily for the 1st week. Results: The study was discontinued after inclusion of 26patients because five of the 13 patients (38%) randomized tomicro-LC were converted to LC. In the remaining 21 pa-tients, overall pain and incisional pain intensity during thefirst 3 h postoperatively increased in the LC group ( n 13)compared with preoperative pain levels ( p < 0.01), whereaspain did not increase in the micro-LC group ( n 8).Conclusions: Micro-LC in combination with a prophylacticmultimodal analgesic regimen reduced postoperative painfor the first 3 h postoperatively. However, the micro-LC ledto an unacceptable rate of conversion to LC (38%). Themicro-LC instruments therefore need further technical de-

velopment before this surgical technique can be used on aroutine basis for laparoscopic cholecystectomy.

Key words: Gallbladder Microlaparoscopic cholecystec-tomy Pain Randomized controlled trial

Laparoscopic cholecystectomy (LC) is traditionally per-formed with two 10-mm and two 5-mm trocars [4], but mostpatients still suffer from early incisional pain [1, 11]. Someauthors have therefore suggested that port incisions should

be reduced even further [6]. In some recent uncontrolledseries, laparoscopic cholecystectomy was performed withthree 2-mm [5, 10] or 3-mm trocars [3, 8, 9], assisted by one10-mm trocar for gallbladder retraction. Compared withearlier reports of patients undergoing LC, postoperative an-algesic requirements were reduced by 70% when 2-mm in-struments were used [5].

However, the effect of 2-mm or 3-mm port incisions(micro-LC) on pain after laparoscopic cholecystectomy hasnot been established in controlled studies. We therefore de-cided to investigate the effect of 2-mm micro-LC on post-

operative pain in a randomized double-blind controlledstudy.

Patients and methods

Patients

We originally planned to randomize 50 patients. The study started October1998 and was discontinued in January 1999. The criteria for exclusion wereASA physical status III or IV, estimated abdominal wall layer of >10 cm,and patients having papillotomy by endocopic retrograde cholangiopan-creatography within 1 month before operation. Moreover, patients wereexcluded if they had chronic pain diseases other than gallstone disease, if they received opioids or tranquilizers (treatment for >1 week up to thecholecystectomy), or if they had a history of alcohol or drug abuse. Patientswere also excluded if the operation was converted from micro-LC to LC orto an open operation, or from LC to an open operation.

Surgical technique

The same two experienced surgeons carried out all operations. The micro-LC learning curve [13] was overcome prior to the beginning of the study.In both surgical groups, laparoscopic cholecystectomy was performed bythe standard French technique with identical placement of trocars [4].

The micro-LC was conducted as follows: Pneumoperitoneum was es-tablished with a Veress cannula. A nondisposable 10-mm trocar with apyramidal tip was inserted (Karl Storz Endoscope system) above the um-bilicus. Three 2-mm MiniSite disposable introducers and trocars (UnitedStates Surgical Corporation, Norwalk, CT, USA), a 2-mm laparoscope(USSC), a 10-mm laparoscope (Olympus), two grasping instruments(MiniSite Endo Grasp, Single Action 2-mm; USSC), an electro-scissorCorrespondence to: T. Bisgaard

Surg Endosc (2000) 14: 340344DOI: 10.1007/s004640020014

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(MiniSite MiniShears 2-mm; USSC), and a 10-mm endoscopic rotatingmultiple clip applier (10-mm ER320; Ethicon ERCA) was used for theoperation.

Dissection was performed via the upper left epigastric port visualizedby the 10-mm laparoscope through the supraumbilical port, as in theFrench technique. The 10-mm clip applier was inserted via the supraum-bilical 10-mm port to secure the cystic duct and artery. Thus, it was nec-essary to shift the camera to the 2-mm laparoscope during clipping andretraction of the gallbladder. The gallbladder was retracted via the supra-

umbilical port. Micro-LC was converted to LC in case of lack of progressin the operation, technical problems, or if safety was compromised.LC was performed using two 10-mm and two 5-mm trocars with py-

ramidal tips (Karl Storz Endoscope system). If necessary, a lateral umbili-cal fascial incision (0.51 cm) was made in patients of both surgical groupsto ease retraction of the gallbladder. Intraoperative cholangiography wasnot performed. All patients received gentamicin (160 mg) at the beginningof surgery. During laparoscopy, intraabdominal pressure was maintained at12 mmHg. The CO 2 was carefully evacuated at the end of surgery bymanual compression of the abdomen with open trocars. In both surgicalgroups, only the fascia and the skin of the 10-mm supra-umbilical incisionwas sutured. The 5-mm and 2-mm incisions were closed at the skin levelwith sterilized strips.

Anesthesia and analgesiaThe same general anesthetic technique was followed in all cases. No pre-medication was used. General anesthesia was induced with intravenousfentanyl (0.003 mg/kg) and propofol (2.02.5 mg/kg). Orotracheal intuba-tion was facilitated by cisatracurium (0.15 mg/kg). Anesthesia was main-tained with oxygen in air (1:2), propofol (10 mg/kg/h), and supplementaldoses of alfentanil (0.51.0 mg) if required, given at the discretion of theanesthesiologist. Minute ventilation was adjusted to keep end-tidal PCO 2 at4.55.5 kPa.

For analgesia, both surgical groups received incisional local anestheticsin all port sites using a total of 140 mg of bupivacaine (0.5% bupivacaine10 ml in the supraumbilical incision and 6 ml in the other three incisions).The infiltration technique has been described in detail elsewhere [1]. Fur-thermore, all patients had intravenous ketorolac (30 mg) 20 min beforethe end of surgery.

In the recovery room, immediately after surgery, a single dose of 2 gparacetamol was given as suppositories. At 3 h after surgery, all patientscommenced oral treatment with ibuprofen (600 mg at 8-h intervals for 4days). If patients requested supplementary analgesic treatment, opioidswere administered (5 mg intravenously in the recovery room, 30 mg orallyor 510 mg IV in the ward).

Pain assessment

Before the operation, patients were instructed to use a 100-mm visualanalogue scale (VAS) (VAS: end points labelled no pain and worstpossible pain) and a verbal rating scale (VRS) (VRS: no pain 0, lightpain 1, moderate pain 2, severe pain 3). Overall pain and inci-sional pain was registered the morning before the operation and hourly forthe first 3 h postoperatively using VAS and VRS at rest (supine) and duringmobilization (supine to sitting). Incisional pain was defined as a superficialpain, wound pain, or pain located in the abdominal wall [1]. During thesame period, morphine requirements were recorded.

In addition, patients registered overall pain and incisional pain in astructured diary from the day before operation and daily throughout the 1stweek at 8 P.M. as average VAS pain during the preceding 24 hs. Averageincisional pain was rated by VRS. Information sheets, contact telephonenumbers, and structured pain questionnaires for the daily pain diary weregiven to all patients on discharge.

Randomization and blinding

The surgeon randomized patients to micro-LC or LC by the envelopemethod after anesthesia was induced and did not attend to the patient or thetwo observers who recorded pain at any time after the operation. Thestarting time of the operation was blinded to the two observers. At the endof the operation, the incisions were blinded with waterproof standard dress-

ings (5 5 cm, DuoDerm, Mini, ConvaTec). Prior to the operation, thepatients were instructed to keep the dressings for the 1st postoperativeweek.

Statistics and ethics

Data from 100 consecutive patients who underwent uncomplicated lapa-

roscopic cholecystectomy in our department have shown that 50% hadmoderate or severe incisional pain for the first 2 postoperative days [un-published data]. We decided that a clinically relevant treatment shouldreduce the incidence of severe or moderate overall pain from 50% to 10%(Minimal Relevant Difference, MIREDIF 40%). With a type I error of 0.05 and a type II error of 0.20, the necessary sample size would be 40patients (20 patients in each group). We chose to study a minimum of 50patients.

For comparison between groups, repeated comparisons at different timepoints were avoided by adding together the pain scores (total pain scores,TPS). Median differences between groups and 95% confidence limits of median differences, as well as the Friedman, Mann-Whitney U, and Fish-ers exact tests were used when appropriate. All values are presented asmedian (range) and percentages when appropriate.

The local ethics committee approved the study, and all patients gavetheir written informed consent to participate in the study.

Results

This study was discontinued after the inclusion of 26 pa-tients (13 patients in each group) because we became con-vinced that the 2-mm micro-LC conversion rate was unac-ceptable: Five of 13 patients (38%) in the micro-LC groupwere converted to LC. All five patients had gross anatomicsigns of chronic cholecystitis and/or dense adhesions in thegallbladder region, whereas only one patient among the re-maining eight patients who underwent successful micro-LChad chronic cholecystitis/dense adhesions ( p 0.0093)

(Table 1).All patients in both study groups were preoperativelyregarded as simple elective cases suitable for laparoscopy.Intention-to-treat analysis showed that the micro-LC grouphad longer operations (Table 1). Furthermore, only the pa-tients in the micro-LC group needed suspension sutures an-chored in the gallbladder to facilitate dissection [2] (Table1), since it was often difficult to grasp the gallbladder withthe very tiny 2-mm instruments.

Micro-LC in combination with a prophylactic multimo-dal analgesic regimen eliminated postoperative pain duringthe first 3 h postoperatively (nonsignificant Friedman test).In contrast, the LC group experienced a significant increase

in pain intensity compared with preoperative values, asshown by a statistically significant Friedman test (Fig. 1a, band Table 2). Comparison between groups showed that themicro-LC group experienced significantly less overall painduring mobilization (as measured by VRS) and significantlyless incisional pain at rest and during mobilization (as mea-sured by VRS) (Table 2). However, statistical comparisonsof VAS pain registrations did not reach statistical signifi-cance (Table 2). Nevertheless, comparison between groups(median differences and 95% confidence intervals of me-dian differences) showed a tendency toward a decrease inpain intensity in the micro-LC group compared with the LCgroup in the first 3 h postoperatively (Table 2).

One patient in the LC group did not receive alfentanilduring anesthetic maintenance (Table 1). This patient re-ceived no more or no less fentanyl than the other patients

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and had no pain in the first 3 h after the operation (TPS 0). One patient in the micro-LC group, as compared withtwo patients in the LC group, required morphine for post-operative analgesia (5 mg and 10 mg, respectively) ( p 1).During the 1st week, there was no difference in TPS be-tween the groups (Fig. 1c and Table 2).

Discussion

Although it was terminated prematurely, our study basicallyshowed that the use of micro-LC reduced pain during thefirst 3 h postop, whereas the LC group had significant post-operative pain in spite of prophylactic multimodal analgesictreatment.

The study was discontinued halfway through becausewe became convinced that 2-mm micro-LC was technicallyinferior to LC because of an unacceptable conversion rate(micro-LC to LC) of 38%. Gross anatomic findings of

chronic cholecystitis/dense adhesions indicated conversionof micro-LC to LC because of problems with grasping anddissection, bending of the thin instruments, and a narrowvision angle with the 2-mm laparoscope. Thus, the area of contact between the jaws of the 2-mm grasping instrumentand the tissue was too small to achieve adequate tractionand manipulation in case of dense adhesions. However, withnormal anatomy, it was quite easy to perform a successfullaparoscopic cholecystectomy using these instruments.Therefore, further improvement of the surgical equipmentfor the 2-mm technique is required before its routine use forlaparoscopic cholecystectomy. These improvements shouldinclude the development of stronger instruments for dissec-

tion in dense tissue; better grasping ability, probably with atraumatic grip; and the development of a 2-mm laparoscope,which can provide a larger and better picture.

We mainly used a 10-mm laparoscope for micro-LC.Micro-LC operations prior to commencement of the studyconvinced us that the 2-mm laparoscope during dissectionprovided inadequate picture quality for use during the entireoperation. Unfortunately, none of the micro-LC series in theliterature have provided sufficient information on perioper-

ative gross anatomic findings and thus possible difficulty of the operation. Earlier studies have used the periumbilical10-mm port for dissection of the gallbladder, and for clip-ping and division of the structures with standard LC instru-ments [9, 12, 13]. These studies comprised a total of 84patients, and the conversion rate (micro-LC to LC) rangedfrom zero to 24%. Durations of operation were comparableto those of our 2-mm micro-LC operations.

In one prospective study of 60 elective selected patients,Gagner and Garcia-Ruz [5] performed 2-mm micro-LC us-ing a technique similar to the one in our study. The opera-tions lasted a median of 98 min (range, 40150), but only5% were converted to LC. However, very few perioperative

details were provided. Davides et al. [3] recently reported aseries of 25 selected elective patients who underwent suc-cessful micro-LC using three 3-mm and one 10-mm trocar.The median operation time was somewhat shorter (75 min;range, 45180), and there were no conversions to LC. As inour study, the micro-laparoscope was only used for the ap-plication of clips and retraction of the gallbladder from theabdomen.

In the present study, which was closed prematurely,only a limited number of patients were available for dataanalysis. However, overall pain and incisional pain intensitywere eliminated in the micro-LC group during the first 3 hpostop, as opposed to patients undergoing LC. Furthermore,

median differences and their confidence limits of painscores during the first 3 h postop indicated that the smallerincisions were associated with less early pain after laparo-

Table 1. Clinical, operative, and general anesthetic data for 26 patients randomized to either micro-laparoscopic cholecystectomy (micro-LC) or traditional laparoscopic cholecystectomy (LC)

micro-LC(n 13)

LC(n 13) p

Clinical datasex ratio (M:F) 3:10 9:4 0.047age (yr) 46 (2571) 53 (2468) 0.857

body mass index (kg/m2

) 25 (1832) 26 (2333) 0.573ASA physical class (I:II) 10:3 10:3 1

Operative dataduration of surgery (min) 85 (45155) 55 (30180) 0.016gallbladder suspension suture (no. of patients) 5 0 0.039gross anatomic findings:

chronic cholecystitis/dense adhesions(no. of patients) 6 (5 converted to LC) 8 0.695

normal anatomic findings(no. of patients) 7 (0 converted to LC) 5 0.695

fascial incision for gallbladder retraction(no. of patients) 9 11 1

General anesthesiafentanyl (mg) 0.3 (0.20.4) 0.2 (0.20.5) 0.511

propofol (mg) 1240 (10202490) 1120 (4582,175) 0.045cisatracurium (mg) 11.0 (7.515.0) 10.0 (7.014.0) 0.360alfentanil (mg) 2.0 (0.55.0) 1.5 (04.0) 0.264

Values given as median (range)

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scopic. Some of the tests of pain scores between the groupsdid not reach statistical significance ( p < 0.05). However,the finding of median differences and confidence limits thatindicated a tendency toward a reduction in pain with smallerinstruments may simply reflect a type II error, due to theinclusion of too few patients in the study.

Generally, pain is most intense the first 4 h followingtraditional laparoscopic cholecystectomy [1, 7]. Therefore,treatment that provides analgesia for even a short duration is

clinically important. In the present study, both incisionalpain and overall pain were reduced, which suggests thatincisional pain is a significant component of overall pain

after laparoscopic cholecystectomy. These findings are inaccordance with those of a previous study of patients whohad traditional laparoscopic cholecystectomy using anesthe-sia and analgesia similar to the present study [1]. In thisstudy, incisional pain dominated over other pain localiza-tions [1] throughout the 1st postoperative week. The effecton pain of reducing port incisions has only been evaluatedin one randomized controlled study that replaced one epi-gastric 10-mm port with a 5-mm port [6], but there was no

effect on pain intensity.We conclude that 2-mm micro-LC in combination witha prophylactic multimodal analgesic regimen eliminated

Fig. 1. The effects of microlaparoscopic cholecystectomy (micro-LC) compared with conventional laparoscopic cholecystectomy (LC) on overall pain ( a)

and incisional pain ( b ) at rest and during mobilization using visual analogue scale (VAS) preoperatively and at 1, 2, and 3 h after operation. Average dailyoverall pain (VAS) during the 1st week is shown in ( c). Values are median. For p values, see Table 2.

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early postoperative pain for the first 3 h but carried anunacceptable conversion rate to LC. Thus, the micro-LC(2-mm) instruments need further development before theycan be recommended for routine use.

Acknowledgments. This work was supported by grants from the Universityof Copenhagen and the Danish Medical Research Council (journal no.9601607) and the King Christian X Foundation.

References

1. Bisgaard T, Klarskov B, Kristiansen VB, Callesen T, Schulze S,Kehlet H, Rosenberg J (1999) Multi-regional local anesthetic infiltra-tion during laparoscopic cholecystectomy in patients receiving pro-phylactic multi-modal analgesia: a randomized, double-blind, placebo-controlled study. Anesth Analg 89: 10171024

2. Bresadola F, Pasqualucci A, Donini A, Chiarandini P, Anania G, Ter-rosu G, Sistu MA, Pasetto A (1999) Elective transumbilical comparedwith standard laparoscopic cholecystectomy. Eur J Surg 165: 2934

3. Davides D, Dexter SP, Vezakis A, Larvin M, Moran P, McMahon MJ(1999) Micropuncture laparoscopic cholecystectomy. Surg Endosc 13:236238

4. Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic chole-cystectomy: preliminary report of 36 cases. Ann Surg 211: 6062

5. Gagner M, Garcia-Ruiz A (1998) Technical aspects of minimally in-vasive abdominal surgery performed with needlescopic instruments.Surg Laparosc Endosc 8: 171179

6. Golder M, Rhodes M (1998) Prospective randomized trial of 5- and10-mm epigastric ports in laparoscopic cholecystectomy. Br J Surg 85:10661067

7. Joris J, Thiry E, Paris P, Weerts J, Lamy M (1995) Pain after laparo-scopic cholecystectomy: characteristics and effect of intraperitonealbupivacaine. Anesth Analg 81: 379384

8. Kimura T, Sakuramachi S, Yoshida M, Kobayashi T, Takeuchi Y(1998) Laparoscopic cholecystectomy using fine-caliber instruments.Surg Endosc 12: 283286

9. Reardon PR, Kamelgard JI, Applebaum B, Rossman L, Brunicardi FC(1999) Feasibility of laparoscopic cholecystectomy with miniaturizedinstrumentation in 50 consecutive cases. World J Surg 23: 128131

10. Tanaka J, Andoh H, Koyama K (1998) Minimally invasive needle-scopic cholecystectomy. Surg Today 28: 111113

11. Ure BM, Troidl H, Spangenberger W, Dietrich A, Lefering R, Neu-gebauer E (1994) Pain after laparoscopic cholecystectomy: intensityand localization of pain and analysis of predictors in preoperativesymptoms and intraoperative events. Surg Endosc 8: 9096

12. Watanabe Y, Sato M, Ueda S, Abe Y, Horiuchi A, Doi T, Kawachi K(1998) Microlaparoscopic cholecystectomythe first 20 cases: is it analternative to conventional LC? Eur J Surg 164: 623625

13. Yuan RH, Lee WJ, Yu SC (1997) Mini-laparoscopic cholecystectomy:a cosmetically better, almost scarless procedure. J Laparoendosc AdvSurg Tech 7: 205211

Table 2. Overall pain and incisional pain scores

Pain variation over time(Friedman test), p-values a

Comparison of TPS (between groups)

micro-LC(n 8)

LC(n 13)

Median difference(95% CI) pb

03 h overall painVAS at rest 0.199 0.003 17 (80 to 25) 0.215VAS during mobilization 0.345 0.001 23 (69 to 10) 0.109VRS at rest 0.172 0.001 1 (4 to 1) 0.183VRS during mobilization 0.295


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Laparoscopic cholecystectomy in acute cholecystitis

A prospective comparative study in patients with acute vs chronic cholecystitis

P. Pessaux, J. J. Tuech, C. Rouge, R. Duplessis, C. Cervi, J. P. Arnaud

Department of Visceral Surgery, 4 rue Larrey, Angers 49100, France

Received: 13 May 1999/Accepted: 7 October 1999

Abstract Background: The aim of this prospective study was to com-pare the outcome of laparoscopic cholecystectomy (LC) inpatients with acute cholecystitis versus those with chroniccholecystitis and to determine the optimal timing for LC inpatients with acute cholecystitis. Methods: From January 1991 to July 1998, 796 patients(542 women and 254 men) underwent LC. In 132 patients(67 women and 65 men), acute cholecystitis was confirmedvia histopathological examination. These patients were di-vided into two groups. Group 1 ( n 85) had an LC prior

to 3 days after the onset of the symptoms of acute chole-cystitis, and group 2 ( n 47) had an LC after 3 days. Results: There were no mortalities. The conversion rateswere 38.6% in acute cholecystitis and 9.6% in chronic cho-lecystitis ( p < 10 8 ). Length of surgery (150.3 min vs 107.8min; p < 10 9 ), postoperative morbidity (15% vs 6.6%; p 0.001), and postoperative length of stay (7.9 days vs 5 days; p < 10 9 ) were significantly different between LC for acutecholecystitis and elective LC. For acute cholecystitis, wefound a statistical difference between the successful groupand the conversion group in terms of length of surgery andpostoperative stay. The conversion rates in patients operatedon before and after 3 days following the onset of symptoms

were 27% and 59.5%, respectively ( p

0.0002). Therewas no statistical difference between early and delayed sur-gery in terms of operative time and postoperative compli-cations. However, total hospital stay was significantlyshorter for group 1.Conclusions: LC for acute cholecystitis is a safe procedurewith a shorter postoperative stay, lower morbidity, and lessmortality than open surgery. LC should be carried out assoon as the diagnosis of acute cholecystitis is establishedand preferably before 3 days following the onset of symp-toms. Early laparoscopic cholecystectomy can reduce boththe conversion rate and the total hospital stay as medical andeconomic benefits.

Key words: Acute cholecystitis Gallbladder Laparo-scopic cholecystectomy Optimal timing

Since its introduction in 1987, laparoscopic cholecystecto-my (LC) has increasingly been accepted as the procedure of choice for the treatment of symptomatic gallstones andchronic cholecystitis [22]. A successful LC is associatedwith a less painful postoperative course, a lower analgesicrequirement, a shorter hospital stay, and less cosmetic dis-figurement [15, 25]. Acute cholecystitis, which is generallyfound in 20% of all admissions for gallbladder disease[24], is no longer considered a contraindication for LC [4,22]. However, the role and timing of LC in the managementof acute cholecystitis remains controversial. In the prelapa-roscopic era, prospective randomized studies [11, 18] dem-onstrated that the outcome for patients undergoing earlyopen cholecystectomy within 7 days of the onset of symp-toms was superior to delayed interval surgery.

The aim of this prospective study was to compare thelaparoscopic treatment of patients with acute cholecystitis tothose with chronic cholecystitis. Our assessment of the re-sults of attempted LC for acute cholecystitis paid particularattention to the interval from the onset of symptoms to thetime of operation.


Patients

From January 1991 to July 1998, a total of 796 patients underwent lapa-roscopic cholecystectomy (LC). During that period, 132 patients (16.6%)had acute cholecystitis (68 phlegmonous and 64 gangrenous). They wereadmitted on an emergency basis with a diagnosis of acute cholecystitisbased on the following symptoms: (a) acute upper abdominal pain withtenderness under the right costal margin, (b) fever >37.8C and/or leuko-cytosis >10 10 9 /L (normal,


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pericholecystic fluid collection) [7, 19]. Histopathological examination of the excised gallbladder confirmed the presence of acute inflammation(Table I). All preoperative, intraoperative, and postoperative data werecollected on standardized forms. We then analyzed the ultrasound findings,time of operation from the onset of symptoms, length of surgery, histologicgallbladder features, conversion rate to open laparotomy, postoperativemortality and morbidity, postoperative length of stay, and rate of earlyreintervention.

The patients with acute cholecystitis were divided into two groups.Group 1 consisted of those who had an LC prior to 3 days after the onsetof symptoms of acute cholecystitis; group 2 consisted of those who had anLC after 3 days following the onset of symptoms.

Statistical analysis

Statistical analysis was performed by the chi-square test, exact Fisherstest, or students t -test, as appropriate. Statistical significance was set at p< 0.05.

Results

Elective LC vs LC for acute cholecystitis

The patient population was comprised of 542 women and

254 men with a mean age of 54.5 years (range, 1495). Inour series of patients with acute cholecystitis, there were 67women and 65 men with a mean age of 58.7 years (range,1490). The average age of these patients was significantlydifferent from that of the 664 patients (475 women and 189men) who underwent elective cholecystectomy (mean age,52.7 years; p < 0.001; range, 1995). Fifty-one patients(38.6%) with acute cholecystitis and 64 (9.6%) who hadelective LC were converted to open surgery ( p < 10 8 ) (Ta-ble 2).

The length of the surgery (150.3 vs 107.8 min), postop-erative length of stay (7.9 vs 5 days), and morbidity (15% vs6.6%) were significantly different between acute cholecys-titis and elective LC. There were no mortalities in eithergroup (Table 3). The most common reason for conversion inpatients with acute cholecystitis ( n 30) was an inability tocomplete the procedure due to difficulties with exposureand dissection associated with the inflammatory reaction.The most common reason for conversion in patients withelective LC was adhesions ( n 29). The other indicationsfor conversion to an open procedure are summarized inTable 4.

Acute cholecystitis

The average length of the operative procedures was 141 min(range, 65380) for 81 patients who underwent successfulLC and 170 min (range, 45350) for 51 patients in whom

the procedure was converted to an open laparotomy. Theaverage length of postoperative hospital stay for those whounderwent successful LC was 6.1 days (range, 230). Forpatients in whom the procedure was converted to an openoperation, the average length of stay was 10.5 days (range,327). There was no statistical difference between the suc-cessful and the conversion groups in terms of morbidity

(Table 5). When conversion to laparotomy in patients withacute cholecystitis was required, 11 of 51 patients (21.5%)developed postoperative complications, as compared to nineof 81 (11.1%) who had a successful LC. In particular, chestinfections developed more frequently after conversion toopen cholecystectomy (Table 6).

Timing of surgery in acute cholecystitis

In 85 (64.4%) of 132 patients, the LC was performed priorto 3 days after the onset of symptoms (group 1), whereas 47(35.6%) underwent the operation after 3 days (group 2).There were 23 patients (27%) in whom the surgical proce-dures was converted to an open operation in group 1 and 28(59.5%) in group 2 (p 0.002). There was no statisticaldifference between early and delayed surgery in terms of operative time and postoperative complications. However,the total hospital stay was significantly shorter in group 1(Table 7). Six patients (12.7%) in the delayed group eitherfailed conservative treatment or developed a recurrent at-tack of acute cholecystitis, requiring emergency LC.

Discussion

Laparoscopic cholecystectomy is the treatment of choice formost patients with symptomatic cholelithiasis. Initially,acute cholecystitis was a contraindication for this procedure[4, 22]. The laparoscopic management of acute cholecystitisis a logical progression from elective LC.

LC patients with acute cholecystitis have significantlyhigher rates of conversion to open cholecystectomy, longeroperating times, longer hospital stays, and an increasedmorbidity rate compared with elective LC. The conversionrate reported in the literature varies from 7 to 60% [8, 10,20, 22]. The total conversion rate in our series was high(38.6%). Our study was performed over a long period, and

the existence of a learning curve was clearly demonstratedby the fact that the conversion rate decreased from 80% to 20% from the beginning to the end of the study (Table 2).

An inability to define the anatomy of the cystic duct dueto inflammation was the most common reason for conver-sion in all reported series (58.8% in our series). Conversionmay be required if the operation progresses poorly, if thereare pathologic conditions best dealt with by open surgery, orif complications arise. Conversion to an open procedureafter an adequate attempt by an experienced laparoscopicsurgeon should not be regarded as a complication or anoperative failure but as a means of preventing complica-tions. Our complication rate of 15% compares favorably to

the 17.439.9% morbidity rate reported for traditional opencholecystectomy in patients with acute cholecystitis [2, 13,21]. There were no mortalities. In cases where the operation

Table 1. Details of patients with acute cholecystitis ( n 132)

Symptom or finding n %

Upper abdominal pain 116 87.8Right upper quadrant tenderness 108 81.8Leukocytosis >10 10 9 /L 91 68.9Fever (>37.8C) 65 49.2Ultrasonographic evidence 118 89.4

Histopathology 132 100

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was performed successfully, the patients enjoyed a shortersurgical time and a briefer postoperative hospital stay (6.1vs 10.5 days; p < 10 7 ).

Many modifications in the surgical technique have beendescribed, including the use of additional cannulas, moreversatile angled or side-viewing laparoscopes, sterile speci-men bags to retrieve lost stones or extract infected tissue,decompression of the gallbladder, routine intraoperativecholangiography, and liberal use of sutures to control the

cystic duct and artery [26]. Most of them were developed inan attempt to facilitate exposure of the biliary anatomy anddiminish the incidence of gallstone or bile spillage.

The results of earlier studies aimed at defining preop-erative factors that would predict conversion to open cho-lecystectomy have been contradictory. Lo et al. [16] foundthat the only factors predictive of conversion were advancedpatient age, larger gallstones in the gallbladder, and severeadhesions. Although several authors claimed that male sexdoes not affect conversion rate [6, 16, 23], others found apositive correlation [1,9]. Other authors reported that sever-ity of the inflammation was an important prognostic factorfor a successful laparoscopic approach in acute cholecystitis[1, 3, 10] and that the intraoperative finding of empyema of gallbladder or gangrenous cholecystitis increased the odds

for conversion.Perhaps the most important predictor of the success of attempted LC in patients with acute cholecystitis was thetiming of surgery. Previous reports [11, 18] on patients un-dergoing conventional open cholecystectomies suggestedthat cholecystectomy should be performed early in thecourse of the disease, preferably in the first 72 h after theonset of symptoms. Is there an optimal timing for the per-formance of laparoscopic cholecystectomy? The conversionrates in patients operated on before and after 3 days after theonset of symptoms were 27% and 59.5%, respectively, andwere significantly different ( p 0.0002). Other laparo-scopic studies [12, 15, 20] have also found that patients with

prolonged preoperative illnesses had higher conversionrates. The most common reason for conversion was theseverity of inflammation, along with the existence of severe

Table 2. Conversion rate during the study in laparoscopic cholecystectomy for acute cholecystitis

1991 1992 1993 1994 1995 1996 1997 1998

LC for acute cholecystitis 4 7 11 19 21 27 29 14Conversions ( n) 3 6 7 8 8 9 7 3Conversion rate (%) 75 85 63.6 42.1 38.1 33.3 24.1 21.4

Table 3. Results for patients undergoing elective LC and patients withacute cholecystitis

Elective LC(n 664)

Acutecholecystitis(n 132) p

Mean age (yr) 52.7 58.7


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adhesions. In the early phase of acute inflammation, adhe-sions are easily separated, and there is usually an edematousplane around the gallbladder that facilitates dissection. Aftera period of conservative treatment, the inflammation andedema are replaced by fibrotic adhesions between the gall-bladder and surrounding structures, which occasionally ren-der laparoscopic dissection extremely difficult.

Postoperative complications were similar in bothgroups. The absence of major complications, such as bileduct injury, suggests that LC can be performed safely inboth early or delayed settings. The major advantage of earlyLC is the reduction of the total hospital stay. One of its mainbenefits is the potential for an earlier return to work; how-ever, the relative recuperation periods were not compared inthis study.

Early LC offers a definitive treatment during the sameadmission and avoids the problems associated with failedconservative management (12.7% in our series). Two recentprospective randomized studies [14, 17] showed that initialconservative treatment followed by delayed interval surgery

cannot reduce the morbidity and conversion rates of lapa-roscopic cholecystectomy for acute cholecystitis. But earlyoperation before 3 days of admission yields both medicaland socioeconomic benefits, in terms of a briefer hospitalstay and an accelerated recuperation period.

In summary, laparoscopic intervention appears to be asafe and beneficial option in the management of selectedpatients with acute cholecystitis. Higher rates of conversionand morbidity were observed, as compared with those forelective laparoscopic cholecystectomy. The complicationrate compares favorably with that of open cholecystectomy.Laparoscopic cholecystectomy should be carried out soonas the diagnosis of acute cholecystitis is established and

preferably within 3 days after the onset of symptoms. Earlylaparoscopic cholecystectomy allows a reduction in both theconversion rate and the total hospital stay as significantmedical and economic benefits.

References

1. Bickel A, Rappaport A, Kanievski V, Vaksman I, Haj M, Geron N,Eitan A (1996) Laparoscopic management of acute cholecystitis: prog-nostic factors for success. Surg Endosc 10: 10451049

2. Cox MR, Gunn IF Eastman MC, et al. (1992) Open cholecystectomy:a control group for comparison with laparoscopic cholecystectomy.Aust N Z J Surg 62: 795801

3. Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RTA, Tooulis J(1993) Laparoscopic cholecystectomy for acute inflammation of thegallbladder. Ann Surg 218: 630634

4. Cuscheiri A, Berci G, McSherry CK (1990) Laparoscopic cholecys-tectomy [Editorial]. Am J Surg 159: 273

5. El Madani A, Badawy A, Henry C, Nicolet J, Vons Smadja C, Franco

D (1999) Cholecystectomie laparoscopique dans les cholecystitesaigues Chirurgie 124: 171176

6. Fabre JM, Fagot H Domergue J, et al. (1994) Laparoscopic cholecys-tectomy in complicated cholelithiasis. Surg Endosc 8: 11981201

7. Fink Bennett D, Freitas JE, Ripley SD, Bree RL (1985) The sensitivityof hepatobiliary imaging and real-time ultrasonography in the detec-tion of acute cholecystitis. Arch Surg 120: 904906

8. Graves Jr MA, Ballinger WF, Anderson WJ (1991) Appraisal of lap-aroscopic cholecystectomy. Ann Surg 213: 655664

9. Hutchinson CH, Traverso LW, Lee FT (1994) Laparoscopic cholecys-tectomy: do preoperative factors predict the need to convert to open?Surg Endosc 8: 875878

10. Jacobs M, Verdeja JC, Goldstein HS (1991) Laparoscopic cholecys-tectomy in acute cholecystitis. J Laparoendosc Surg 1: 175177

11. Jarvinen HJ, Hastbacka J (1980) Early cholecystectomy for acute cho-lecystitis: a prospective randomized study. Ann Surg 501505

12. Kenny P, Richard C (1996) Laparoscopic cholecystectomy in acutecholecystitis: what is the optimal timing for operation? Arch Surg 131:540545

13. Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E (1998) Randomisedtrial of laparoscopic versus open cholecystectomy for acute and gan-grenous cholecystitis. Lancet 351: 321325

14. Lai PBS, Kwong KH, Leung KL, Kwok SPY, Chan ACW, ChungSCS, Lau WY (1998) Randomized trial of early versus delayed lapa-

roscopic cholecystectomy for acute cholecystitis. Br J Surg 85: 76476715. Lo CM, Liu CL, Lai ECS, Fan ST, Wong J (1996) Early versus

delayed laparoscopic cholecystectomy for treatment of acute chole-cystitis. Ann Surg 223: 3742

16. Lo CM, Fan ST, Liu CL, Lai ECS, Wong J (1997) Early decision forconversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg 173: 513517

17. Lo CM, Liu CL, Fan ST, Lai ECS, Wong J (1998) Prospective ran-domized study of early versus delayed laparoscopic cholecystectomyfor acute cholecystitis. Ann Surg 227: 461467

18. Norrby S, Herlin P, Holmin T, Sjodahl R, Tagesson C (1983) Early ordelayed cholecystectomy in acute cholecystitis? A clinical trial. Br JSurg 70: 163165

19. Ralls PN, Colletti PM, Lapin SA, et al. (1985) Real-time sonographyin suspected acute cholecystitis: prospective evaluation of primary andsecondary signs. Radiology 155: 767771

20. Rattner DW, Ferguson C, Warshaw AL (1993) Factors associated withsuccessful laparoscopic cholecystectomy for acute cholecystitis. AnnSurg 217: 233236

21. Roslyn JJ, Binns GS, Hughes EFX, et al. (1993) Open cholecystecto-my: a contemporary analysis of 42,474 patients. Ann Surg 218: 129137

22. Schirmer BD, Edge BS, Dix J, et al. (1991) Laparoscopic cholecys-tectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg213: 665676

23. Schrenk P, Woisetschlager R, Wayand NU (1995) Laparoscopic cho-lecystectomy: cause in conversion in 1,300 patients and analysis of risk factors. Surg Endosc 9: 2528

24. Sharp KW (1998) Acute cholecystitis. Surg Clin North Am 68: 269279

25. Southern Surgeons Club (1991) A prospective analysis of 1518 lapa-roscopic cholecystectomies. N Engl J Med 334: 10731078

26. Zucker KA, Flowers JL, Bailey RW, Graham SM, Buell J, ImbemboAL (1993) Laparoscopic management of acute cholecystitis. Am JSurg 165: 508514

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Original articles

Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prostheticpatch repair of ventral hernia

Prospective comparison to open prefascial polypropylene mesh repair

E. J. DeMaria, J. M. Moss, H. J. Sugerman

Department of Surgery, Section of General and Endoscopic Surgery, MCV Station Box 980519, Medical College of Virginia of VirginiaCommonwealth University, Richmond, VA 23298, USA

Received: 5 June 1998/Accepted: 15 October 1999

Abstract Background: The purpose of this study was to determinewhether laparoscopic intraperitoneal polytetrafluoroethyl-ene (PTFE) prosthetic patch (LIPP) repair of a ventral her-nia is superior to open prefascial polypropylene mesh(OPPM) repair in a tertiary care university hospital in anurban environment. Methods: Data on 39 consecutive patients undergoing eitherLIPP repair ( n 21) or OPPM repair ( n 18) werecompared. Results: Findings showed that LIPP repair is characterizedby less painful recovery and shorter hospital stay, with 90%of patients treated successfully as outpatients as comparedwith 7% in the OPPM group. The total facility costs for theLIPP repair ($8,273 $2,950) was significantly lower thanfor the OPPM repair ($12,461 $5,987) ( p < 0.05). Twoserious delayed complications in the LIPP group weretreated by reoperation (colocutaneous fistula, mesh infec-tion), but the higher readmission costs in this group did notnegate the overall cost advantage for LIPP repair. In thefollow-up evaluation, 1 hernia recurrence was found in theLIPP repair group, and none in the OPPM group.Conclusions: Initial experience suggests that LIPP repairhas advantages over OPPM repair in terms of decreasedhospitalization, postoperative pain, and disability. Refine-ments in the technique to reduce complications may makeLIPP repair the procedure of choice for repair of ventralhernias.

Key words: Laparoscopic intraperitoneal polytetrafluoro-ethylene Laparoscopic intraperitoneal prosthetic patch

Ventral hernias remain a major cause of morbidity and theneed for reoperation in patients undergoing abdominal sur-gery. Furthermore, subsequent hernia recurrence as well assignificant incisional pain and postoperative disability oftenaccompany ventral hernia repair performed using traditionalsurgical techniques.

Recently, laparoscopic techniques for prosthetic meshrepair of ventral abdominal wall hernias have been de-scribed [5, 6, 8, 10]. Although these preliminary reportssuggest superior results in terms of postoperative disabilityand pain as compared with traditional open techniques forrepair, at this writing, no prospective comparison with tra-ditional repair techniques has been reported. Furthermore,in this era when the economic impact of health care inter-ventions is increasingly scrutinized, it has been shown thatminimally invasive surgical techniques do not necessarilyprovide a cost advantage over traditional surgical tech-niques. Such is the case for laparoscopic cholecystectomyand groin hernia repair, in which decrease in the length of hospitalization has not translated into a decrease in the costfor the procedure. However, in the case of ventral hernia, for

which a significant period of hospitalization is required forrecovery from the traditional surgical procedure, it is con-ceivable that decreasing the postoperative hospitalizationthrough laparoscopic techniques may, in fact, decrease thecost of the procedure.

The current study was undertaken to compare the resultsof laparoscopic ventral hernia repair directly with a tradi-tional open surgical technique in which repair of the herniadefect is reinforced by polypropylene mesh anchored to theanterior abdominal fascia in the prefascial position. Wehave previously used this open technique in a large numberof patients, demonstrating a low recurrence risk in using theprocedure for ventral hernia [11, 12]. The laparoscopic pro-

cedure used was a modification of the technique describedby Park et al. [8], in which the fascial defect was repaired byintraperitoneal placement of a patch of expanded polytetra-Correspondence to: E. J. DeMaria



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fluoroethylene (PTFE) anchored to the fascia by means of acommercially available tacking device (Origin Medsystems,Inc., Menlo Park, CA).


All patients undergoing ventral hernia repair, performed by the authors asthe primary surgical procedure at Medical College of Virginia Hospitalsbetween January 1, 1996 and June 1997, were studied. After a full in-formed consent discussion, the surgeon chose to perform either a tradi-tional open surgical placement of polypropylene mesh (OPPM) as a pre-fascial reinforcement [11, 12] or the laparoscopic intraperitoneal placementof a polytetrafluoroethylene (PTFE) patch (LIPP).

The open surgical procedure was performed in a standard fashion usinga technique previously published by our group and found to have a 1% risk of hernia recurrence during the follow-up period [11, 12]. The laparoscopicrepair was performed using a modification of the technique previouslydescribed by Park et al. [8]. Laparoscopic access to the abdominal cavitywas attained using an open insertion technique away from previous areasof incision followed by insertion of two or three additional 5- or 10-mmtrocars under direct vision. Adhesions were lysed sharply to expose thehernia defect, and no attempt was made to excise the hernia sac. Anappropriate size of 1-mm-thick PTFE mesh (Dualmesh, W. L. Gore andAssociates, Inc., Phoenix, AZ, USA) was chosen to cover the fascial de-fect, with a 2-cm overlap of the fascial edges.

The mesh was placed through a 10-mm trocar after four-quadrant-longsutures of nonabsorbable material were placed in the four quadrants of thematerial to facilitate positioning the patch by passage of a grasping needledevice (Endoclose, United States Surgical, Norwalk, CT, USA) through theabdominal wall in the appropriate positions and pulling the sutures throughto position the patch against the fascia covering the defect. The patch thenwas anchored to the fascia using a commercially available 5-mm tackingdevice (Origin Medsystems).

Data are presented as mean standard error. Data between groups werecompared utilizing students t-test, Fishers exact test, and by the Wilcoxanrank sum test as appropriate. A p value of less than 0.05 was required forstatistical significance.

Results

Baseline preoperative data in the two groups are presentedin Table 1. Patients undergoing LIPP repair did not differfrom those undergoing OPPM in terms of age or gender.Previously, 46% of the patient population had been treatedby proximal gastric bypass surgery to manage morbid obe-sity, and there was no difference between the two groups inthe frequency of previous bariatric surgery. The LIPP grouphad a significantly greater proportion of patients with re-current ventral hernias. Similarly, more patients in the LIPP

group had large hernia defects (>6 8 cm), although thisdifference between the groups did not reach statistical sig-nificance.

Data on the outcome of hernia surgery in the two groupsexamined are presented in Table 2. Despite the increasedfrequency of large hernia defects and more recurrent her-nia

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