EndoScope." world literature reviews Surgical

Endoscopy Snrg Endosc (1996) 10:765-767 © Springer-Verlag New York Inc. 1996

Original articles from a wide range of international surgical journals are selected by our editors and presented here as a structured summary and critical review. EndoScope serves as a quick and comprehensive survey of the expansive endoscopic literature from all the corners of the globe.

Section Editor: J. M. Sackier

Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia

Wilson MS, Deans GT, Brough WA British Journal of Surgery (1995) 82:274-277

Objective: To compare the immediate postoperative results of the Lichtenstein repair to laparoscopic transperitoneal hernia repairs in a prospective manner. Methods: Nonrandomized prospective study whereby pa- tients referred to this surgical unit underwent laparoscopic repair (mostly by a single surgeon, W.A.B.) or Lichtenstein repair by the other surgeons. Each surgeon was experienced in the technique used. An additional group of patients un- dergoing a modified Bassini repair was used as a historical control. Patients were assessed for postoperative pain, hos- pital stay, and return to normal activity. Results: 121 patients had laparoscopic hernia repair, 121 underwent a Lichtenstein repair, and 115 had a modified Bassini repair. The complications included bruising, scrotal hematoma, cord seroma or thickening, numbness or meral- gia, pain, missed lipoma, wound infection, and conversion to open. There have been no recurrences in the short fol- low-up. Conclusion: Both laparoscopic and Lichtenstein repairs are suitable for outpatient surgery. Both are less painful than the Bassini repair. The laparoscopic approach had a shorter re- turn to normal activity and more rapid return to work that was statistically significant. Comments: Unfortunately this is not a randomized study. It

Table 1.

Laparoscopic Lichtenstein Bassini

Length of surgery 35 rain 40 rain Hospital stay 1 day 2 days Visual analog pain

score 3 3 Return to normal

activity 7 days* 14 days Return to work i0 days** 21 days Complications 23 (19%) 36 (29.7%)

35 min 3 days

Values are average. *p < 0.001.

**p < 0.0005.

would also have been informative to collect the complete data on the Bassini repairs. Although in this study there seems to be an advantage for the laparoscopic approach in more rapid return to normal activity and work, it is difficult to understand why this is so since the pain scores for the laparoscopic and Lichtenstein repairs were the same. This study demonstrates that when one looks for complications, one finds them. The complications reported are for the most part minor but do affect patient comfort and convalescence and appropriately are reported. In the United States, all these repairs are performed as outpatient surgery.

Management of Mirizzi syndrome by laparoscopic cholecystectomy and laparoscopic ultrasonography

Meng WCS, Kwok SPY, Kelly SB, Lau WY, Li AKC British Journal of Surgery (1995) 82:396

Objective: To demonstrate that laparoscopic cholecystec- tomy can be safely performed in Mirizzi's syndrome with the aide of ERCP and laparoscopic ultrasound. Methods: Case report: Patient with obstructive jaundice underwent preoperative ERCP with removal of distal com- mon bile duct stone. A stone impacted in the cystic duct impinging on the common hepatic duct could not be re- moved. A nasobiliary drain relieved the obstruction. The patient underwent laparoscopic cholecystectomy 3 days later. The anatomy was obscured by inflammation, edema, and fibrosis. After identifying the relationship of the com- mon hepatic duct to the stone impacted in the cystic duct, a cholecystectomy with stone removal was followed by re- moval of the gallbladder to the level of the cystic duct. The remaining portion of the gallbladder at the level of the cystic duct was closed over a T-tube and a drain was placed. Results: The patient had an uneventful postoperative course. Comment: Since no attempt was made to dissect Calors triangle, I ' m not sure just how much laparoscopic ultra- sound contributed to defining the anatomy and if it en- hanced the safety of the procedure. The most important aspect of this case is the good judgment used by the sur- geons in leaving a very small portion of the gallbladder rather than attempting to dissect a very inflamed porta hep- atis with the potential for injuring the common hepatic duct. An age-old principle used in open surgery was applied lapa- roscopically to insure a good outcome.

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Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis

Cox MR, Wilson TG, Toouli J British Journal of Surgery (1995) 82:257-259

Objective: To demonstrate that peroperative (meaning in- traoperative) endoscopic sphincterotomy with extraction of common bile duct stones during laparoscopic cholecystec- tomy is not only feasible but possibly the optimal way to manage choledocholithiasis. Methods: All patients with choledocholithiasis found at in- traoperative cholangiography underwent peroperative endo- scopic sphincterotomy (ES) to attempt stone removal. Prior to attempted ES, intravenous hyosine and glucagon was administered to relax the sphincter of Oddi and an attempt was made to flush the stone out with saline administered through the cholangiocatheter. If this was not successful the duodenoscope was passed with the patient in the supine position. Selective cannulation of the common bile duct was performed and an endoscopic sphincterotomy large enough for stone extraction was performed. The stone was either flushed through using saline infusion through the cholan- giocatheter or by standard basket or balloon catheter extrac- tion using the duodenoscope. Upon successful extraction, laparoscopic cholecystectomy was completed. If stone ex- traction failed, open common bile duct exploration was per- formed. Results: Eleven of 13 patients had successful stone removal with peroperative ES. In these patients the median hospital stay was 3 days. In those with failed peroperative stone removal which required open common bile exploration, the hospital stay was 9 days. The reason for failed peroperative ES was inability to selectively cannulate the common bile duct in one and inability to perform a large-enough sphinc- terotomy to extract a 15-mm common bile duct stone in another.

Overall the median CBD diameter was 100 ram. Only three patients had ducts smaller than 6 ram. There was cannulation of the pancreatic duct in three patients. One of these three developed pancreatitis. Overall two patients de- veloped postoperative pancreatitis requiring hospitalizations of 5 and 6 days. One additional patient developed pulmo- nary atelectasis. There was no long-term complications and all patients were assymptomatic at 3-month follow-up. Conclusion: The advantage of peroperative ES is the ability to perform complete stone extraction at one time. The tech- nique is no more difficult in the supine position than in a standard prone position. It reduces the expense of the high negative ERCP rate associated with attempted preoperative endoscopic stone extraction. It also eliminates the disadvan- tage of postoperative ERCP, which can be unsuccessful in 7-14% of attempts. The big disadvantage is the need to bring in all the necessary equipment, which can be time consuming and logistically difficult, especially if the sur- geon is not the endoscopist. The time for peroperative ES is 60-75 min longer than for laparoscopic cholecystectomy

alone. The advantage over the laparoscopic transcystic com- mon bile duct exploration or choledochotomy is that these are much more technically demanding and most surgeons do not yet have the skills to perform them. It is impossible to know with this small series if the complication rate is any higher than with pre- or postoperative ERCP. Comments: I agree with the authors that peroperative en- doscopic sphincterotomy is a reasonable option to preop- erative and postoperative ERCP for the reasons mentioned. I also agree that it is a potential logistics nightmare. My own practice is to perform laparoscopic common bile duct ex- ploration and perform intraoperative ERCP for those cases in which there is technical difficulty in laparoscopic ap- proach. Additionally, the only time I am able to get the equipment is in the late afternoon after the scheduled ERCPs have been completed and before the endoscopy nurses have left for the day. Additionally, in most places surgeons do not do their own ERCPs, and a gastroenterolo- gist must be called in. For those who have mastered both laparoscopic and endoscopic techniques, open surgery will rarely be required.

Three-dimensional reconstruction of the biliary tract using spiral computed tomography

Kwon AH, Uetsuji S, Yamada O, Inoue T, Kamiyama Y, Bokr T British Jourual of Surgery (1995) 82:260-263

Objective: To compare three-dimensional reconstruction of intravenous cholangiography with spiral computed tomog- raphy to intravenous cholangiography and endoscopic ret- rograde cholangiography in assessing the anatomy of the biliary tree prior to laparoscopic cholecystectomy. Methods: 92 consecutive patients underwent IVC and IVC- SCT, 42 of these patients underwent intraoperative cholan- giogram, and 22 underwent preoperative ERCP. Results: The junction of the cystic duct with the common bile duct was seen in 32% of patients undergoing IVC and in 86% of patients with IVC-SCT. Of those patients who had both ERCP and IVC-SCT, ERC found the cystic duct- common bile duct junction in 19 and IVC-SCT in 18. Forty of the 42 attempted introperative cholangiograms were suc- cessful and common bile duct stones were found in two patients. Conclusion: Three-dimensional reconstruction of IVC-SCT is a technique which is useful for anatomical assessment before laparoscopic cholecystectomy. It deserves further evaluation. Comments: 3-D reconstruction is an interesting technology that we should be aware of. In its current form, the infor- mation gained is not as good as that of intraoperative chol- angiography in defining the biliary anatomy or in detecting common bile duct stones. A good command of the tech- nique of laparoscopic cholecystectomy and a knowledge of the variations in biliary anatomy will keep the prudent sur- geon from injuring the biliary tree.

767

Retroperitoneal endoscopic adrenalectomy

Heintz A, Junginger Th, Bottger Th British Journal of Surgery (1995) 82:215

Objective: To describe a laparoscopic retroperitoneal ap- proach for adrenalectomy. Methods: With the patient in a fight lateral position a trocar was inserted into the retroperitoneal space. Dissection was carried out with a balloon to create a space. Laparoscopic

technique was used to dissect and remove a 4 x 5 cm ad- renocortical adenoma. Results: The patient was release from the hospital 4 days postop. Conclusion: For small or medium-size unilateral adrenal lesions, this approach may be a viable alternative to lapa- roscopic transperitoneal methods. Comments: A reasonable alternative.

Reviewers for this issue: M. Arregui, J. Sackier