Abstract

Laparoscopy was developed by Kalki of Germany in 1929 as a routine procedure in the University and Michaelis-Midwifery School, Kiel, Germany internal medicine for diagnosis of liver diseases. Air was insufflated to create the pneumoperitoneum, and an electric lamp was placed at the end of the laparoscope to provide illumination of the abdominal cavity. Entrance into the peritoneal cavity was in the upper abdomen two finger breadths under the ribs. The danger of damaging the bowel by burning, etc. was very low. Previously laparotomized patients were considered an absolute contraindication for Laparoscopy. In 1946 Palmer, France turned the laparoscope from the upper abdomen to look into the lower abdomen. He called this technique Coelioscopy. It was used as for a diagnostic procedure mainly for the sterility patient in Gynecology. For coelioscopy Palmer used the same instruments as were used for Laparoscopy. The danger of burning bowel increased enormously as the protector of the upper abdomen, the omentum, was missing in the lower abdomen.

Abstract

Dramatic advances continue to occur with video-directed endoscopic operations. This commentary will follow the same format as the one in the previous edition two years ago. Most of the predictions anticipated in our last writing have been met or exceeded. Change will continue to accelerate, though the individual innovations will be of smaller magnitude.

Abstract

Two years after laparoscopic cholecystectomy was introduced, and new horizons in laparoscopic surgery were being developed, a noted academic surgeon told me that although he had initially doubted the viability of laparoscopic cholecystectomy, he had become an avid supporter. He cautioned, however, that many surgeons would perform the operation with minimal training and marginal laparoscopic skills and that the injury rate would be devastating. Unfortunately, that prophecy has come to pass. In this dissertation, I would like to discuss some of those complications and how to avoid them. I choose not to dwell on minor or peripheral complications such as wound infection, pneumonia, deep venous thrombosis, urinary tract infection and the like, but rather, concentrate on complications related directly to laparoscopy and laparoscopic surgery. Laparoscopic complications are either a direct result of poor laparoscopic technique or related to anatomic misidentification. Technical complications include major vascular or intestinal injury or insufflation injury. Anatomic injuries usually involve the bile ducts, ureter or sensory nerves due to poor dissection and identification.

Abstract

As is pointed out in multiple publications, laparoscopic cholecystectomy has rapidly gained recognition an acceptance in the management of chronic cholecystitis and most cases of acute cholecystitis. A low incidence of complications accompanies laparoscopic cholecystectomy now that experience has been gained with this procedure by laparoscopically skilled surgeons. However, the management of stones found or suspected in the common bile duct continues to be controversial. The gold standard for treatment of choledocholisthiasis remains the open exploration of the bile ducts with a reported mortality of 0.3%-0.19% and a rate of retained stones of between 2-4%. Both surgeons and gastroenterologists skilled in endoscopy have espoused endoscopic retrograde cholangiopanreatography and sphincterotomy (ERCP/ES) preoperatively or postoperatively for the treatment of known common bile duct stones. This approach adds additional procedures and potentially compounds the complications of the separate operative interventions to deal with the diseased gallbladder and to clear the common bile duct of obstruction. In several series of patients the morbidity of endoscopic sphincterotomy has ranged from 9-16%, with bleeding, acute pancreatitis, acute cholangitis, residual stones, duodenal perforation, and common bile duct perforation the leading causes of complications. There continues to be an incidence of retained stones of 9.1-14.7% with ERCP/ES. Furthermore, as high as 86% of indiscriminate preoperative ERCP studies show no evidence of stones in the common bile duct, making this an unnecessary intervention in such cases. There has been no consistent reduction in subsequent mortality in complicated biliary cases by the use of ERCP/ES alone, even with the gallbladder left in situ.

Abstract

With the introduction of laparoscopic cholecystectomy, the general surgery community was introduced to the world of minimally invasive surgery. In less than two years, just about every meeting, journal, and medical trade show demonstrated this "new" found technique. Surgeons have been very quick to pick up on the laparoscopic technique, and have actively sought other applications for the laparoscopic approach. With approximately 400,000 inguinal hernia repairs being performed in the United States annually, the laparoscopic repair of this common malady was very quickly embraced as a possible new application. The concept of a trans-abdominal repair of a hernia defect is not new, having been described as early as the original description of "the modern day" hernia repair by Marcey. A trans-abdominal laparoscopic repair has a potential advantage over a conventional groin approach by it's avoidance of the groin incision and the need to mobilize the cord structures. This not only minimizes post operative pain, but also the risk of long term morbidity related to mobilization of the cord. (neuroma formation secondary to injury of the cutaneous nerves, epididymitis and orchitis) There is also the possible advantage of an earlier return to normal activities. In contrast to laparoscopic cholecystectomy, there are technical differences between the laparoscopic and open hernia repairs. This difference raises the question as to whether or not the laparoscopic repair will yield results that will compare with an open technique. Open surgical techniques are considered a safe and effective means of treating inguinal hernias. The operation avoids the violation of the abdominal cavity, can be performed under local anesthesia, and is often performed on an outpatient basis. This raises the question "why via the laparoscope »? Despite reports from specialized hernia centers reporting a recurrence rate of 0 to 2 percent, large series from community based surgeons continue to report recurrence rates in the range of 5 to 10 percent. This recurrence rate has changed very little since Bassini reported a recurrence rate of 10 percent at the turn of the century. Although the overall morbidity of an open repair is only in the range of 2 percent, this morbidity consists almost entirely of complications related to the wound and mobilization of the cord structures. The standard open hernia repair is not a perfect operation, and any attempt at its improvement is warranted. Since the laparoscopic repairs approaches the defect from within avoiding a large surgical incision and mobilization of the cord structures, the repair logically makes sense. Despite the intuitive advantages of the laparoscopic repair, questions regarding recurrence rates and safety of the laparoscopic repair still need to be answered.

Abstract

Laparoscopic surgery has been in existence for nearly a century, yet its widespread acceptance and application in the field of general surgery is a relatively recent occurrence. With the rapid acceptance of laparoscopic cholecystectomy, surgeons have sought other procedures which would be amenable to laparoscopic approaches. This, combined with a technology boom in laparoscopic instrumentation has made possible the development of advanced laparoscopic procedures such as colectomy. It is important to emphasize that laparoscopic colon surgery is still in an evolutionary stage, and that the procedures described are being continually refined as more experience is gained, as newer instruments are developed, and as software and video applications continue to improve. Nevertheless, the goal of any surgeon performing a laparoscopic procedure should be to perform an operation identical to the one done through a large incision.

Abstract

Gastroesophageal reflux disease (gerd) is a common disorder of the foregut. Over the past twenty-five years the developement of instrumentation and techniques to study GERD have revealed it to be a complex disorder. Increasingly effective pharmacotherapeutics have been developed over the same time frame. As such the great majority of patients are adequately treated by a medical regimen. Patients who are medically refractory or those requiring long term medications are potential candidates for anti-reflux surgery. Over the past decade decreasing numbers of anti-reflux surgical procedures have been performed. The two main reasons are improved pharmacology i.e. Prilosec and the complication rate associated with antireflux surgery. The laparoscopic performance of anti-reflux surgery offers dramatic benefits to the patient. As in the performance of laparoscopic cholecystectomies the decreased postoperative morbidity and rapid return to normal activities ensures overall cost savings. We present our experience with laparoscopic anti-reflux surgery to include the work up, technique, results, and a new laparoscopic anti-reflux procedure.

Abstract

Thoracoscopy - looking into the thoracic cavity was first described in 1910 by the Swedish physician, Jacobeus. He used a cystoscope intrapleuraly in order to diagnose pleural diseases. He also used his method for cutting adhesions in order to achieve collapse of the lung in patients with tuberculosis of the lung. Thoracic sympathicotomy was first performed by Kotzareff in 1920. The operation was found to be effective for treatment of palmar hyperhidrosis. Different open techniques for sympathicotomy have since been described, the most common being the dorsal approach by Cloward in 1969. Sympathicotomy was found to be effective not only for palmar, but also axillar hyperhidrosis, vascular insufficiency of the arm and hand, causalgia and angina pectoris (Lindgren 1950). However, the operation using the open technique was difficult and, though effective, not many patients were prepared to meet the demands for problems such as hyperhidrosis. Therefore, the operation became rather common. In the middle of the 1940'S, several attempts were made to make the sympathicotomy through thoracoscopic approach and in 1951, Kux described a large number of patients treated in this way for many different diseases such as duodenal ulcer, diabetes mellitus, as well as the generally accepted indications. He published his experiences in a book; but for some obscure reason, his technique did not achieve general acceptance. In the late 1970'S and the 1980'S, the principle was again taken up by different centers (Byrnes, et. al.). I will describe here a technique which can be regarded as a simplification of previous methods. The technique was elaborated in our department and the first operation was performed in 1987 (Claes, et. al.). By June 1993, six hundred and seventy operations have been carried out.

Abstract

In the extremities, the vascular response to sympathetic stimulation is vasoconstriction with blanching and cooling of skin and increased sweating, whereas, blocking of the sympathetic system results in increased blood flow through cutaneous arteriovenous fistulae and cessation of sweating, thereby, resulting in increased dryness, warmth and accentuation of pink color. In the past, sympathetic denervation of the upper extremity was suggested as a treatment of many disorders; bronchial asthma, essential hypertension, peptic ulcer disease, hyperthyroidism, hyperhidrosis, vasospastic syndromes (Raynaud's disease), thoracic outlet syndrome, causalgia, post-traumatic sympathetic dystrophy (Sudeck atrophy), and angina pectoris. The indications for upper thoracic sympathectomy are imited today to hyperhidrosis, causalgia, severe vasospastic disorders, and ischemic changes of the extremities (Buerger's disease).