The impact of previous abdominal surgery on outcome following laparoscopic cholecystectomy

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.

METHODS

Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.

RESULTS

Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.

CONCLUSIONS

The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

The safety and feasibility of laparoscopic common bile duct exploration for treatment patients with previous abdominal surgery

The purpose of this study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) in patients with previous abdominal surgery (PAS). The outcomes were compared in 139 patients (103 upper and 36 lower abdominal surgeries) with PAS and 361 without PAS who underwent LCBDE. The operative time, hospital stay, rate of open conversion, postoperative complications, duct clearance, and blood loss were compared. Patients with PAS had longer operative times (P = 0.006), higher hospital costs (P = 0.043), and a higher incidence of wound complications (P = 0.011) than those without PAS. However, there were no statistically significant in the open conversion rate, blood loss, hospital stay, bile leakage, biliary strictures, residual stones, and mortality between patients with and without PAS (P > 0.05). Moreover, compared with those without PAS, patients with previous upper abdominal surgery (PUAS) had longer operative times (P = 0.005), higher hospital costs (P = 0.030), and a higher open conversion rate (P = 0.043), but patients with previous lower abdominal surgery (PLAS) had a higher incidence of wound complications (P  = 0.022). LCBDE is considered safe and feasible for patients with PAS, including those with PUAS.

Major vascular injury in laparoscopic urology

BACKGROUND AND OBJECTIVES

Major vascular injury is the most devastating complication of laparoscopy, occurring most commonly during the laparoscopic entry phase. Our goal is to report our experience with major vascular injury during laparoscopic entry with closed- and open-access techniques in urologic procedures.

METHODS

All 5347 patients who underwent laparoscopic urologic procedures from 1996 to 2011 at our hospital were included in the study. Laparoscopic entry was carried out by either the closed Veress needle technique or the modified open Hasson technique. Patients' charts were reviewed retrospectively to investigate for access-related major vascular injuries.

RESULTS

The closed technique was used in the first 474 operations and the open technique in the remaining 4873 cases. Three cases of major vascular injury were identified among our patients. They were 3 men scheduled for nephrectomy without any history of surgery. All injuries occurred in the closed-access group during the setup phase with insertion of the first trocar. The injury location was the abdominal aorta in 2 patients and the external iliac vein in 1 patient. Management was performed after conversion to open surgery, control of bleeding, and repair of the injured vessel.

CONCLUSIONS

Given the high morbidity and mortality rates associated with major vascular injury, its clinically higher incidence in laparoscopic urologic procedures with the closed-access technique leads us to suggest using the open technique for the entry phase of laparoscopy. Using the open-access technique may decrease laparophobia and encourage a higher number of urologists to enter the laparoscopy field.

Laparoscopic right colectomy in patients treated with previous gastrectomy

PURPOSE

Laparoscopic colorectal surgery is increasingly being performed in patients treated with previous abdominal surgery. This is a retrospective study designed to evaluate the feasibility of laparoscopic right colectomy in patients with a previous history of gastrectomy.

METHODS

Of 838 consecutive patients who underwent elective laparoscopic right colectomy, 23 had previously undergone gastrectomy (PG group) and 516 had no history of previous abdominal surgery (NS group). The short-term surgical outcomes were retrospectively investigated in the PG and NS groups.

RESULTS

The median patient age was 75 years in the PG group and 67 years in the NS group (p = 0.0026), and the median body mass index in both groups was 19.2 and 22.6 kg/m(2), respectively (p = 0.0006). The mean operative time, amount of blood loss and postoperative hospital stay were similar. One patient in the PG group and five patients in the NS group required conversion to laparotomy (p = 0.1307). Three patients in the PG group experienced postoperative complications, one each with an intraperitoneal abscess, wound infection and enterocolitis; however, none of these complications were directly attributable to adhesiolysis. The rates of intraoperative and postoperative complications were similar.

CONCLUSIONS

Laparoscopic right colectomy is feasible in patients treated with previous gastrectomy.

Male gender impact on the outcome of laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Our aim was to assess the impact of male gender on the outcomes of laparoscopic cholecystectomy by eliminating associated risk factors for conversion.

METHODS

A quantitative comparative study was set up on the background of our null hypothesis that male gender has no impact on the outcomes of laparoscopic cholecystectomy. We performed a retrospective study of 241 patients and recorded the duration of surgery, length of postoperative hospital stay, conversion rate, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of < .05 was considered the cutoff point to indicate the amount of evidence against the null hypothesis. We used SPSS for Windows, version 12 (IBM, Armonk, New York). Parametric data were analyzed with the independent-samples t test, and nonparametric data were analyzed with the χ(2) test.

RESULTS

A total of 175 women (72.6%) and 66 men (27.4%) underwent laparoscopic cholecystectomy. The mean age was 51.4 ± 14.8 years for women and 55 ± 12.7 years for men (P = .08). Women had a higher body mass index (28.4 ± 4.5) than men (26.8 ± 3.5) (P < .005). There were no statistically significant differences in the conversion rate and perioperative morbidity rate. The conversion rate was 2.9% for women and 7.5% for men (P = .142); the morbidity rate was 10.2% and 12.1%, respectively (P = .66). The mean duration of surgery was longer in men, at 67.9 ± 27.8 minutes, than in women, at 56.5 ± 23.98 minutes (P < .002). Both genders had an equal length of postoperative hospital stay, with 1.9 ± 1.8 days for men and 1.9 ± 2.1 days for women (P = .8).

CONCLUSIONS

Male gender has no impact on the outcomes of laparoscopic cholecystectomy. Gender affects the duration of surgery. Larger-scale studies may disclose the factors responsible for variations in the operative time.

Prior abdominal open surgery does not impair outcomes of laparoscopic colorectal surgery: a case-control study in 367 patients

AIM

This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS).

METHOD

From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay.

RESULTS

A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849).

CONCLUSION

This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

Laparoscopic common bile duct exploration in patients with previous upper abdominal operations

Backgrounds/Aims

We aimed to to evaluate the feasibility of laparoscopic common bile duct exploration (LCBDE) in patients with previous upper abdominal surgery.

Methods

Retrospective analysis was performed on data from the attempted laparoscopic common bile duct exploration in 44 patients. Among them, 5 patients with previous lower abdominal operation were excluded. 39 patients were divided into two groups according to presence of previous upper abdominal operation; Group A: patients without history of abdominal operation. (n=27), Group B: patients with history of upper abdominal operation. Both groups (n=12) were compared to each other, with respect to clinical characteristics, operation time, postoperative hospital stay, open conversion rate, postoperative complication, duct clearance and mortality.

Results

All of the 39 patients received laparoscopic common bile duct exploration and choledochotomy with T-tube drainage (n=38 [97.4%]) or with primary closure (n=1). These two groups were not statistically different in gender, mean age and presence of co-morbidity, mean operation time (164.5±63.1 min in group A and 134.8±45.2 min in group B, p=0.18) and postoperative hospital stay (12.6±5.7 days in group A and 9.8±2.9 days in group B, p=0.158). Duct clearance and complication rates were comparable (p>0.05). 4 cases were converted to open in group A and 1 case in group B respectively. In group A (4 of 27 (14.8%) and 1 of 12 (8.3%) in group B, p=0.312) Trocar or Veress needle related complication did not occur in either group.

Conclusions

LCBDE appears to be a safe and effective treatment even in the patients with previous upper abdominal operation if performed by experienced laparoscopic surgeon, and it can be the best alternative to failed endoscopic retrograde cholangiopancreatography for difficult cholelithiasis.

Impact of risk factors for prolonged operative time in laparoscopic cholecystectomy

OBJECTIVE

Laparoscopic cholecystectomy (LC) remains one of the most frequent surgical therapies for symptomatic gallstone disorders. Prolonged operative time is frequently associated with increased complication rates. The aim of this study was to identify the risk factors for prolonged operative times to minimize perioperative morbidity and optimize clinical management.

METHODS

A total of 677 consecutive patients underwent LC. The exclusion criteria were conversion to an open procedure, intraoperative cholangiography, and liver cirrhosis (n=81). Data were analyzed retrospectively with respect to age, sex, BMI, ASA score, previous abdominal surgery, preoperative endoscopic retrograde cholangiopancreatography, acute cholecystitis, and surgeon's experience. Univariate and multivariate analyses were performed.

RESULTS

A total of 596 patients, mean (± SD) age of 52.2 ± 16.7 years, were analyzed. In all, 29% of the patients were obese (BMI ≥ 30 kg/m); 11% had ASA III. Five percent of patients had undergone previous upper abdominal surgery. Overall, 105/596 patients had an acute cholecystitis. Residents of general surgery performed 58% of all operations. The median operative time was 80 min (range, 15-281 min). No statistical significance was found between intraoperative and postoperative complications by surgeon's experience. Statistically, independent preoperative predictors for prolonged operative time as identified through multivariate analysis were acute cholecystitis, obesity, previous upper abdominal surgery, male sex, and low degree of surgical expertise.

CONCLUSION

The risk for prolonged operative times in LC can be assessed on the basis of patients' characteristics. Assessment of these factors not only helps to optimize the individual outcome for each patient but also improves the decision process toward operative training for junior surgeons.

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

PURPOSE

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach.

METHODS

Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009.

RESULTS

Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival.

CONCLUSIONS

These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

Laparoscopic nephrectomy for nonfunctioning kidneys is feasible after previous ipsilateral renal surgery: a prospective cohort trial

PURPOSE

Previous renal surgery is a relative contraindication to laparoscopic nephrectomy because adhesion formation makes surgical dissection difficult. We determined whether previous surgery at the same anatomical site would affected the surgical outcome in patients who underwent transperitoneal laparoscopic nephrectomy.

MATERIALS AND METHODS

During the study period 79 consecutive patients who underwent transperitoneal laparoscopic nephrectomy were evaluated prospectively. All patients had symptomatic nonfunctioning small or hydronephrotic kidneys. Patients were divided into 29 with and 50 without prior surgery at the same anatomical site. Previous surgery included open nephrolithotomy in 16 patients, percutaneous nephrolithotomy in 8, open and percutaneous nephrolithotomy in 3, pyelolithotomy in 1 and pyeloplasty in 1.

RESULTS

Patients who underwent prior surgery were older than patients who did not (average age 46.6 vs 34.9 years, p=0.008). Other patient characteristics, including gender ratio, body mass index and side of surgery, did not differ significantly between the 2 groups. Mean operative time was longer in patients with previous surgery than in the other group (98.6 vs 62.3 minutes, p=0.03). Other operative data, including blood loss, intraoperative and postoperative complications, open conversion and hospital stay, were similar in the groups. One case per group was converted to open surgery due to difficult pedicle dissection.

CONCLUSIONS

Transperitoneal laparoscopic nephrectomy in patients with a history of ipsilateral renal surgery can be done safely in timely fashion. Although mean operative time was longer, there was no significant increase in the operative complication rate in patients with prior surgery.

Effect of previous uterine surgery on the operative hysteroscopic outcomes in patients with reproductive failure: analysis of 700 cases

OBJECTIVE

To determine the effect of previous uterine surgery according to whether the uterine cavity is opened or not on the operative outcomes in a series of women undergoing surgical hysteroscopy guided by concomitant diagnostic laparoscopy for management of reproductive failure.

METHODS

Records of 700 consecutive major hysteroscopic surgical procedures guided by concomitant diagnostic laparoscopy and performed for women with previous pelvic surgery were reviewed. All women were suffering from reproductive failure. Patients were categorized according to whether the uterine cavity was opened or not and according to the type of hysteroscopic procedure performed. Analysis of overall previous uterine surgery of any type combined and of individual matched types of hysteroscopic procedure separately was done. Patient age, American Society of Anesthesiologists (ASA) patient classification, surgical history, perioperative change in serum sodium concentration and hemoglobin level, fluid balance, transfusion rate, rate of failed hysteroscopic procedure, operative hysteroscopic time, complication rate and hospital stay were assessed in each patient.

RESULTS

Of the 700 patients, 366 (52%) had never undergone uterine surgery, 105 (15%) had a history of uterine surgery with cavity opened and 229 (33%) had uterine surgery with cavity not opened. Overall previous uterine surgery of any type was associated with an increased age, and higher ASA score (P = 0.001). A history of uterine surgery with cavity opened was associated with increased operative time (P = 0.03) and increased hospital stay (P = 0.02). No patients have required a transfusion. Differences in perioperative serum sodium concentration and hemoglobin level, the complication and failure rates in patients with and without a history of uterine surgery did not attain significance. Outcomes analysis of individual matched types of hysteroscopic surgery showed similar results except for hysteroscopic metroplasty. In these cases, previous uterine surgery was not associated with increased age or ASA score.

CONCLUSION

Previous uterine surgery among young women with reproductive failure whether the uterine cavity is opened or not does not appear to affect adversely the performance and safety of subsequent major surgical hysteroscopy guided by concomitant diagnostic laparoscopy.

Risk factors for bile duct injury during laparoscopic cholecystectomy: a case-control study

Common bile duct injury is a serious but uncommon complication of laparoscopic cholecystectomy. A case-control epidemiologic study of patients who had undergone cholecystectomy in Ontario, Canada, between 1991 and 1997 was performed. Four patients who had undergone a laparoscopic cholecystectomy at the same hospital 2 months prior to a case were selected as controls. The risk of bile duct injury associated with various exposures was estimated by unconditional logistic regression. There were 28 cases and 88 controls. Emergency operation (adjusted odds ratio = 5.0; 95% confidence interval, 1.4-17.8) and failure to identify the cystic duct (adjusted odds ratio = 13.7; 95% confidence interval, 2.5-76.3) were statistically significant risk factors for operative bile duct injury. No other characteristics were independent risk factors for bile duct injury. Failure to identify the cystic duct and the emergency surgery are independent risk factors for bile duct injury.

Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study

BACKGROUND

Adhesions are a major risk for visceral injury and can increase the difficulty of both laparoscopic and open colectomy. The aim of the present study was to evaluate the impact of previous abdominal surgery on laparoscopic colectomy in terms of early outcome.

METHODS

We performed a case-control study of patients who underwent laparoscopic colectomy for colorectal disease. The case group comprised 91 patients with a history of prior abdominal surgery, while the 91 controls had no such history. Case and controls were matched for age, gender, site of primary disease, comorbidity on admission and body mass index.

RESULTS

The two groups were homogeneous for demographic and clinical characteristics. Conversion rate was 16.5% in the case group and 8.8% in the control group (p=0.18). Of the 7 patients who underwent conversion because of adhesions, six had prior surgery (cases) and one did not (p=0.001). Operative time was 26 minutes longer in the case group than in the control group (p=0.001). Morbidity rate was 25.3% among cases and 23.1% for controls. Patients in the two groups experienced a similar time to recovery of bowel function, length of postoperative stay, and 30-day readmission rate.

CONCLUSIONS

Laparoscopic colectomy in previously operated patients is a time-consuming operation, but it does not appear to affect the short-term postoperative outcome.

A 14-year Analysis of Laparoscopic Cholecystectomy

BACKGROUND

Contraindications to laparoscopic cholecystectomy diminished over the last decade but still conversion is about 5% to 6% in elective cases and higher in acute cholecystitis. The aim of this study was to analyze the reason for conversion in all patients operated on in our department and to create strategies for critical moments, which may need conversion.

METHODS

From 1990 to 2004, operations have been divided in 3 groups: primary open cholecystectomy (OC), laparoscopic cholecystectomy, and conversion. These groups were analyzed regarding the reason for conversion and postoperative complications.

RESULTS

Of the 5376 patients who underwent cholecystectomy, 327 had concomitant OC without further evaluation and 544 OC (11%). Of the 4505 patients (3159 women, 1346 men) who were all started by laparoscopy 5.4% [245 patients (123 women, 3.9%; 122 men, 9.1%; P<0.05)] were converted to OC. Acute cholecystitis (29.4%), difficulties with the anatomy in Calot's triangle (17.1%), and adhesions (14.3%) have been the main reasons for conversion beside difficulties in establishing pneumoperitoneum (3.7%).

CONCLUSIONS

The key scenes for conversion are the creation of the pneumoperitoneum, intra-abdominal adhesions, and difficulties in Calot's triangle, especially in acute cholecystitis. Conversion should not be seen as a complication.

Impact of previous abdominal surgery on laparoscopic appendectomy for acute appendicitis

BACKGROUND

Laparoscopic appendectomy is one of the most commonly performed laparoscopic procedures. Impact of previous abdominal surgery on laparoscopic appendectomy has not been previously reported.

METHODS

From January 2001 to December 2005, 2029 patients with clinically suspected acute appendicitis underwent laparoscopic surgery in our hospital. Of these, 234 patients (11.5%) were found to have other pathology by intraoperative or histologic findings and were excluded from the study. The 1795 patients who underwent laparoscopic appendectomy for acute appendicitis were divided into three groups: group 1, patients without a history of previous abdominal surgery (n = 1652, 92%); group 2, patients with a history of upper abdominal surgery (n = 20, 1.1%); group 3, patients with a history of lower abdominal surgery (n = 123, 6.8%). Data were collected retrospectively by chart review and analyzed for conversion rate, operative time, intraoperative and postoperative complications, and hospital stay.

RESULTS

Of the 1795 patients, 13 (0.7%) were converted to open appendectomy because of technical difficulty. Overall mean operative time was 57.2 (range, 20-225) min. There was no mortality or intraoperative complications. Overall postoperative complication rate was 10.7% (n = 193): rate of surgical wound infection was 8.2% (n = 147), surgical wound seroma 1.3% (n = 24), and intra-abdominal abscess 0.8% (n = 14). Overall postoperative hospital stay averaged 3.2 (range, 0-39) days. There were no significant differences between the three groups regarding the conversion rate (0.8% vs. 0% vs. 0%, p = 0.567), operative time (57.3 vs. 55.8 vs. 56.9 min, p = 0.962), postoperative complication rates (10.7 vs. 10 vs. 12.2%, p = 0.863), and hospital stay (3.2 vs. 3.6 vs. 3.1 days, p = 0.673).

CONCLUSIONS

Previous abdominal surgery, whether upper or lower abdominal, has no significant impact on laparoscopic appendectomy for acute appendicitis.

Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

Previous abdominal operations do not affect the outcomes of laparoscopic colorectal surgery

BACKGROUND

Previous abdominal surgery has been regarded as a relative contraindication for laparoscopic surgery. However, studies on laparoscopic cholecystectomy have showed that the presence of prior abdominal procedures does not affect the outcomes of surgery. This study aimed to investigate the impact of previous abdominal surgery on laparoscopic colorectal surgery.

METHODS

This study enrolled 295 consecutive patients who underwent laparoscopic colorectal surgery from May 2000 to May 2003. The patients were divided into two groups: those with previous abdominal surgery (n = 84) and those without a prior operation (n = 211). The outcomes of surgery for the two groups were compared with respect to the duration of surgery, blood loss, conversion rate, time to return of bowel function, resumption of diet, complications, and the hospital stay.

RESULTS

The study included 158 men and 137 women. The median age of the patients was 70 years (range, 33-91 years). Significantly more female patients and patients with benign diseases had prior abdominal surgery. Conversion was required for 17.8% of the patients with and 11.4% of the patients without previous surgery (p = 0.181). There were no differences in the operating time or blood loss between the two groups. The time to bowel movement and resumption of diet were similar in the two groups. The median hospital stay was 7 days for both groups. Of the 39 conversions, 28.2% were necessitated mainly by the presence of adhesions. In the patients who underwent conversion because of adhesions (n = 11), nine had prior surgery and two did not (p = 0.001).

CONCLUSIONS

The presence of prior surgery does not affect the operating time or blood loss of patients undergoing laparoscopic colorectal surgery. The conversion rate is not increased for patients with prior surgery. The postoperative outcomes in terms of ileus, complication rate, and hospital stay are not worse for patients with prior surgery. Previous abdominal surgery should not be considered as a contraindication for laparoscopic colorectal surgery.

Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery

BACKGROUND

Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. This study specifically examined the effect of previous intraabdominal surgery on the feasibility and safety of laparoscopic cholecystectomy.

METHODS

Data from 1,638 consecutive patients who underwent laparoscopic cholecystectomy were reviewed and analyzed for open conversion rates, operative times, intra- and postoperative complications, and hospital stay.

RESULTS

Of the 1,638 study patients 473 (28.9%) had undergone previous abdominal surgery: 58 upper and 415 lower abdominal operations. The 262 patients who had undergone only a previous appendectomy were excluded from further analysis. Adhesions were found in 70.7%, 58.8% and 2.1% of patients respectively, who had previous upper, lower or no previous abdominal surgery with adhesiolysis required, respectively, in 78%, 30% and 0% of these cases. There were no complications directly attributable to adhesiolysis. Patients with previous upper abdominal surgery had a longer operating time (66.4 +/- 34.2 min), a higher open conversion rate (19%), a higher incidence of postoperative wound infection (5.2%), and a longer postoperative stay (3.4 +/- 2.1 days) than those who had undergone previous lower abdominal surgery (50.8 +/- 24 min, 3.3%, 0.7%, and 2.6 +/- 1.4 days, respectively) and those without prior abdominal surgery (47.4 +/- 25.6 min, 5.4%, 1.2%, and 2.8 +/- 1.9 days, respectively).

CONCLUSIONS

Previous abdominal operations, even in the upper abdomen, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with an increased need for adhesiolysis, a higher open conversion rate, a prolonged operating time, an increased incidence of postoperative wound infection, and a longer postoperative stay.

The effect of previous abdominal surgery on urological laparoscopy

PURPOSE

Abdominal surgery causes adhesions that may render subsequent laparoscopic access and dissection problematic. We determined the effect of previous surgery on the operative outcome in a large series of patients undergoing urological laparoscopy.

MATERIALS AND METHODS

The records of 700 consecutive laparoscopic procedures performed at a single institution from 1995 to 2001 were reviewed. Patient gender, American Society of Anesthesiologists (ASA) patient classification, surgical history, operative time, estimated blood loss, transfusion rate, rate of conversion to an open procedure, complication rate and hospital stay were assessed in each patient. Patients were categorized by anatomical site of previous surgeries and the type of laparoscopic procedure performed. Statistical analysis was performed with 1-way ANOVA, and the chi-square, Fisher exact and Kruskal-Wallis tests.

RESULTS

Of the 700 patients 366 (52%) had never undergone surgery, 105 (15%) had a history of abdominal surgery at the same anatomical region and 229 (33%) had a history of abdominal surgery at a different region. Overall previous abdominal surgery of any type was associated with female gender, higher ASA classification, increased age and an increased rate of perioperative transfusion (p = 0.0001). A history of surgery at the same site was associated with increased operative time (p = 0.03) and increased hospital stay (p = 0.02). Differences in operative blood loss (p = 0.3), and the complication (p = 0.11) and conversion (p = 0.08) rates in patients with and without a history of surgery did not attain significance. Outcomes analysis of individual types of surgery showed similar results except for renal biopsy. In these cases previous surgery was not associated with increased age, ASA score or transfusion rate.

CONCLUSIONS

Of all patients presenting to a single center for urological laparoscopy 48% had a history of abdominal surgery. Overall compared with patients with no history of surgery those with such a history tended to be older, predominantly female and at significantly higher operative risk. Patients with a history of surgery who underwent nephrectomy or pyeloplasty were also more likely to have received blood transfusion perioperatively, which was probably related to their increased age and higher degree of medical co-morbidity. There were no significant differences in operative blood loss, rate of conversion to open procedure or rate of operative complications. Therefore, previous abdominal surgery does not appear to affect adversely the performance of subsequent urological laparoscopy.

Laparoscopic surgery for extrauterine pregnancy in hemodynamically unstable patients

STUDY OBJECTIVE

To assess the feasibility and safety of laparoscopic surgery in treatment of ectopic pregnancy in hemodynamically unstable women.

DESIGN

Three-year observational study (Canadian Task Force classification II-2).

SETTING

Tertiary university hospital.

PATIENTS

One hundred one women with ectopic pregnancy who underwent laparoscopic surgery, 18 with substantial intraabdominal bleeding and with clinical signs and symptoms of hemodynamic instability.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Compared with stable patients, hemodynamically unstable women had significantly more free blood in the abdomen (1244 +/- 590 vs 173 +/- 301 ml, p <0.0001), had significantly lower hemoglobin levels (7.8 +/- 1.4 vs 11.9 +/-1.4 g%, p <0.0001), and required significantly more frequent blood transfusions (83% vs 3.6%, p <0.0001). Similarly, their hemodynamic values such as pulse rate and blood pressures were worse. Among these women, 15 (83%) had a tubal pregnancy, 2 had an interstitial pregnancy, and 1 had a tubal abortion. Those with tubal pregnancy who were hemodynamically unstable underwent salpingectomy. Only one required conversion to laparotomy. No major intraoperative or postoperative complications occurred, and all women made a full and uneventful recovery.

CONCLUSION

Improved anesthesia and cardiovascular monitoring, together with advanced laparoscopic surgical skills and experience, justifies operative laparoscopy for surgical treatment of ectopic pregnancy even in women with hemodynamic instability.

Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen

BACKGROUND

In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure.

PATIENTS AND METHODS

We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach.

RESULTS

In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations.

CONCLUSION

Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures

BACKGROUND

The preferred treatment for stones in the bile duct is endoscopic sphincterotomy followed by stone extraction. When this fails, percutaneous treatment is an alternative to surgery. The purpose of this study was to evaluate the success and complication rate of percutaneous treatment.

METHODS

Between April 1990 and April 1997, a total of 31 consecutive patients (20 men, 11 women, mean age 70.1 years) underwent percutaneous treatment of bile duct stones (average of 2.2 per patient, range 1 to 10). The percutaneous treatment was considered successful if all stones could be removed. Time and number of sessions needed for imaging, percutaneous treatment, and complications were scored.

RESULTS

Twenty-seven patients (87%) were free of stones after 2 to 15 sessions (mean 5.6). The median time for treatment was 16 days (3 to 299). Complications occurred in 3 of the 31 patients: one myocardial infarction during extracorporeal shockwave lithotripsy, one pancreatitis, and one bacteremia. None of these complications were life threatening. Four patients (13%) underwent surgery after failed percutaneous treatment.

CONCLUSION

Percutaneous treatment of bile duct stones is an alternative with a high success rate when endoscopic stone removal fails. Surgery can be avoided in nearly 90% of cases.

Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy

OBJECTIVE

To compare the outcome of pregnancy after operative laparoscopy or laparotomy for the management of adnexal pathology during pregnancy.

DESIGN

Retrospective comparative study.

SETTING

University tertiary care referral center for endoscopic surgery.

PATIENT(S)

Eighty-eight pregnant women who underwent 93 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 39 patients. The remaining 54 patients underwent laparotomy, 25 during the first trimester and 29 during the second trimester.

INTERVENTION(S)

Laparoscopy or laparotomy for the management of adnexal masses during pregnancy.

MAIN OUTCOME MEASURE(S)

Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn long-term outcome.

RESULT(S)

No operative or postoperative maternal complications occurred in the pregnant women who underwent laparoscopic surgery. In this group of 39 women, 5 women had a first-trimester miscarriage and 2 newborns had congenital malformations (hypospadias and cleft lip and palate). Two miscarriages occurred in the first-trimester laparotomy group, and 1 congenital malformation (transposition of the great vessels) was diagnosed in the second-trimester laparotomy group.

CONCLUSION(S)

Laparoscopic gynecologic surgery appears to be safe during pregnancy, although prospective controlled studies and national registries encompassing larger numbers of cases are needed.

Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock

STUDY OBJECTIVE

To determine the safety of operative laparoscopy in the management of ectopic pregnancy in women with hypovolemic shock.

DESIGN

Retrospective chart review.

SETTING

University-affiliated hospital.

PATIENTS

Two hundred eleven women with tubal pregnancy, of whom 33 were suffering from hypovolemic shock, based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SEM intraabdominal blood loss was significantly (p <0.01) higher in women with hypovolemic shock, 1369 +/- 149 versus 114 +/- 14 ml. Blood transfusions were given to 88% and 0.5%, respectively (p <0. 01). Laparoscopic salpingectomy was performed in all hemodynamically compromised women compared with 87% of stable women. Conversion to laparotomy was required in three patients in the hypovolemic shock group and five in the stable group. All patients had an uncomplicated postoperative course and made a full recovery.

CONCLUSION

The availability of optimal anesthesia and advanced cardiovascular monitoring, and the ability to convert rapidly to laparotomy if required, allow safe performance of operative laparoscopic surgery in most women in hypovolemic shock. In fact, the superior exposure of laparoscopy, providing rapid diagnosis and control of the source of bleeding, makes it a highly suitable approach.

The difficult laparoscopy

As others have emphasized, a progressive and structured training process is necessary to understand and avoid the potential pitfalls of laparoscopy. A surgeon who is poorly trained or has minimal skills and experience finds that many cases are "difficult." Nevertheless, even those with appropriate skill and experience encounter intellectual and technical challenges in laparoscopy. It is also very important to realize that some procedures simply should not be done laparoscopically. A review of 77,604 laparoscopic cholecystectomies documented that more than half the deaths were from technical complications occurring during the procedure. Traditional methods of surgery may have their own characteristics of limitations and morbidity, but in most cases, the old operation might still be a very good one in the face of unfavorable laparoscopic conditions.