Faculty Bibliography

Repair of recurrent inguinal hernias using the conventional open technique has been associated with high rates of recurrence and complications. Stoppa has reported a low recurrence rate using the open preperitoneal approach. Evolution of laparoscopic techniques has allowed the reproduction of the open preperitoneal repair via an endoscopic totally extraperitoneal (TEP) approach. This study reviewed all the recurrent inguinal hernias repaired laparoscopically and evaluated the complication and recurrence rate. A total of 512 inguinal hernias were treated laparoscopically using the TEP approach. Of these, 75 were recurrent. The ages of the 61 men ranged from 36 to 65 years. There were 41 direct and 34 indirect hernias. Fourteen were bilateral. None of the repairs was converted to an open procedure. The operating time ranged from 20 to 145 min (median 42 min). All patients were discharged home on the same day. There were no deaths. The complications consisted of two instances of urinary retention and one groin collection. Patient follow-up ranged from 6 to 72 (median 40) months, and there have been no recurrences to date. The TEP repair for recurrent inguinal hernias can produce results comparable to the open preperitoneal technique with low morbidity and recurrence rates.

BACKGROUND: The aim of this study was to assess the cost effectiveness of routine preoperative blood type and screen testing before laparoscopic cholecystectomy. METHODS: All 2,589 laparoscopic cholecystectomies and 603 open cholecystectomies performed at our institution between January 1990 and December 1996 were retrospectively reviewed to identify the incidence and causes of blood transfusions. With the use of ICD-9-CM coding, a computerized retrospective research was done to match the corresponding codes for the aforementioned operations and blood transfusion. Individual charts were reviewed to identify the indications for blood transfusion. RESULTS: Of the 2,589 laparoscopic cholecystectomies performed, 12 patients required blood transfusion, and of the 603 open cholecystectomies, 33 patients required blood transfusion. The incidence of blood transfusions was 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy. Two of the blood transfusions given intraoperatively were due to major vascular injury in the laparoscopic cholecystectomy group. The remaining blood transfusions were found to be the result of preexisting medical conditions including sickle-cell anemia, end-stage renal disease, and chronic iron deficiency anemia. CONCLUSIONS: Laparoscopic cholecystectomy has become a widely used therapeutic modality in general surgery. The procedure is safe, effective, and well tolerated by the patient. In the era of managed healthcare, the cost effectiveness of commonly ordered tests is frequently questioned. In the absence of preoperative indications, routine preoperative blood type and screen testing should be eliminated for laparoscopic cholecystectomy. The elimination of routine preoperative blood type and screen testing could have saved our institution $79,800 during a 6-year period.

Communicating hydrocephalus can be handled either by the ventriculoperitoneal or, occasionally, the ventriculoatrial shunt. The lumboperitoneal shunt is another option. It does not require a transcranial approach; therefore, it is safer for the patient. We describe a technique that can be performed easily by a skilled laparoscopic surgeon through an anterior approach transabdominally. The lumboperitoneal (LP) shunt is placed laparoscopically under direct videoscopic vision, with the catheter inserted transabdominally through the L3 disc space into the thecal sac. In our patient, the lumboperitoneal shunt was placed at the L3 disc space for communicating hydrocephalus. There were no intraoperative or postoperative complications. The LP shunt can be easily placed by a skilled laparoscopic surgeon. The incidence of infection and complications is lower, and the patency rate is higher. This should be the initial choice for communicating hydrocephalus.

The clinical outcome and complication rates related to the choice of technique and insertion site in the placement of a Greenfield filter (GFF) is still controversial. Moreover, there is no consensus as to which technique and placement site produces the best outcome. This study evaluated the charts of 364 patients who received GFFs during a 5-year period. Seventy-one filters were placed surgically and 293 were placed percutaneously in the operating room by general and vascular surgeons. Seventy-eight were placed using the femoral approach and 296 were placed using the jugular approach. Demographics were recorded as well as preoperative, intraoperative, and postoperative variables. All immediate complications were examined including failure of the GFF to open, suboptimal placement, multiple attempts at placement, abandoned procedures, guidewire related difficulties, hematoma, bleeding, phlegmasia cerulea dolens, pneumothorax, arrhythmia, and death. There was no statistically significant difference between complications derived from surgical placement versus percutaneous placement. There were no statistically significant differences among variables based on jugular versus femoral placement. There was a statistically significant difference in the time required for the percutaneous placement versus the open surgical procedure (33 +/- 28 min, vs 45 +/- 27 min., p<0.05). These findings suggest that the technique and site of the GFF insertion can be left to the discretion of the surgeon based on each patient's profile.

When first introduced, the advanced breast biopsy instrumentation (ABBI(R)) system seemed to have many advantages as a diagnostic procedure. Problems have arisen, however, both in terms of patient unsuitability and mechanical failure. In addition, there has been uncertainty as to whether the complete lesion removal it afforded could be considered definitive treatment in malignant cases. Incision margins were looked at to investigate that possibility. Of the 183 patients we saw in our first year of experience with ABBI, 48 (26%) were rejected for being poor candidates for it. In the remaining 132 biopsies there were 31 (23%) technical difficulties. All told, 14 malignancies were discovered, all of which appeared to have pathology-free incision margins radiologically. However, 13 of these 14 (93%) proved on pathologic examination to have residual malignancy.

BACKGROUND: This report reviews our experience with 512 groin hernias treated by a laparoscopic extraperitoneal approach over the past 5 years. We detail the modifications that have been made to this procedure and compare our morbidity and recurrence rates with other laparoscopic and open herniorrhaphy techniques. METHODS: Between September 1991 and September 1996, 395 male patients underwent 512 hernia repairs by an endoscopic total extraperitoneal approach (TEP). Their ages ranged from 18 to 82 years. There were 267 indirect, 218 direct, 17 pantaloon, and 10 femoral hernias. Of these, 117 were bilateral and 54 were recurrent. All repairs were done with polypropylene mesh. All patients were given general anesthesia except 16 (4.05%) who had epidural anesthesia. RESULTS: Of 512 hernia repairs, seven required conversion to an open procedure (1.3%). There were 19 complications (4.8%), including eight cases of urinary retention, six of groin collection, one bladder injury, one trocar site infection, one transient neuralgia, one cardiac arrhythmia, and one laryngospasm. Follow-up on 354 patients (41 were lost to follow-up) ranged from 6 to 66 months (mean, 38). There were six hernia recurrences (1.69%), but no deaths. Operative time ranged from 15 to 185 min. CONCLUSIONS: The endoscopic extraperitoneal approach to groin hernia repair has a recurrence rate comparable with open and other laparoscopic techniques. Operative time has decreased considerably with experience. Familiarity with the technique has eliminated the need for balloon dissectors, cauteries, suction irrigation, Foley catheters, and stapling of the mesh. These advances, along with shortening of the operative time and employment of reusable trocars, have permitted a significant decrease in the cost of the procedure. This study provides the longest follow-up reported with this technique. In experienced hands, the TEP repair produces results that are comparable with the open, tension-free repair and represents a reasonable alternative.

This article reports our early experience using laparoscopic instruments and techniques when performing radical retropubic prostatectomy through an entirely extraperitoneal endoscopic approach. Two patients with localized adenocarcinoma of the prostate underwent endoscopic radical retropubic prostatectomy through an entirely extraperitoneal approach (EERRP). The procedure was evaluated for its efficacy in removing prostate and seminal vesicles and in effecting complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathology were also evaluated. Complete endoscopic removal of the prostate and seminal vesicles was achieved in both patients. Endoscopic reconstruction of the bladder neck with watertight anastamosis was successful in both. Operative time and estimated blood loss improved from 5 h and 45 min and 600 cc, respectively, in patient 1 to 4 h and 400 cc in patient 2. Hospital stay was 2.5 days for both. The early experience for EERRP is encouraging. Further evaluation to standardize technique and determine its efficacy and role in treating prostate cancer is in order.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. METHODS: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. RESULTS: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. CONCLUSIONS: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.