Faculty Bibliography

Laparoscopic hernia repair has evolved considerably since its introduction. Different methods have been described, and multiple studies have been performed reporting widely varying outcomes. This study was undertaken to review all the major publications on laparoscopic herniorrhaphy from 1993 to 1996 and evaluate the rates of recurrence and complications involved in the various techniques. In a total of 11,222 laparoscopic hernia repairs, the procedure performed most frequently was the transabdominal preperitoneal patch (TAPP), followed by the total extraperitoneal patch (TEP). There were 300 (2.7%) recurrences. From 9,955 hernia repairs, there were 1,534 (15.4%) complications. Hematoma/seroma (456), neuralgia (199), urinary retention (150), and chronic pain (39) were the most frequently reported complications. Laparoscopic herniorrhaphy is a higher effective method of hernia repair with results comparable with the open technique. TAPP is still the most widely performed technique. TEP is becoming more popular, mainly because of its excellent outcome. The major drawback of TEP is the difficulty of reproducibility by different general surgeons with comparable results. Other techniques such as plug and patch carry a high rate of recurrence and complications and should probably be completely abandoned.

With recent advances in laparoscopy, specifically the development of laparoscopic splenectomy, a complete laparoscopic Hodgkin's staging procedure is now possible. Using five trocars and the patient in the right semidecubitus position, six laparoscopic staging procedures were performed. All were stages IIA or IIB pre-operatively, and none were upgraded to stage III or IV as a result of the procedure. Operative time was from 185-255 min. (mean 210 min.) There were no operative morbidities or mortalities associated with the procedure. We believe this procedure will be adopted by more surgeons as they become more comfortable in performing laparoscopic splenectomies.

OBJECTIVES: We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach. METHODS: A 62-year-old man with a Gleason score of 7 and clinical stage T1c adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated. RESULTS: Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins. CONCLUSIONS: The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order.

BACKGROUND: Large-core biopsies or open biopsies with needle localization have been the mainstay of treatment for evaluating nonpalpable mammographic abnormalities. The newly introduced Advanced Breast Biopsy Instrumentation (ABBI) system combines digital stereotactic imaging with a highly developed single-use biopsy device to locate and remove a radiographically discovered breast lesion to an accuracy of 1 mm. STUDY DESIGN: We conducted a review of the first 58 cases involving the use of the ABBI system. This article evaluates the accuracy of specimen targeting, the success rate of lesion removal, the operative complications, the mechanical difficulties, and patient satisfaction with the ABBI system. RESULTS: The lesion was removed successfully in 47 of the 58 cases. Nine patients were eliminated in initial screening and the procedure could not be completed in two. Although the success rate was high, 14 of the procedures required conversion to "open" ABBI procedures for completion of the biopsy. CONCLUSIONS: The ABBI system is an alternative to open biopsy with needle localization or large-core biopsy for nonpalpable mammographic abnormalities. This technique allows complete removal of the lesion in a one-step procedure. The ABBI system has certain limitations and mechanical problems, at least currently, and offers an advantage over current diagnostic modalities in a very limited number of cases only.

Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion.

The objective of this study was to determine whether extraperitoneal lymph node dissection for the staging of prostate cancer and extraperitoneal herniorrhaphy could be performed concomitantly with acceptable operative time and morbidity. Sixty patients underwent endoscopic extraperitoneal lymph node dissection (EEPLND) between 1991 and 1996. Eleven of these had 14 hernias repaired with polypropylene mesh. Endoscopic hernia repair added an average of 15 to 20 minutes to the EEPLND, resulting in an average operative time of 127 minutes (range 90 to 182 minutes). There was no difference in postoperative pain between patients undergoing combined operations and those undergoing EEPLND alone. The mean hospital stay after either procedure was 48 hours. There were no complications in the group undergoing herniorrhaphy. We conclude that extraperitoneal endoscopic hernia repair can be safely performed with EEPLND when necessary.