Faculty Bibliography

The Advanced Breast Biopsy Instrumentation (ABBI) system combines a cylindrical single-use biopsy device with digital stereotactic imaging that achieves targeting of radiographic lesions to +/- 1 mm. This allows complete removal of specimens in a one-step procedure that does not involve separate trips to radiology and then surgery. The ABBI system improves on core needle biopsy and fine-needle aspiration and may reduce the need for open biopsy. The authors' initial 34 cases utilizing the ABBI system were reviewed. The accuracy of specimen targeting, the success rate of lesion removal, and operative complications were some of the issues assessed. Six cases were not suitable for the procedure: the mammographic lesion was not visualized in four, and the breast was too thin on compression in two. There was successful removal of the lesion in 27 of the remaining 28 cases. There were no local wound complications, and patient satisfaction was high in all completed biopsies. The ABBI system is an effective new form of minimally invasive breast surgery. It provides complete excision of mammographic abnormalities. Its use of the most direct path to these lesions allows for minimal removal of adjacent normal tissue. In this study there were no complications and very little patient pain.

The role of endoscopic extraperitoneal herniorrhaphy (EEPH) in the management of giant scrotal hernias has not been well defined, and the technical details relating to operations on such hernias have not been described. We present our experience with 17 patients undergoing repair of giant scrotal hernias. Foley catheter bladder decompression was routinely employed. The Retzius space was developed early in the procedure and hernia sac contents were reduced in all cases. The inferior epigastric vessels were likewise divided in all patients. The average operative time was 76 min and all patients were discharged home the same day. There have been no recurrences on follow-up. There was no mortality, and morbidity was limited to seroma formation in two patients. We conclude that with certain technical modifications, EEPH can be safely employed for the treatment of giant scrotal hernias.

Pneumothorax was identified as a complication of endoscopic hernia repair in two patients with insufflation pressures of 15 mmHg and operating times exceeding 2 h. These patients also showed intraoperative perturbations in both oxygen saturation and end-tidal CO2 production. A prospective study was undertaken to determine whether similar complications would arise if preperitoneal insufflation pressures were limited to 10 mmHg. Postoperative chest x-rays were obtained on all patients to check for pneumothoraces, even clinically occult ones. Fifty patients were studied, with average operating times of 67 min. No patient demonstrated any hemodynamic or ventilatory changes, and none had any evidence of pneumothorax on x-ray. We conclude that these complications were not present when insufflation pressure was maintained at 10 mmHg and that routine x-ray is not warranted. Larger randomized trials of insufflation pressures are needed.

A retrospective review of all cholecystectomies performed at a single institution since the advent of laparoscopic cholecystectomy at that institution was undertaken. Of the 1848 cases analyzed, 1372 were completed laparoscopically. There was an increase in utilization of ERCP prior to cholecystectomy, and an increase in the number of cases being done laparoscopically for acute and gangrenous cholecystitis over the 48 months of the study. Of the 1442 cases started laparoscopically, eight technical complications were recognized, and conversion was required in five of these. Only two bile duct injuries were identified in the laparoscopic group. Data analyzed over the past 2 years of the study, when the number of surgeons performing laparoscopy remained stable, showed a decrease in both complication and conversion rates. There are no strong data to support the practice of routine intraoperative cholangiography.

The use of laparoscopic methods to explore the common bile duct is now well-established, although they continue to undergo continuous evolution and improvement. In experienced hands laparoscopic management of choledocholithiasis may be undertaken with morbidity and mortality at least as good as that of open surgery. The use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy before or after laparoscopic intervention must be evaluated. The degree of acceptance that laparoscopic techniques for common bile duct exploration (CBDE) will achieve within the surgical community remains to be determined, but will likely increase as more practicing surgeons familiarize themselves with them.

The posterior approach for groin hernia repair as popularized by Stoppa and Nyhus is one of the most solid repairs available. It requires a larger incision than the anterior approach, which has limited its use to recurrent and bilateral hernias. The endoscopic extraperitoneal herniorrhaphy (EEPH) accomplishes a similar repair via three minute incisions. This study suggests that EEPH is at least as safe and efficient as the open preperitoneal repair. Three hundred sixteen male patients underwent 405 hernia repairs by an endoscopic extraperitoneal approach. Ages ranged from 18 to 82 years old. There were 204 indirect, 182 direct, 13 pantaloon, and six femoral hernias. Eighty-nine were bilateral and 42 were recurrent. All repairs were done using polypropylene mesh. Follow-up has been achieved in 89% of patients and ranged from 7 to 50 months, with a median of 25 months. Seven patients (2.2%) required conversion to an open approach. Five recurrences have developed to date. Complications (5.7%) have included urinary retention, bladder injury, groin and/or scrotal hematoma, trocar site infection, lateral femoral cutaneous nerve neuralgia, and cardiac arrhythmia. Endoscopic extraperitoneal herniorrhaphy may provide an appropriate alternative to other methods of hernia repair when performed by experienced laparoscopists.

Endoscopic extraperitoneal herniorrhaphy (EEPH) was utilized to repair 326 groin hernias in 249 patients over a 32-month period. Nearly one in ten of the repairs was for a recurrent hernia. Several patients had contralateral hernias diagnosed only at the time of endoscopic examination. A recurrence rate of 1.6% and an overall complication rate of 5.2% are cited. After a plateau was reached on the surgeon's learning curve, various modifications in technique were implemented. Through these modifications, EEPH has become a safe, efficient, and standardized operation that can be performed with decreasing costs to the hospital and with increasing advantages to the patient.