Abstract:

The history of the development ofthefine art of physical examination is a record of the physician's efforts to pry ever deeper and deeper into the inner recesses of his patients (H. V.Findlay, 1937).The laparoscopic revolution or evolution caught the surgical field by surprise. Just a few years earlier, the term "endoscopic surgery" was not part of the vocabulary of most surgeons. As with all breakthroughs, the incorporation of laparoscopy into surgery posed its own set of challenges, including: (1) the growing significance of economic factors, (2) increasing pressure from industry, (3) a shift from the hospital to out-patient settings, (4) a different approach to surgical training, (5) changes in the surgeon-patient relationship, and (6) a range of ethical issues.

Authors:

Grzegorz S. Litynski, Institute for History of Medicine, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt/Main, Germany; Zoltan Szabo, Ph.D., F.I.C.S., M.O.E.T. Institute, San Francisco, CA, Fetal Treatment Center, Division of Pediatric Surgery, University of California School of Medicine, San Francisco, CA

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Abstract:

Ultrasonography has been an integral part of gynecology and general surgery in recent years. New technology has allowed this modality to be extended to include intraoperative assessment through a laparoscopic approach. This allows more accurate imaging with higher resolution than previously attainable. Combining the ultrasonic and visual images on the monitor screen simultaneously (picture in a picture) allows a further dimension of information which can modify surgical direction. The equipment used by the author is described and clinical experience discussed. Further clinical applications are considered and the practicality of the methodology assessed.

Authors:

Duncan Turner, M.D., M.B., B.S., F.A.C.O.G., Santa Barbara, CA

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Abstract:

The subject of the economic considerations involved in using disposable versus reusable instrumentation has become a controversial issue.The economic evaluations performed purely by economists may not appeal to the surgeon and may not be applicable in different parts of the world. The quality of disposable instruments and their convenience in laparoscopic surgery is not at issue; the controversy, instead, centers on the question of the cost-effectiveness of disposable equipment. High-quality instruments enable safe, suecessful operations. Some instruments are not available in reusable form and the quality of some reusable instruments (e-g-, laparoscopic scissors) is sometimes questionable, particularly as they are periodically in need of servicing or repair. For a routine cholecystectomy, clips can be mounted on a reusable applier to ligate the cystic duct and artery. This can save considerable cost. However, disposable clips and their appliers should be available in the operating room (OR) in case of emergencies such as uncontrolled bleeding.

Authors:

Raghu S. Savalgi, M.B.B.S., L.R.C.P., M.R.C.S., F.R.C.S., Ph.D.(Surg.), Yale University School of Medicine, New Haven, CT

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Abstract:

The worldwide explosion of laparoscopic surgery within general surgery began in the late 1980s and early 1990s. From its inception, surgeons have expected the image on the video monitor to resemble closely the image obtained in similar open surgery. The monitor image, however, is presented in two dimensions - height and width. Orientation of the surgeon to the anatomy is more difficult and requires a sound knowledge of anatomy, the relationships of organs to each other, and an understanding of the individual patient's unique structures. Adding a third dimension, depth, to imitate natural vision in open surgery may provide surgeons with the confidence to perform more advanced procedures. In addition, trainee surgeons, without the experience of open surgery which their senior colleagues have gained, may more rapidly appreciate orientation of the anatomy and learn the surgical task more quickly.

Authors:

Andreas Fountoulakis, M.D., Northwick Park and St. Mark's Hospital, London, U.K.; Alan Lomax, M.D., F.R.C.S.C., Dawson Creek District Hospital, Dawson Creek, B.C., Canada; Stephen Chadwick, M.S., F.R.C.S., Northwick Park Hospital, Harrow, London, U.K.

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Abstract:

The present trend in laparoscopic surgery is to make use of the Veress needle as an instrument for palpation of the abdominal cavity to secure "safe" blind introduction of the first trocar. The oxymoron is witness to the many mishaps experienced by the most daring surgeons who approach blindly each and every abdomen, irrespective of previous surgery. The "bayonet technique" heralded by the gynecological school of laparoscopy has never been accepted by us, due to its inherent characteristic risk of injuries to the pelvic or retroperitoneal organs. Whenever the patient has had previous abdomino-pelvic surgery, the open laparoscopy technique is preferred with the Hasson's trocar either at the navel or at any other location, as deemed appropriate by the site of old incisions. Experience and laparoscopic findings have led us to enforce the principle that open laparoscopy should be instituted if any scar, even from previous Iaparoscopy, is present over the anterior abdominal wall. A variation in the technique for introduction of the Veress needle and safe execution of the pneumoperitoneum was devised to be used when the peritoneal cavity has not been violated surgically.

Authors:

Osvaldo Contarini, M.D., F.A.C.S., F.I.C.S., Ashok Roychoudhury, M.D., Memorial Medical Center, Baptist Medical Center, Jacksonville, FL

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Abstract:

Reflux of duodenal contents into the stomach is a normal physiological event occurring most commonly at night but also in the fasting and postprandial daytime periods. Previously, the terms "bile reflux" and "alkaline reflux" have been used to describe this process. However, duodenal contents contain more than just "bile" and studies have shown that the term "alkaline reflux" is a misnomer since pH > 7 does not correlate with reflux of duodenal contents. Therefore, duodenogastroesophageal reflux (DGER) may be a more appropriate term to describe the pathological regurgitation of duodenal contents through the pylorus into the stomach with subsequent reflux into the esophagus.

Authors:

Michael F. Vaezi, M.D., Ph.D., University of Alabama at Birmingham, Birmingham, AL; Joel E. Richter, M.D., F.A.C.P., F.A.C.G., The Cleveland Clinic Foundation, Cleveland, OH

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Abstract:

Thoraco-Iaparoscopic surgery presents a series of technical difficulties linked mainly to the necessity of acquiring proper motor coordination and spatial reconstruction of an operative field that is seen from a distance on a two-dimensional video monitor, in the absence of any direct tactile feedback. In an effort to improve the motor coordination of the operating surgeon and of the surgical team, many apparatuses have recently become available on the market that allow the reproduction of a 3-D image on a video monitor. Such apparatuses have technical characteristics that are substantially diverse in technology and provide significantly different end results.

Authors:

Emanuele Lezoche, M.D., F.A.C.S., Alessandro M. Paganini, M.D., Ph.D., F.A.C.S., University of Ancona, Ancona, Italy; Davide Lomanto, M.D., Ph.D., University of Rome "La Sapienza," Rome, Italy; Francesco Carlei, M.D., University of L'Aquila, L'Aquila, Italy

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Abstract:

Morbid obesity is a serious disease that is responsible for several co-morbid conditions. Increased risks of hypertension, adult onset diabetes mellitus, dyslipidemia, pulmonary disease (Pickwickian syndrome), musculo-skeletal disorders, gallbladder disease, deep vein thrombosis, venous stasis ulcers, and increased prevalence of certain types of cancers (uterine, breast, colon carcinoma) have been reported, together with severe psychological and social disability. Nonsurgical treatment options including various combinations oflow-calorie or very-low-calorie diets, behavior modification, exercise, and drug therapy may achieve acceptable transient weight reduction but fail to maintain reduced body weight in most patients.

Authors:

Alessandro M. Paganini, M.D., Ph.D., F.A.C.S., Mario Guerrieri, M.D., Francesco Feliciotti, M.D., Emanuele Lezoche, M.D., F.A.C.S., Ospedale Umberto I, University of Ancona, Ancona, Italy

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Abstract:

Blind insertion of the Veressneedle and the conventional primary trocar have remained troublesome steps during laparoscopic surgical procedures. The standard primary trocar can be inserted directly without preexisting pneumoperitoneum, thus avoiding use of the Veressneedle. This approach still requires blind insertion, and inadvertent traumatic injuries have been reported. Complications from such trocar insertions can be severe and at times lethal. Although the rate of such complications is acknowledged to be small, the absolute number becomes a relevant public health issue in light ofthe high frequency of both operative and diagnostic laparoscopic procedures worldwide. Traumatic injuries to vessels, bowel, and other abdominal organs continue to occur despite proper surgical training, operator experience, and use of up-to-date equipment.

Authors:

Steven G. Kaali, M.D., F.A.C.O.G., David H. Barad, M.D., F.A.C.O.G., Irwin R. Merkatz, M.D., Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY

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Abstract:

Laparoscopic surgery has been widely applied not only in cholecystectomy but also in gastrointestinal operations. In previous reports the authors proposed their original operative technique, laparoscopic intragastric surgery (LIGS), in which all trocars and surgical instruments are inserted directly into the gastric lumen to perform the resection of mucosal or submucosal lesions of the stomach. The purpose of this article is to introduce laparoscopic gastrotomy as a new technique for removing early gastric cancer by LIGS.

Authors:

Shuichi Ohashi, M.D., Yosuke Yoden, M.D., Hiroki Kanno, M.D., Kazuhide Tei, M.D., Akinori Akashi, M.D., Manzurul Haque, M.D., Takarazuka City Hospital, Kohama, Takarazuka, Hyogo, Japan

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Abstract:

Early stages of rectal cancer, well and ~oderately differentiated, have a low rate of regional spread and therefore may be treated by conservative therapy. Transanal Endoscopic Microsurgery (TEM) was introduced into clinical practice by G. Buess in 1983. This technique allows for the local treatment of benign lesions and the early stages of rectal cancer through a modified rectoscope, yielding good exposure of the operative field with-three-dimensional vision; mucosectomy and full thickness excision procedures can be performed. TEM benefits are the same as other minimally invasive techniques: less pain, reduced morbidity, faster recovery time, and an absence of skin scars. In the present paper, the authors report the technique and the results of the experience of 89 TEM procedures for the treatment of rectal tumors.

Authors:

Mario Guierrieri, M.D., Alessandro M. Paganini, M.D., Ph.D., F.A.C.S., Francesco Feliciotti, M.D., Emanuele Lezoche, M.D., F.A.C.S., Ospedale Umberto I, University of Ancona, Ancona, Italy

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Abstract:

The incidence of mesenteric cysts is relatively uncommon. Sprague examined its frequency and noted that five large hospitals located in the Los Angeles area averaged one documented case of mesenteric cyst per 100,000 hospital admissions. The most common location appears to be the mesentery of the small bowel, especially that of the ileum. Cysts of the mesentery of the large bowel are somewhat less frequent, accounting for approximately 38% of the total incidence. Those involving the large bowel most commonly involve the mesentery of the sigmoid colon.

Authors:

Istvan Gal, M.D., Ph.D., Laszlo Mecseky, M.D., Istvan Kovaks, M.D., Bugat Pal Hospital, Gyöngyös, Hungary

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Abstract:

Advantages of laparoscopiC cholecystectomy (LC) in terms of shorter hospital stay, less pain, and diminished disabilrty are well documented. Less well documented are the long-term comptications of this procedure. We report a patient who developed obstructive jaundice 8 months following LC from a spilled gallstone. In our review of the literature using MEDLINE from January 1990to June 1995,we did not find this complication reported.

Authors:

Venkatachala I. Sreenivas, M.D., Hospital of St. Raphael, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT; Phaniraj Iyengar, M.D., Suresh T. Bhagia, M.D., Hospital of St. Raphael, New Haven, CT; Viswanadham Pothula, M.D., Hospital of St. Raphael, New Haven, CT

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