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Study Aim: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome., Patients and Methods: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up., Results: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossetti's type TF became the reference procedure (80.3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80 min). The rate of conversion decreased from 10.2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 14.3% to 4% and then 0%. Seven cases of recurrence occurred (4.6%), 5 in group I (10.2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up)., Conclusion: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with "guidance" during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.

Situation: In spite of recent progress in medical imagery, the findings of preoperative investigations of the liver are not always accurate and precise. Since the development of surgical laparoscopy, advantages of the laparoscopic examination are associated with advantages of laparoscopic ultrasonography., Objective: The purpose of this work is to report the technique of staging laparoscopy with laparoscopic contact ultrasonography in the intraoperative assessment of patients with liver tumors, and to analyse its impact on the selection of patients for hepatic resection with curative intent., Methods: The basic exploration follows at first portal branches and then hepatic veins. During the course of vascular exploration, the corresponding liver parenchyma is examined. A mobilization of the probe with clockwise or anticlockwise rotation movements allows full exploration of the liver., Results: The association of laparoscopic examination and laparoscopic ultrasonography allows to localize with accuracy malignant and benign lesions and to perform ultrasound guided biopsy. Liver tumors not visible on preoperative imagery may be identified, relationships with adjacent vessels and presence of tumoral thrombi in major vascular structures may be assessed. Resectability of the liver tumors is at the best specified., Conclusion: Staging laparoscopy with laparoscopic ultrasonography improves selection of patients for liver resection and facilitates choice and performance of the most appropriate resection.

Study Aim: The aim of this study was to assess the feasibility of routine intra operative cholangiography during laparoscopic cholecystectomy (LC) and to evaluate its impact in the detection of common bile duct stones or iatrogenic bile duct injuries., Patients and Method: From January 1991 to January 1999, 1,050 patients (mean age: 52.5 years) with symptomatic or complicated cholelithiasis were operated on laparoscopically. Intraoperative cholangiography was attempted in all patients before cholecystectomy, performed with an ureteral catheter (diameter: 5 F) introduced into the cystic duct under control of intensifier screen. In case of detection of common bile duct stones (CBDS) or bile duct injury, a surgical management was routinely attempted laparoscopically., Results: Cholangiography was successfully performed in 840 cases (82.4%). The mean duration of this examination was 15 min (7-45). The success rate was significantly higher in patients with uncomplicated cholelithiasis (90.4%), compared to patients with acute cholecystitis (61.9%) (p = 0.01). The failure rate decreased with experience, falling from 23% for the first 100 attempts to 1% for the last 100. CBDS were identified in 62 patients (7.4%) in 18% of those with acute cholecystitis and 4.6% of those with uncomplicated cholelithiasis. In 21 cases (33%), there were no predictive factors to suggest CBDS. There were 8 false positive (0.9%). Among the 6 cases of bile duct injury observed in this series (0.57%), four patients had an intraoperative cholangiography and the injury was diagnosed peroperatively in two patients and immediately repaired. There was no postoperative death in this series., Conclusions: Routine intraoperative cholangiography appears to be the best method for the detection of common bile duct stones and improves prognosis of bile duct injuries when they are immediately detected and peroperatively repaired.

Study Aim: The aim of this retrospective study was to compare two concurrent series of patients operated on for inguinal hernia with the same laparoscopic procedure, the first one in a teaching hospital with a number of trained surgeons and the second one in a private center with only one trained surgeon., Patients and Method: Five hundred and forty-one patients with 757 hernias were operated on over a period of six years by a totally pre-peritoneal laparoscopic approach. Two hundred and sixteen patients were operated on in a teaching hospital by 48 surgeons (six senior and 42 trainee surgeons; group I), 325 were operated on in a private center by one surgeon who had been trained in the same teaching hospital (group II). The two groups of patients and their hernias were comparable. The comparison was established on the following criteria: duration of operation, rate of conversion, length of hospitalization, morbidity and mortality rate, recurrence rate and costs., Results: Operations performed by surgical trainees were associated with: (1) a mean operative time significantly (P = 0.01) longer for both unilateral (68 vs. 41 min) and bilateral (108 vs. 68 min) hernias. The operative time did not change in the teaching hospital and decreased with experience in private practice (from 62 to 25 min for unilateral hernias); (2) more frequent per-operative complications, particularly opening of the peritoneum (28% vs. 3%, P = 0.001); (3) a mean duration of hospitalization significantly (P = 0.05) longer, on average by 1.6 d; (4) a morbidity rate after 30 days significantly higher (16.2% vs. 4.9%, P = 0.01); and, (5) higher costs. There was no significant difference concerning mortality rate (nil), conversion rate (1.5%) and recurrence rate (1.3% vs. 0.6%, non significant)., Conclusion: Surgical training for laparoscopic treatment of inguinal hernias was associated with a longer operation time and hospital stay, and with higher morbidity and costs. After a good initial training in a teaching hospital, surgeons were capable of performing laparoscopic repair of inguinal hernias with good results.

The authors report a case of laparoscopy post mortem for unexplained inpatient death. It is minimally invasive, easy to perform, accurate, and not disfiguring. As well, it is easy to accept among mourning families. It should be considered when consent for conventional autopsy is lacking.

Aim: The aim of videoparietoscopic surgery is to repair an abdominal wall weakness or defect without affecting the overlying skin, mainly for cosmetic reasons, and especially in young women., Patients and Method: A supra-pubic or umbilical approach was used, depending on the site of the lesion to be repaired. A 10 mm trocar with a sponge mandrin was placed in contact with the aponeurosis. After an initial dissociation of the cellular tissue, progressive insufflation with CO2 produced extensive detachment of the cutaneous plane upwards and laterally. Using one or two 5 mm trocars, the aponeurotic plane was progressively freed and the pathological zones were identified and repaired with standard endoparietal sutures or with percutaneous sutures using a Reverdin needle. Fifteen patients (14 females, one male) with a mean age of 30 years (19-36), were treated by parietoscopy for a diastasis of the rectus abdominis (five cases), an eventration (three cases) or an epigastric or linea alba hernia (seven cases)., Results: A conversion to a classical technique was necessary in one man with a diastasis of the rectus abdominis, due to fibrous tissue which did not allow a subcutaneous plane of detachment to be obtained. Successful repair was possible in 14 cases. The mean operating time was 1 h 20 min; the mean duration of hospitalisation was 2 days (1-3). There was no mortality or morbidity. With a mean 18-month follow-up (range: 4-40), cosmetic and functional results were excellent., Conclusion: Abdominal videoparietoscopy allows repair of minor parietal pathologies while preserving the overlying skin. It is indicated for cosmetic reasons in young women with normal skin overlying a localised abdominal wall defect or weakness.

Background: The classical treatment of perforated sigmoid diverticulitis with generalised peritonitis is based on the principle of two-stage surgical procedures with a temporary initial defunctioning colostomy. This approach is associated with significant morbidity, concerning mainly the abdominal wall., Patients and Methods: Ten consecutive patients, eight female and two male, with a mean age of 54.6 years, underwent an emergency laparoscopy for generalised peritonitis secondary to perforated diverticula. Six had had previous infectious episodes; six were obese; four were diabetic and two had chronic lung disease. After exploration of the abdominal cavity and discovery of a purulent peritonitis (n = 8) or faecal peritonitis (n = 2), an extensive peritoneal lavage was performed (average 15 litres), the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. In some cases, drainage of dependent zones was also performed. No colostomies were performed. Antibiotic therapy instituted as soon as the diagnosis had been made was continued, on average, for 7 days., Results: There was no mortality. There was a low morbidity: one case of lymphangitis on catheter and one of broncho-pulmonary infection. No cases of abdominal wall sepsis or residual deep collections were observed. The mean duration of hospitalisation was 8 days. Nine patients underwent a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later, with a mean duration of hospitalisation of 6 days. One conversion to laparotomy was necessary., Conclusions: Laparoscopic treatment of generalised peritonitis secondary to perforated sigmoid diverticulitis constitutes an alternative to classical surgery. It is associated with a decreased morbidity and a marked reduction in duration of the hospitalisation. Colostomy can be avoided and the patient's quality of life is improved during the period previous to secondary colectomy, performed by laparoscopy eight times out of nine. In addition, the cost of this approach is significantly lower.

Study Aim: This prospective study was undertaken to evaluate the efficiency of staging laparoscopy associated with laparoscopic ultrasonography in the assessment of tumoural extension and surgical resectability in patients with carcinoma of the pancreatic head., Patients and Methods: From June 1995 to March 1997, 26 consecutive patients (11 male and 15 female patients), with a mean age of 62.5 years, were included in this study. The lesion was located in the pancreatic head with jaundice. Four staging methods were used: percutaneous ultrasonography (n = 26) computed tomography (n = 26), endoscopic ultrasonography (n = 26). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination., Results: Results of percutaneous ultrasonography and computed tomography were similar, predicting unresectability in 50% of the patients. Endoscopic ultrasonography performed in the 16 patients without visible metastases according to the previous procedures predicted surgical resectability in seven patients only. With staging laparoscopy associated with laparoscopic ultrasonography, undiscovered metastases were found and unresectability was predicted in 21 patients out of 26; the sensitivity was 100% for liver metastases, peritoneal metastases and vascular involvement, 90% for lymph node involvement and 88% for diagnosis of the primitive lesion. A Whipple procedure was performed in five patients and a palliative bypass in all the other patients except one. An unnecessary laparotomy was avoided in 12 patients., Conclusions: Staging laparoscopy associated with laparoscopic ultrasonography is superior to all other staging methods. It should be the first step of a potentially curative surgical treatment (five cases only in this series) or of a palliative bypass. Laparotomy was avoided in 12 cases.

Long-term survival (2 to 11 years) in 5 patients who underwent the Beger operation for severe, predominantly cephalic chronic pancreatitis showed that total pain relief has been achieved in all cases, together with weight gain (2 to 18 kg) and return to former occupation. In 3 of the 4 patients who did not have a concomitant biliary derivation, jaundice (2 cases treated by bile duct-duodenum anastomosis) or angiocholitis (1 case) was observed 7, 2 and 3 years after the initial operation. These results are better than with classical exeresis or derivation. The disadvantage of the procedure is that it is technically difficult. In case of a voluminous cystic cavity, the Frey operation should be preferred.

Angiomyolipoma is a benign mixed mesenchymal tumor. It is a well known entity in the kidney, but very rare in the liver. A case of renal and hepatic angiomyolipoma without no evidence of tuberous sclerosis is presented. This association has been previously described only once before. Radiologic and ultrasonographic findings may be suggestive of the lesion, showing both fatty and hypervascular components. The definitive diagnosis requires histologic and immunohistochemical confirmation by fine needle aspiration biopsy. Surgical excision is unnecessary unless abdominal discomfort is present or malignant tumor is not completely ruled out.