Search

Abstract: Objective: To choose between laparoscopic “vascular hitch” (VH) and dismembered pyeloplasty (DP) in treatment of aberrant lower pole crossing vessels potentially responsible for pelviureteric junction obstruction (PUJO) in older children. Patients and methods: Retrospective study of 19 patients treated laparoscopically for PUJO. Based on videos of the procedures, we studied the anatomical relationship between the renal pelvis, the pelviureteric junction, and the aberrant vessels. Results: Eight patients had laparoscopic VH and 11 had DP. All patients with DP needed drainage. In the VH group, 7/8 patients were asymptomatic and had decreased pelvic dilation. Half of them accepted MAG3 scintigraphy, and in these patients the obstructive syndrome disappeared completely. The last patient in this group was lost to follow-up. We observed three anatomical variations in the location of polar vessels: type 1 (in front of the dilated pelvis), type 2 (in front of the pelviureteric junction), type 3 (under the pelviureteric junction, resulting in ureteral kinking). Conclusion: Laparoscopic VH is a simple technique involving no urinary anastomosis or drainage, but we cannot guarantee that the crossing vessels are the sole etiology for PUJO. Following our experience, only patients with type 3 anatomical variations and with a normal pelviureteric junction should be proposed for VH. [Copyright &y& Elsevier]

Interstitial pregnancy is a rare form of ectopic pregnancy. Interstitial pregnancy refers to an ectopic pregnancy implanted in the interstitial portion of the tube. This is the segment of Fallopian tube traversing the muscular wall of the uterus, beginning at the tubal ostium and proceeding superiorly and laterally away from the uterine cavity to join the isthmic portion of the tube arising from the fundus. The interstitial portion, being a relatively thicker portion of the tube, has a greater capacity to expand before rupture takes place. Therefore, such pregnancies may present late and rupture can result in life-threatening haemorrhage, particularly because of the high vascularity of this region. Diagnosis is difficult and treatment has not been standardized. A high index of suspicion is required to diagnose this type of pregnancy. Access to high-resolution transvaginal ultrasonography and highly sensitive quantitative β-hCG assays has increased early detection and appropriate management. A wide array of treatment methods have been tried for the management of this condition. The optimum therapeutic option depends on variables related to each individual case. [ABSTRACT FROM PUBLISHER]

Page kidney is defined as the external compression of the kidney, typically by a subcapsular hematoma, that leads to hypertension due to hypoperfusion and ischemia. The treatment options include medical anti-hypertensive treatment, percutaneous drainage, surgical decortication and nephrectomy. Laparoscopic decortication of Page kidney is a newly defined minimally invasive management technique. We describe 2 cases of Page kidney that failed to improve with percutaneous drainage but were successfully treated with the laparoscopic approach. [ABSTRACT FROM AUTHOR]

Abstract: The objectives of this retrospective case series were to report our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center and to present a review of the literature. Four patients experienced recurrent cornual ectopic pregnancy, and 1 patient had 2 consecutive recurrences. Laparoscopic surgery was performed to treat recurrent cornual ectopic pregnancy in all 4 patients. These 4 cases together with 10 cases collated from the literature review confirm that this entity is rare. Cornual ectopic pregnancy can recur as early as 4 months and as late as 5 years after the first ectopic pregnancy. There seems to be no correlation between the treatment method of the first ectopic pregnancy and the risk of recurrence. The etiology of recurrent cornual ectopic pregnancy is not fully understood, although it shares similar risk factors with tubal ectopic pregnancy. Both medical therapy and surgery are used to treat recurrent cornual ectopic pregnancy, with surgery often performed via laparotomy. These 4 cases constitute the largest case series of recurrent cornual ectopic pregnancy treated laparoscopically. Our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center reveals that it is effective and safe. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate fertility outcomes after laparoscopic and ART management of endometriosis in an infertile population. Patients and methods: Retrospective analysis including 79 infertile patients treated by laparoscopic surgery. Fertility was studied in relation to pregnancy''s mode (spontaneous or ART) and to endometriosis stages (rAFS). Results: After laparoscopy, 8.9% of patients had a spontaneous pregnancy. IIU led to a cumulative rate of pregnant women of 21.5%. Then after laparoscopy, IIU and IVF, 68.4% of patients were pregnant. The average delay was 460 days between laparoscopy and spontaneous pregnancy, 271 days between surgery and IIU pregnancy and 600 days between surgery and IVF pregnancy. Among women with stages I-II endometriosis (62 cases), 11.3% patients obtained a spontaneous pregnancy, the cumulative rate of pregnant women after laparoscopy and IIU was 25,8%. After laparoscopy, IIU and IVF, 66.1% of patients were pregnant. The average post-surgical time to spontaneous pregnancy was 460 days. The average delay between surgery and IIU pregnancy was 279 days and 589 days between surgery and IVF pregnancy. In case of stages III-IV (17 patients), 76.4% of pregnancies were obtained. No spontaneous pregnancy was observed. 94.1% of patients were treated with IVF, leading to a global rate of pregnancy of 70.5%. The average delay between surgery and IVF pregnancy was 563 days. Conclusions: With a combination of surgery and ART, two-third of patients were pregnant with an average time between surgery and pregnancy of less than two years. This combination (surgery and ART) increases the chances of becoming pregnant. At the moment, the delay between surgery and ART needs to be established. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the feasibility of laparoscopic management of women with gynecologic emergencies by the residents and the chief resident in an organized resident training program. Methods: A retrospective study of patients with gynecologic emergencies who underwent laparoscopic surgery between January 1, 1999, and May 31, 2006 was done. Results: For the 369 patients included, the mean operative time of 74±31.35minutes was significantly increased by advanced patient age (P <0.001), pelvic inflammatory disease with or without tubo-ovarian abscess (PID±TOA) (P <0.050), the first semester of chief residency (P <0.050), and conversion to laparotomy (P <0.001). Mean length of hospital stay was 40±24hours. Factors such as advanced patient age (P <0.001), prolonged length of surgery (P <0.001), PID±TOA (P <0.001), first semester of chief residency (P <0.050), conversion to laparotomy (P <0.001), and blood transfusion (P <0.050) significantly increased the length of hospital stay. The conversion rate to laparotomy was 4.6% (n=17), and it was significantly associated with advanced women age (OR 1.11; 95% CI, 1.05–1.17, P <0.001) and PID±TOA (OR 6.04; 95%CI, 2.17–16.62, P< 0.001). Postoperative complications were recorded in 3 (0.81%) patients. Conclusion: Laparoscopic management of gynecologic emergencies by senior residents and a chief resident within an organized resident training program is feasible. These results reinforce the relevance of a well-structured residency endoscopic training program. [Copyright &y& Elsevier]

Background: Persistent urachal sinuses or fistulas are rare but may potentially cause various symptoms and lead to repeated operations. Both laparoscopic and open surgery have been used for the resection of the urachus. Methods: This report describes the first case of an external urachal fistula with recurrent infections and discharge of the umbilicus treated by complete resection using single-incision laparoscopic surgery (SILS). This involved a laparoscopic single-incision three-trocar-technique, leaving the infected site of the umbilicus untouched. Results: Healing of the umbilicus was uneventful and complete. To date, the authors have not seen any recurrence of the fistula or its symptoms. Conclusions: Remnants of the urachus should be considered in cases of recurrent infections or discharge of the umbilicus. The SILS procedure is an excellent option for the radical resection of the remnant urachus. Compared with the standard laparoscopic approach, it requires only one incision, decreasing the risks compared with those of several trocars. At the same time, the patient benefits from the better cosmetic result. [ABSTRACT FROM AUTHOR]

Objective: To investigate the coexistence of endometriosis in women presenting with symptomatic leiomyomas. Design: Retrospective study. Setting: Tertiary university medical center. Patient(s): We reviewed the medical records of 131 patients who underwent laparoscopic myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of endometriosis. Intervention(s): All patients underwent laparoscopic myomectomy or hysterectomy. Main Outcome Measure(s): The main outcome measure of the study was the presence or absence of endometriosis. Result(s): Of the 131 patients, 113 were diagnosed with endometriosis and fibroids, while 18 were diagnosed with fibroids alone. Patients with fibroids were on average 4.0 years older than those with endometriosis and fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with fibroids alone. Conclusion(s): An overwhelming majority of patients with symptomatic fibroids were also diagnosed with endometriosis. Overlooking the concomitant diagnosis of endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution. [Copyright &y& Elsevier]

The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature. [Copyright &y& Elsevier]

Abstract: Study Objective: To describe our experience with surgical treatment of endometriosis. Design: Observational cohort study (Canadian Task Force classification II-2). Setting: Private hospital. Patients: One hundred sixty-three patients with histologically confirmed endometriosis who had completed a preoperative questionnaire, had available intraoperative findings and photographic documentation, and had been followed up to 6 years. Intervention: Laparoscopic electrosurgical excision of endometriotic implants. Measurements and Main Results: Patients completed a visual analogue scale (VAS) for 6 components of endometriosis-related symptoms. The EuroQol Group EQ-5D questionnaire was used for evaluation of quality of life. Long-term follow up was performed using a questionnaire and review of patient medical records. Mean (SD; 95% confidence interval) patient age at surgery was 31.01 (8.5; 29.7–32.3) years. The primary symptom at initial consultation was dysmenorrhea in 94 patients (57.67%, nonmenstrual pelvic pain in 44 (27%), dyspareunia in 11 (6.75%), menorrhagia in 8 (4.9%), infertility in 4 (2.45%), and pelvic mass in 2 (1.23%). Thirty-three patients (20%) had undergone previous surgery because of endometriosis. At surgery, endometriosis was stage I in 50 patients (30.67%), stage II in 65 (39.88%), stage III in 23 (14.11%), and stage IV in 25 (15.34%). Other surgical procedures performed with the index surgery were cystoscopy in 48 patients (29.45%), laparoscopic ovarian cystectomy in 24 (14.72%), laparoscopic hysterectomy in 15 (9.2%), laparoscopic appendectomy in 9 (5.5%), sigmoidoscopy in 6 (3.68%), laparoscopic oophorectomy in 6 (3.68%), extensive laparoscopic adhesiolysis in 5 (3.07%) bowel resection in 2 (1.25%), laparoscopic myomectomy in 1 (0.61%), and bladder resection in 1 (0.61%). Surgery proceeded to laparotomy in 6 patients (3.68%). Major surgical complications included bowel perforation, severe pelvic pain 1 week after laparoscopic excision, and temporary numbness of the right side of the perineum in 1 patient each. Minor postoperative complications included urinary tract infection in 3 patients and port site infections that resolved with oral antibiotic therapy in 2 patients. Follow-up was 37.82 (20.09; 34.74–40.92) months. Surgical excision of endometriosis had a positive effect on endometriosis-related symptoms. Four pain scores were reduced, with statistically significant differences (p <.001 and p <.05): dysmenorrhea, pelvic pain not related to menstruation, dyspareunia, and dyschezia. The positive effect of surgical excision on patient quality of life was demonstrated by a statistically significant difference on the EQ-5D index (p <.001) and the EQ-5D VAS (p <.001). Thirty-two (20%) patients underwent a second procedure after the index surgery. Endometriosis stage affects the probability of requiring further surgery because of recurrent symptoms. There was evidence of endometriosis at histologic analysis in only 13 (40.62%) patients who required further surgery. Conclusion: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life as measured by both the EQ-5D index and the EQ-5D VAS, with a low complication rate. [Copyright &y& Elsevier]

Abstract: Objective: The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse. Study design: Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse. Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia. At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually. Results: We treated 165 women, with an average age of 67 (range 58–76 years; S.D. 19.22), average parity of 3 (range 2–5), and average body mass index of 28 (range 24–30). In many of them, more than one additional procedure was performed. At a median follow-up of 43 months (range 6–96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina. Conclusions: Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate). [Copyright &y& Elsevier]

Introduction: Laparoscopy may have a place in the treatment of VUR, as previously reported in some small series without impacth on current management. In this study we present the results of laparoscopic extravesical transperitoneal treatment on 41 units of VUR. Material and methods: Between January 2001 and December 2007, 34 children (41 units) with primary VUR were treated with extravesical reimplantation (Lich-Gregoir technique) with a transperitoneal laparoscopic approach. Twenty-seven patients had unilateral VUR and seven had bilateral VUR. Four patients had double total collector system associated to reflux without ureterocele. Patients average age was 48. 2 months (range 12-62 months), 27 (80%) female and 7 male (20%). Results: The average surgical time was 110 minutes in unilateral and 180 in bilateral VUR. All procedures were successfully completed laparsorcopically and the reflux was corrected in all except in one patient with grade III VUR who changed to grade I. We had 4 mucosal perforations, 3 of them without leakage, one had a urinoma as the result of early urinary catheter removal by the patient. Maximal hospital stay was 72 hours. After 15 to 49 months follow-up only one patient had a urinary tract infection. Conclusion: This study shows that laprasocopic extravesical transpseritoneal reimplantation for vesicoureteral reflux is a safe and successful procedure, with less postoperative complaints, even in bilateral simultaneous and duplex ureters, with similar success rate, as with open surgery; a considerably shorter hospital postoperative stay, and earlier discharge. Mucosal perforation was treated maintaining a Foley catheter for 3 or 4 days. [ABSTRACT FROM AUTHOR]

No studies have been performed to evaluate and compare adhesion formation after laparoscopic ovarian drilling with that after ovarian wedge resection by minilaparotomy at the very early stage one week after surgery in women with polycystic ovarian syndrome (PCOS). We investigated adhesion formation after surgical ovarian wedge resection by minilaparotomy (group I; n=37) and laparoscopic ovarian electrodrilling (group II; n=39) in 76 clomiphene citrate-resistant anovulatory infertile women with PCOS. All patients underwent an early second-look laparoscopy one week after operation. Thirty-six women (92.3%) in group II were found to be free of adhesions, whereas 81.1% (30 of 37) of the women in group I had periovarian adhesions. The frequencies of periovarian, intra-abdominal and uterine adhesions in group I were significantly higher than those in group II. There were significant differences in the AFS adhesion scores between group I (9.0±9.7 points) and group II (0.1±0.5 points). After surgery all women ovulated spontaneously or with clomiphene citrate. The pregnancy rate within 1 year after surgery in group II (87.2%) was significantly higher than that in group I (59.5%). The women with PCOS who were treated with laparoscopic ovarian electrodrilling were almost free of postoperative adhesion formation and most of them conceived within 1 year after surgery. This laparoscopic technique should be considered at an early stage in infertile women with PCOS who have failed to respond to clomiphene citrate therapy. [ABSTRACT FROM AUTHOR]

Ectopic pregnancy is a life‐threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig‐Holstein. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study was to compare laparoscopic and abdominal approach in the treatment of endometrial cancer in our department. Study design: From January 1999 to November 2002, 77 patients underwent surgery for stages I–III endometrial cancer. The first group of 36 patients had abdominal hysterectomy as well as salpingo-oophorectomy, with or without lymphadenectomy. The remaining 41 patients received laparoscopic assisted vaginal hysterectomy as well as salpingo-oophorectomy, with or without lymphadenectomy. In this retrospective study, we have compared the surgical results, the short- and long-term morbidity and the outcome of the two patient groups. Results: Body mass index (BMI) was significantly higher in the laparoscopic group (27.3 versus 24.6; p =0.009). The average time for surgery was significantly longer for the laparoscopic group (143.6min versus 109.7min; p =0.0001), but lymphadenectomy was performed in more patients (63.4% versus 25%; p =0.001). Postoperative hospital stay was significantly longer in patients undergoing the abdominal approach (4.59 days versus 3.18 days; p <0.0001). No blood transfusions were performed and the rates of complications were similar in the two groups. No differences were found in recurrence and survival rate. Conclusions: In our experience, laparoscopic and abdominal surgery can achieve similar results in the treatment of endometrial cancer. In our series, even with the BMI and the number of lymphadenectomies being higher in the laparoscopic group, the rates of complications were similar in the two groups. [Copyright &y& Elsevier]

Hydatid disease is a rare entity primarily affecting the population of developing countries. The parasite shuttles between the liver and lungs. but almost any organ can be invaded, forming cysts. Septation and calcification of the cysts with a high antibody titre in the patient''s serum confirm the diagnosis, although more sophisticated tests have been applied recently. Surgery constitutes the primary treatment, with a variety of techniques based on the principles of eradication and elimination of recurrence by means of spillage avoidance. Minimally invasive techniques and percutaneous drainage of the cysts are now feasible because of progress in the field. The aim of this review is to collect the experience from three different institutions and to provide practical guidelines for diagnostic and therapeutic strategies. [Copyright &y& Elsevier]

Background Laparoscopic treatment of hydatid disease of the liver can be performed safely in selected patients. Methods Six hundred and fifty patients were treated for hydatid disease of the liver between 1980 and 2003 at the Hepatopancreatobiliary Surgery Unit of Istanbul Medical Faculty, Istanbul University. Of these, 60 were treated laparoscopically between 1992 and 2000. A special aspirator-grinder apparatus was used for the evacuation of cyst contents. Ninety-two percent of the cysts were at stages I, II or III according to the ultrasonographic classification of Gharbi. Results Conversion to open surgery was necessary in eight patients due to intra-abdominal adhesions or cysts in difficult locations. There was no disease- or procedure-related mortality. Most of the complications were related to cavity infections (13.5%) and external biliary fistulas (11.5%) resulting from communications between the cysts and the biliary tree. There were two recurrences in a follow-up period ranging between 3.5 and 11 years. Discussion Laparoscopic treatment of hydatid disease of the liver is an alternative to open surgery in well-selected patients. Important steps are the evacuation of the cyst contents without spillage, sterilization of the cyst cavity with scolicidal agents and cavity management using classical surgical techniques. Our specially designed aspirator-grinder apparatus was safely used to evacuate the cyst contents without causing any spillage. Knowledge of the relationship of the cyst with the biliary tree is essential in choosing the appropriate patients for the laparoscopic technique. In our experience of 650 cases, the biliary communication rate was as high as 18%; half of these can be detected preoperatively. In the remaining, biliary communications are usually detected during or after surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are helpful to overcome this problem. As hydatid disease of the liver is a benign and potentially recurrent disease, we advocate the use of conservative techniques in both laparoscopic and open operations. [ABSTRACT FROM AUTHOR]

Background: Bleeding from esophageal varices is the major cause of death in patients with portal hypertension. The ideal surgical procedure should effectively control bleeding and maintain liver function with low rates of encephalopathy. Based on this objective, laparoscopic devascularization of the lower esophagus and upper stomach was studied.Methods: Eighteen patients were studied prospectively who underwent a laparoscopic esophagogastric devascularization procedure for variceal hemorrhage. The diaphragmatic hiatus and esophagus are dissected. The lower 7 or 8 cm of esophagus is devascularized. Devascularization of the gastric fundus is then accomplished by meticulous dissection and ligation of the short gastric vessels. The hepatogastric ligament is opened, permitting identification and isolation/ligation of the left gastric vessels. The dissection and ligation of the vessels at lesser curvature proceeded up to the diaphragmatic hiatus with devascularization of the external varices from the retroperitoneum or mediastinum at the esophagogastric junction.Results: Mean operating room time was 111 min (range, 80-140 min) (6 emergent/12 elective). Mean blood loss 388 ml (range, 150-650 ml). Intensive care unit stay averaged 48 h, with a mean hospitalization of 11 days. Liver function and coagulation parameters remained stable postoperatively. Duplex sonography on the portal and splenic veins revealed patency in all patients. The flow velocity in the portal vein decreased from 15.5 +/- 4.1 to 13.4 +/- 3.5 cm/s postoperatively ( p = 0.021). Splenic vein velocity was unchanged. Bleeding recurred in 6 patients, and grade 1 encephalopathy developed in 1 patient. Follow-up endoscopy (8-24 months) demonstrated substantial reduction in variceal grade.Conclusion: Laparoscopic devascularization of the lower esophagus and the upper stomach is technically feasible and promising. Rapid recovery and control of variceal hemorrhage are accomplished in most patients without exposing them to the risk of open surgery. [ABSTRACT FROM AUTHOR]

Background: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease resulting in obstructive jaundice and remains surgically challenging. Mirizzi syndrome is generally considered a contraindication to laparoscopic surgery. We present the surgical experience of 11 consecutive patients with Mirizzi syndrome who were diagnosed correctly preoperatively and treated laparoscopically.Methods: From January 1991 to December 2001, 4,560 patients underwent laparoscopic cholecystectomy for gallbladder lesions, 11 (0.24%) of whom were diagnosed with Mirizzi syndrome.Results: The 11 patients diagnosed with Mirizzi syndrome included four men and seven women, with ages ranging from 21 to 72 years (median, 54). There were 10 patients with Mirizzi syndrome type I (one was caused by gallbladder cancer in the neck), and 1 patient with type II, according to McSherry's classification. Right upper quadrant abdominal pain was the most common symptom, occurring in all 11 patients. All 11 patients were diagnosed correctly preoperatively by endoscopic retrograde cholangiography (ERCP) with 100% sensitivity. Four of the 11 patients (36.4%) were converted to open procedure. The postoperative course was uneventful, except for one patient complicated with a residual common bile duct stone. Hospital stay ranged from 4 to 33 days (median, 7).Conclusions: Mirizzi syndrome is an uncommon disorder. Preoperative suspicion is crucial for correct preoperative diagnosis. ERCP is the most useful tool for correct preoperative diagnosis and consequent prevention of common bile duct injury during operation. Should Mirizzi syndrome be diagnosed, laparoscopic treatment is a feasible and safe procedure, especially for type I Mirizzi syndrome. [ABSTRACT FROM AUTHOR]

OBJECTIVES To present the results of a minimally invasive treatment of symptomatic simple renal cysts, and to propose an algorithm for their management. PATIENTS AND METHODS Seventeen patients presenting with suspected symptomatic simple renal cysts were referred for trial aspiration; 16 presented with loin pain and one with a flank mass. If the cyst and symptoms recurred after a temporary response, they were managed by re-aspiration with sclerotherapy using 95% ethanol, or by laparoscopic de-roofing of the cyst. RESULTS Of the 17 patients referred, one failed to respond to aspiration and was excluded from further analysis. Three patients had sustained pain relief from simple aspiration alone, 13 required further treatment for symptom relapse, of whom six had aspiration and sclerotherapy, and seven had laparoscopic de-roofing. After a mean follow-up of 17 months, pain had recurred in all five patients originally presenting with pain and managed by sclerotherapy, and the patient who presented with a painless mass from a large cyst also developed pain after sclerotherapy. In contrast, the subsequent seven patients managed by laparoscopic treatment are pain-free at a mean follow-up of 17.7 months. CONCLUSION Evaluation including a diagnostic aspiration is essential to diagnose a symptomatic cyst. When treatment is indicated, laparoscopic de-roofing appears to be more effective than sclerotherapy. [ABSTRACT FROM AUTHOR]

Background. To decide "how and when to treat intra-abdominal infection" is one of the most important challenges for surgeons interested in abdominal sepsis. The minimally invasive approach to intra-abdominal infection, both diagnostic and therapeutic, has gained great popularity in recent years: the cause of infection is assessed as soon as possible by means of sophisticated radiography and minimally invasive surgery, patients with intra-abdominal infection are treated with the least surgical injury in order not to aggravate the systemic response ("second hit"), and clinicians rely on clinical scoring combined with new imaging techniques to decide for reintervention. In some patients with severe intra-abdominal infection damage control followed by a few planned relaparotomies seems necessary to provide a solid basis for the patient to start recovering. Paying close attention in these patients to maximal support vital systems and preventing local complications seems crucial for their eventual prognosis. Discussion. In this context we discuss important surgical topics such as primary resection and anastomosis in perforated diverticulitis, planned relaparotomy vs. relaparotomy "on demand," intra-abdominal hypertension, and primary and delayed abdominal wall closure techniques after operation for severe intra-abdominal infection. [ABSTRACT FROM AUTHOR]

The aim was to assess the value of treament of inguinal hernias by a totally extraperitoneal laparoscopic route. Between January 1993 and December 1998, 541 patients (490 men, 51 women) with 757 hernias were operated laparoscopically by a totally extraperitoneal route. Whenever the parietal repair required the insertion of a prosthesis, this was the method chosen. The procedure was perfomed under general anesthesia. One or two polypropylene prostheses of 15 × 12 cm were placed at the deep aspect of the abdominal wall, split but not fixed. The patients were followed up at one, six and twelve months and then annually. The mean operation time decreased with experience, from 66 minutes in 1993 to 47 minutes in 1998 for unilateral hernias and from 104 to 71.5 minutes for bilateral cases. The laparotomy conversion rate was 2%. Mortality was nil. Morbidity was as follows: hemorrhagic scrotal extravasations 10%, serous effusions 3.5%, phebitis 0.3%, pneumopathies 0.3%. The mean period of hospitalization was 2.9 days and the global recurrence rate was 0.6% (4 cases in the first year, 1 case at three years). The totally extraperitoneal laparoscopic route seems to be the method of choice for the treatment of inguinal hernias requiring a prosthesis. It reduces hospital stay and allows earlier return to work and is associated with only minor morbidity and a low recurrence rate. [ABSTRACT FROM AUTHOR]

Introduction: As a result of the relatively high frequency of high-speed accidents, diaphragmatic rupture is a diagnosis that is increasingly being established. Not all of these, usually multi-traumatized, patients are diagnosed as having diaphragmatic rupture immediately following the traumatic event – rather, an appreciable number of these injuries are not detected until some time later – often after a considerable delay. Most of the cases involve rupture of the left diaphragm, with most defects occurring in the region of the central tendon. Methods: During the course of the second half of the year 1998, we operated on three patients with left diaphragmatic rupture. Two of these patients were treated immediately following traumatization, while the third case was a 10-year-old rupture originally misdiagnosed as a para-esophageal hernia. In all three cases, we were able to reduce the hernia and close the diaphragmatic defect laparoscopically. In the case of the two patients with a fresh rupture, the post-operative course was unremarkable, while in the patient with the missed rupture, a serous pleural effusion requiring drainage occurred on the left side. Conclusion: Overall, it would appear that in the case of an acute traumatic diaphragmatic rupture in particular, laparoscopic management, with its low level of traumatization and excellent access, offers a favorable alternative to conventional surgery. A point to be considered, however, is the fact that probably not every hospital will have the facilities for laparoscopic management available on a 24-h basis. In the case of long-standing ruptures, reduction of herniated bowel and treatment of the rupture will make considerable demands on the surgeon. [ABSTRACT FROM AUTHOR]