Laparoscopic Gastrointestinal Surgery G . WHITELEY, R. NAIR & R. McCLOY University Dept. of Surgery and Pancreatobiliary Service, Manchester Royal Infirmary, Manchester,
England
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Whiteley G, Nair R, McCloy R. Laparmpic gastrointestinal surgery. Scand J Gastroenterol 1992;U Suppl 192:136141. The growth and scope of laparoscopic gastrointestinal surgery are outstripping the ability of medical journals to print series and reports of experience, and much data remain anectodal and preliminary. Laparoscopic cholecystectomy has become established, although, unfortunately, peroperative cholangiograpty has not yet become normal practice, despite convincing published evidence that it is likely to reduce the increased number of bile ducts that are damaged by laparoscopic surgeons. Imaging the bile ducts and the overall management of choledocholithiasis need re-evaluation, and the approach will change as more surgeons explore the bile ducts laparoscopically. Laparoscopic hiatal anti-reflux surgery will soon be routine, and a whole range of laparoscopically assisted operations on the oesophagus, colon, and rectum will become commonplace. Operations on the liver remain anecdotal. Throughout this rapid progress, surgeons must not forget the principles of (open) surgical practice, whilst carefully kept registers and regular audit of operations will provide new surgical standards. Key words: Appendicectomy; biliary bypass; cholangiography; choledocholithiasis; colorectal surgery; gastric surgery; laparoscopic cholecystectomy; laparoscopic surgery; laparoscopy; oesophageal surgery
R. F. McCloy, University Depr. of Surgery, Manchester Royal Infirmary, Manchester, V .K . M13 9WL
In recent years the explosion of interest in laparoscopic surgery has seen minimal-access techniques being applied to different branches of surgery. The aim of this review is to highlight the recent developments in laparoscopic surgery as applied to the gastrointestinal tract. The crucial issues of training and accreditation are beyond this remit. As with any innovation, the techniques must be fully explored and evaluated. At this early stage most of the applications of laparoscopic or pleuroscopic surgery are anecdotal or the subject of very small series with little or no follow-up, and controlled trials are notable by their absence. The rapid and prolific development of new instrumentation will continue to open new horizons in the field of laparoscopic and thoracoscopic surgery. LAPAROSCOPIC CHOLECYSTECTOMY The popularity of this technique can be gauged from the fact that in the United States, 87.9% of all cholecystectomies are currently being performed laparoscopically (1). In Europe, the figure ranges from 66% to 97% in different centres (2). Data from the Confidential Comparative Audit Service of the Royal College of Surgeons of England (3), which provides data on 3988 open cholecystectomies (from 185 surgeons) and 2131 laparoscopic cholecystectomies (from 105 surgeons) performed during 1991, indicates how rapidly the practice of laparoscopic cholecystectomy has grown since its inception in the U.K in 1990. The cost savings per case done laparoscopically amount to USD700 per patient in the United States (4), and GBP900 per patient in England (2).
It has been estimated that if all the 30,000 cholecystectomies performed annually in the U.K. were done laparoscopically, the resultant saving to the National Health Service in terms of bed-days would be GBP 21 million (5). The mortality for laparoscopic cholecystectomy has been low-1 death in 1518 patients (0.07%) (1) and no deaths in 1203 patients (2). Figures for the U.K. from the Royal College of Surgeons Confidential Comparative Audit Service show a lower mortality for laparoscopic cholecystectomy (3 of 2131 patients, or 0.16%) than open cholecystectomy (32 of 3988 patients, or 0.9%) (3). Respiratory complications were commoner with open cholecystectomy (3.4%) than laparoscopic cholecystectomy (1.2%), whereas intraoperative bleeding was more frequent with laparoscopic cholecystectomy (1.3%) than open cholecystectomy (0.7%) (3). Overall, these figures may favour the laparoscopic operation owing to surgeons selecting patients who are fitter and less at risk for this approach during the early phase of their experience of laparoscopy. As surgeons become more experienced in the performance of laparoscopic cholecystectomy, the rate of conversion to an open procedure has fallen. It now stands at 5.7% in the U.K. (3), 3.6% in Europe (2), and 4.7% in the United States (1). The Confidential Comparative Audit Service data suggest that the mortality for patients requiring conversion to open cholecystectomy was similar to that for open surgery (0.1%). However, the mean rate of complications for the converted patients may be higher than for primary open cholecystectomy (18.6% versus 12.9%, respectively) (3). It is appropriate that the mortality and morbidity for the
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Laparoscopic Gastrointestinal Surgery
converted cases be added to the risks of the laparoscopic operation. but this is usually not the case in published series. The widespread performance of laparoscopic cholecystectomy has led to concern about the incidence of bile duct injuries, which is higher with laparoscopic cholecystectomy than with open cholecystectomy. In a large American series. the incidence of bile duct injuries was 0.5% at laparoscopic cholecystectomy ( I ) , whereas in Europe the incidence was 0.33% (2) and in the U.K. 0.31% (3). At open cholecystectomy the incidence of bile duct injury is only 0.1% (6) and was recently reported as 0.18% of 3988 cholecystectomies (3). Published reports to date demonstrate that the rate of bile duct injury is unacceptably high in series i n which peroperative cholangiography has not been done and that performance o f an operative cholangiogram during laparoscopic cholecystectomy can reduce the rate of bile duct injuries to zero. Ferguson et al. (7) reported 5 bile duct injuries in 315 cases (1.58%1), and Qureshi et al. (8) 2 bile duct injuries in 300 cases (0.67%) in their series in which peroperative cholangiograms had not been done. In contrast. Petelin (9) and Corbitt & Cantwell (10) have reported a 0% incidence of bile duct injuries i n series comprising 444 and 300 patients, respectively, in which peroperative cholangiography was routinely performed. Many authorities have emphasized that the incidence of bile duct injuries can be reduced by performing peroperative cholangiography, both at laparoscopic cholecystectomy ( 1114) and at open surgery (1s-17). At open cholecystectomy X4-90f% of surgeons perform operative cholangiograms (18. 19). yet 25-50%1 o f surgeons surveyed said that they did not d o s o at laparoscopic cholecystectomy (3. 19). The reluctance of surgeons to perform peroperative cholangiograms with the laparoscopic approach is probably complex. stemming from their philosophy that there may be no point in performing a roentgenogram to identify stones that the majority of surgeons still cannot tackle laparoscopically. Other reasons may include the technical difficulty of the cannulation and a feeling that they should learn to d o .the operation first’ and perhaps attempt operative cholangiography ‘later’ and when it is ‘necessary’. With practice. most surgeons become adept at performing laparoscopic cholangiography, and the stereotactic proficiency achieved will stand them in good stead for any other delicate laparoscopic manoeuvres learned subsequently. Success rates for cholangiography of 9(j-Y8% have been reported by Berci et al. (6). Bagnato et al. (12), and Corbitt & Cantwell ( l o ) , in contrast to failure rates of 20-30% reported by others (20, 21). An average time of 1&30 min is required for peroperative cholangiography ( 12). and the expense has t o be balanced against the cost of repairing bile duct injuries and removing retained stones by endoscopic retrograde cholangio-pancreatograph y (ERCP). It is more important to perform a peroperative cholangiograni primarily for the anatomy of the biliary tree and only secondarily t o identify stones. The position of the clips,
I31
the length of the cystic duct beyond the clip, and the presence of anatomic abnormalities can be judged, information that is vital in preventing bile duct injury and which is missed if the cholangiogram is not done. Operative cholangiography can show up anatomic abnormalities such as a short cystic duct, which was seen in 22 of 516 cases, or 4%, in the series of Sackier et al. (13), or a cystic duct parallel to the common bile duct. Furthermore, bile duct injuries occurring before imaging is achieved can be detected by operative cholangiography and occurred in 1 of 516 cases in the same Sackier series (13). The use of preoperative E R C P or intravenous cholangiography can only provide a ‘road map’ of the ductal system before surgery. Instead ‘sign posts’ during surgery, in the form of peroperative cholangiogram/clip landmarks, are required if the surgeon is to know, for certain, where his/her scissors are on ‘the road’. CHOLEDOCHOLITHIASIS More and more surgeons are becoming proficient in laparoscopic bile duct exploration. The incidence of bile duct stones in patients undergoing cholecystectomy is 8-16% (22), and 5-9% of patients undergoing laparoscopic cholecystectomy without peroperative cholangiography are likely have retained stones (13). Currently, bile duct stones are usually removed at laparoscopy by a transcystic duct approach. A flexible choledochoscope or a nephroscope can be used to confirm complete clearance of the bile ducts and to remove any stones left behind. Petelin (9) has reported complete clearance of the bile ducts in 87%’of cases, Bagnato et al. (12) in 69% Helms & Czarnetzki (23) in 70% Gelin (24) in 61%~,and Sackier et al. (13) in 60%) of cases. However, laparoscopic clearance of the bile ducts with the equipment currently available is more likely to fail if there are multiple bile duct stones or if stones are impacted and lying in the common hepatic duct, since the cystic duct approach directs any instrumentation down the common bile duct. I t is rarely possible to explore the hepatic ducts via this route. However, fornial choledochotomy to enable the usual open techniques of duct exploration is now being practised laparoscopically. but not commonly. Medical and surgical gastroenterologists appear to have been confused by the impact of laparoscopic surgery on the management of bile duct stones and are failing to practice appropriate risk management of their patients. We present a simple algorithm (Fig. 1) for the management of bile duct stones on the basis of the age of the patient and the ability or the lack of ability of the surgeon to perform laparoscopic exploration of the ducts. We assume that the surgeon is capable of performing a peroperative cholangiogram. Age is important since endoscopic sphincterotomy at the time of ERCPcarries a significant mortality of about 1% irrespective of the patient’s age (25). Prelaparoscopic E R C P as a routine in every case cannot be justified but should be performed selectively in patients ‘at-risk’ of choledocholithiasis, on the
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C. Whiteley et al. no history of jaundice abnormal LFTs dilated ducts or CBD stones on U/S
U/S shows gallbladder stones only, ducts normal
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1
age < 55
on gallbladder
+ peroperative cholangiography
open CBD exploration
age > 55
no action
combined PTC + ERCP
Fig. 1. Algorithm for the management of choledocholithiasis with the availability of laparoscopic procedures for cholecystectomy. operative cholangiography, and exploration of the bile duct.
basis of a history of jaundice, abnormal liver function tests, or dilated bile ducts (26). The mortality of open exploration of the common bile duct is significantly less than that of endoscopic sphincterotomy in younger patients. When considering appropriate management protocols for patients with stones in their bile ducts it is essential to add the mortality and morbidity of any diagnostic or therapeutic ERCP performed pre- or post-operatively to those for laparoscopic cholecystectomy. Only then will comparable risk-benefits with open surgery be obtained.
LAPAROSCOPIC BILIARY BYPASS Laparoscopic cholecysto-jejunostomy, using a hand-sewn anastomosis has been described by the Dundee group (27) and by St. Mary's Hospital, London (R.D. Rosin. Persona: communication, 1992). At Manchester Royal Infirmary we have performed a hand-sewn laparoscopic side-to-side choledochoduodenostomy for gross choledocholithiasis. Refinement in laparoscopic needle holders, knotting techniques, and intracorporeal stapling devices are making these procedures, hitherto regarded as impossible, increasingly easy for the more advanced laparoscopic surgeon to perform.
LAPAROSCOPIC APPENDICECTOMY Laparoscopic appendicectomy was described by Semm in 1983 (28) but has not been practised as widely as laparoscopic cholecystectomy. The laparoscopic approach has several advantages. First, the wound infection rate for laparoscopic appendicectomy (2.3% (29)) may be less than that for conventional open appendicectomy ( 4 7 % (30)). The use of a bag to remove the appendix laparoscopically may reduce the wound infection rate even further. Second, the rate of intraabdominal adhesion formation is likely to be less after laparoscopic appendicectomy than after open appendicectomy . De Wilde (31), who performed 'second-look' laparoscopy on patients subjected to conventional and laparoscopic appendicectomy, found adhesions in 80% of the former but in only 10% of the latter. Third, the laparoscopic approach results in an earlier discharge from hospital and return to full activity. After open appendicectomy the average hospital stay is 4-6 days (32), whereas laparoscopic appendicectomy hospital stays of 2-3 days (29) and 1-2 days (33) have been reported. The diagnosis of acute appendicitis was possible in 97% of cases with suspected acute appendicitis in the series of Nowzaradan et al. (34). The average operating time was 15-20min (28, 32). A 2% conversion rate to open
Laparoscopic Guslroinieslinal Surgery
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appendicectomy was reported by Pier et al. (29), whereas Cristalli et al. (35) reported no conversions. Furthermore, an unnecessary laparotomy can be avoided in a patient with undiagnosed right iliac fossa pain by using the laparoscopic approach. If appendicitis is diagnosed, the appendix can be removed immediately by a laparoscopic technique. If the appendix is not inflamed, the whole abdomen can be inspected laparoscopically , and an alternative diagnosis may be confirmed. This is an important advantage, since inspection of the whole abdomen is not possible through any of the conventional incisions for appendicectomy should a normal appendix be discovered at open surgery. LAPAROSCOPIC ANTIREFLUX SURGERY Nissen's fundoplication by a laparoscopic approach has been described by Dallemagne et al. (36) and Cuche et al. (37). The essential features of the operation reported by these authors include the use of a 60-French bougie in the oesophagus and the use of Teflon pledgets to hold the sutures. Dallemagne reported successful performance of the operation in 38 of 41 patients, and Cuche in 12 of 14. Reasons for failure included oesophageal shortening, making the fundoplication difficult, and dense adhesions between the or the gastric fundus with the peritoneal sac oesophagus . of the hiatal hernia, which proved impossible to dissect laparoscopically. Cuche performed 9 of 12 fundoplications using a stapler. A laparoscopic ligamentum teres cardiopexy has been described by the Dundee group (38) for the repair of hiatal hernia. In this procedure the ligamentum teres is dissected out. anchored to the gastro-oesophageal junction by sutures, and passed to the anterior wall of the stomach, to which it is sutured, deepening the angle of His. The gastric fundus is then sutured to the lower oesophagus. Good results have been reported in all the three series quoted above, but the follow-up period is short. ranging from 6 to 8 months. LAPAROSCOPIC GASTRIC SURGERY Elective operations for chronic peptic ulcer disease performed laparoscopically include anterior seromyotomy with posterior truncal vagotomy (31)). selective vagotomy (40), and transthoracic vagotomy for recurrent peptic ulcer after previous gastric surgery, reported by Chisholm et al. (41) and Lawset al. (42). At Manchester Royal Infirmary we have developed a technique for a formal laparoscopic proximal gastric vagotomy (R. G. Nair, G. S. W. Whiteley, T. H. Brown, R. F. McCloy. Unpublished observations); acid secretion studies showed an 86% reduction in postoperative basal acid output, and modified sham feeding-stimulated acid output did not rise above basal levels, confirming the completeness of the vagotomy. Reports of laparoscopic proximal gastric vagotomy have also been made by Legrand et al. (43) and Weerts (44). Anecdotal reports of laparoscopic gastrectomy are now being discussed and should be published shortly.
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Laparoscopic surgery for perforated peptic ulcer has been described, using either a technique of laparoscopic oversewing (45) or an omental patch held in place by fibrin glue to seal the perforation (46). Gastrostomy by a laparoscopic approach has been described by Edelman et al. (47). They emphasize that this technique is appropriate in patients unsuitable for percutaneous endoscopic gastrostomy because of head or neck malignancy or large hiatal hernias in which an endoscope cannot be passed. The laparoscopic approach also obviates possible damage to other structures that may occur when percutaneous gastrostomy is performed by interventional radiologists. Ramstedt's pyloromyotomy has been performed laparoscopically by Alain et al (48). LAPAROSCOPIC SURGERY OF THE LIVER Superficially located benign liver lesions have been resected (49), and laparoscopic-guided drainage of superficially located liver abscesses has also been performed (50). A laparoscopic technique for the resection of liver cysts associated with polycystic liver disease has been described by Paterson-Brown & Garden (51). THORACOSCOPIC OESOPHAGEAL SURGERY Thoracoscopic oesophagectomy has been described by McMahon ( 5 2 ) , and the technique has been described in detail by Buess et al. (53). Motility disorders of the oesophagus have been treated by thoracoscopic means. Cuschieri's group (54) has performed long oesophageal myotomy for nutcracker oesophagus, and we have performed cardiomyotomy for achalasia pleuroscopically ( 5 5 ) . No reports of resection of oesophageal diverticula have as yet reached the literature, but a thoracoscopic approach to this problem is inevitable with the development of stapling devices. OTHER LAPAROSCOPIC GASTROINTESTINAL PROCEDURES A wide range of laparoscopic operations in neonates and infants, including removal of the appendix, gallbladder, congenital cysts, and tumours and adhesiolysis have been reported by Waldschmidt & Schier (56). A laparoscopic approach to Meckel's diverticulectomy has been described by Attwood et al. (57). and repair of instrumental colonic perforation during laparoscopy has been described by Birns (58). LAPAROSCOPIC COLORECTAL SURGERY Laparoscopic procedures on the colon and rectum have been approached in various ways. The bowel may be mobilized laparoscopically and then externalized through an appro-
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G. Whiteley el al.
priately placed minimal-access incision, which most often is only about 5 cm long, to enable resection and anastomoses. Other workers have adopted an entirely laparoscopic approach with intracorporeal anastomoses being performed, usually with stapling devices. This can lead to problems as to how to remove the specimen and various routes, including the transanal route or placing the specimen in a bag for morcellation before removal, have been described. The fully laparoscopic techniques are far more time-consuming and are, as yet, less commonly practised. It is likely that the former, laparoscopically assisted resections, are the most appropriate at present. Espalieu & Boulez (59) have performed diverse operations such as colectomy , reversal of Hartmann’s operation, drainage of diverticular perforation, and colostomy transposition by a laparoscopic route. The technique for colectomy included a 30-mm abdominal incision for delivery of the specimen and an extracorporeal anastomosis. Their conversion rate was 1 of 17 colectomies. One anastomotic leakage led to an open operation. Cooperman et al. (60) have described a technique for laparoscopic colonic resection, and Lange et al. (61) have described the laparoscopic creation of a loop colostomy. A technique for laparoscopic fixation of sigmoid volvulus has been described by Miller et al. (62). At present, surgeons are content for perform colonic resections laparoscopically for benign conditions. Yet right, transverse, left, and sigmoid colectomies are being performed for cancer, as are anterior resection and abdominoperineal resection of the rectum. However, series with significant numbers have yet to be reported, and doubts have been raised about the ability to perform an adequate ‘radical’ clearance of all involved lymph node territories when malignant lesions of the colon are resected laparoscopically. Enthusiasts of the technique claim that full clearance is still possible. It will probably remain for appropriate follow-up studies to settle these issues, since it is difficult to initiate controlled trials in this new field of surgery. As with other areas of minimal-access surgery, critical audit of individual and pooled results will be necessary if outcomes are to be improved. National and multicentre ‘registers’ of procedures such as cholecystectomy, oesophagectomy, and colorectal resections could play a useful role towards this end. CONCLUSIONS Minimal-access gastrointestinal surgery can and is being performed from the neck to the anus for a wide spectrum of conditions. However, the philosophy of this burgeoning field should be ‘a new approach to old operations’. In other words, the tried and tested principles of gastrointestinal surgery, hard won in years past, should not be lost in the tidal wave of current enthusiasm. At present, this ‘new’form of gastrointestinal surgery is being limited by the rate at which new instruments and technology can be developed
and produced, but in the future the only limits may be those of the surgeons’ imagination or, possibly, their foolishness.
REFERENCES
I. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:10758. 2. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161: 385-90. 3. Dunn DC, Fowler S. Analysis of 1991 general surgery data. London: Confidential Comparative Audit Service. The Royal College of Surgeons of England, 1991. 4. Peters JH, Ellison EC, Innes JT, et al. Safety and Efficacy of laparoscopic cholecystectomy. A prospective analysis of lo00 initial patients. Ann Surg 1991;213:3-12. 5. Wastell C. Laparoscopic cholecystectomy. Br Med J 1991;302: 303-4. 6. Berci G , Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiogram during laparoscopic cholecystecomy . Am J Surg 1991;161:355-60. 7. Ferguson CM. Rattner DW, Warshaw AL. Bile duct injury in laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:17. 8. Qureshi A, Leahy A, Osborne H, et al. Routine cholangiography is unnecessary for laparoscopic cholecystectomy. Gastroenterology 1992;102 Suppl:A330. 9. Petelin JB. Laparoscopic approach to common duct pathology. Surg Laparosc Endosc 1991;1:33-41. 10. Corbitt JD, Cantwell DV. Laparoscopic cholecystectomy with operative cholangiogram. Surg Laparosc Endosc 1991;1:229-32. 11. Deyo GA. Complications of laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:41-8. 2. Bagnato VJ, McGee G E , Hatten LE, Varner JE. Culpepper JP. Justification for routine cholangiography during laparoscopic cholecystectomy. Surg Laparosc Endosc 1991;1:8993. 3. Sackier JM, Berci G , Phillips E, Carroll B, Shapiro S, PazPartlow M. The role of cholangiography in laparoscopic cholecystectomy. Arch Surg 1991;126:1021-5. 4. Rossi RL, Schirmer WJ, Braasch JW, Sanders LB, Munson JL. Laparoscopic bile duct injuries. Risk factors, recognition and repair. Arch Surg 1992;127:596-602. 15. Mossa AR, Mayer AD, Stabile B. Iatrogenic injury to the bile duct. Arch Surg 1990;125:1028-30. 16. Andren-Sandberg A, Alinder G , Bengmark S. Accidental lesions of the bile duct at cholecystectomy. Ann Surg 1985; 201:328-32. 17. Kelly CJ, Blumgart LH. Peroperative cholangiogram and post cholecystectomy strictures. Ann R Coll Surg Eng 1985;67:93-5. 18. Cahill CJ, Pain JA. Current practice in biliary surgery. Br J Surg 1988;75:1169-72. 19. Aldridge MC, Super P, Horner J . Perioperative cholangiography during laparoscopic cholecystectomy: does it still have a role? Jersey: Annual meeting of the Society of Minimally Invasive General Surgeons, 1992. 20. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB. Jones RS. Laparoscopic cholecystectomy-treatment of choice for symptomatic cholelithiasis. Ann Surg 1991 ;213:665-76. 21. GravesHA, Ballinger JF, Anderson WJ. Appraisal of laparoscopic cholecystectomy. Ann Suutg 1991;213:655-62. 22. Nahrwold D. The biliary system. In: Sabiston DC, editor. Textbook of surgery. Philadelphia: WB Saunders, 1991:1045. 23. Helms B, Czarnetzki HD. Complete laparoscopic therapy of gallbladder and common bile duct stones. Br J Surg 1992;79 Suppl:S68. 24. Gelin M. Laparoscopic treatment of common bile duct stones. Br J Surg 1992;79 Suppl:S69. 25. Cotton PB. Endoscopic management of bile duct stones (apples and oranges). Gut 1984;25:587-97. 26. Cotton PB, Baillie J, Pappas TN, Meyers WS. Laparoscopic
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 11/20/14 For personal use only.
Laparoscopic Gastrointestinal Surgery cholecystectomy and the biliary endoscopist. Gastrointest Endosc 1991;37:74-94. 27. Shimi S, Banting S, Cuschieri A. Laparoscopy in the management of pancreatic cancer: endoscopic cholecysto-jejunostomy for advanced disease. Br J Surg 1992;79:317-19. 28. Semm K. Endoscopic appendicectomy. Endoscopy 1983;15:5964. 29. Pier A. Gotz F, Bacher C. Laparoscopic appendicectomy in 625 cases: from innovation to routine. Surg Laparosc Endosc 1991;1:b13. 30. Krukowski ZH, Irwin ST, Denholm S, Matheson NA. Preventing wound infection after appendicectomy: a review. Br J Surg 1988;75:102.3-33. 31. de Wilde RL. Goodbye to late bowel obstruction after appendicectomy. Lancet 1991;338:1012-7. 32. Loh A, Taylor RS. Laparoscopic appendicectomy. Br J Surg 1992;79:28%90. 33. Saye WB. Rives DA. Cochran EB. Laparoscopic appendicectomy three years experience. Surg Laparosc Endosc 1991; 1 :109-15, 34. Nowzaradan Y, Westmoreland J . McCarver CT, Harris RJ. Laparoscopic appendicectomy for acute appendicitis: indications and current use. J Laparoendosc Surg 1991;1:247-57. 35. Cristalli B. Cayol A, Izard V, Levardon M. Appendicectomie per celioscopie. Resultats preliminaires d’une nouvelle technique. J Chir Paris 1991;128:302-5. 36. Dallemagne B, Weerts J , Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen’s fundoplication. Xansas City: International Minimal Access Surgery Symposium, 1991. 37. Cuche F, Pelissier EP, Girard JF. Preliminary results of laparoscopic Nissen’s fundoplication. Br J Surg 1992; 79 Suppl:S68. 38. Nathanson LK. Shimi S, Cuschieri A. Laparoscopic ligamentum teres cardiopexy. Br J Surg 1991;78:947-51. 39. Katkhouda N, Mouiel J . A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocelioscopy. Am J Surg 1991;161:361-4. 40. Bailey RU’, Flowers JL, Graham SM. Zucker KA. Combined laparoscopic cholecystectomy and selective vagotomy. Surg Laparosc Endosc 1991;1:45-9. 41. Chisholm EM, Chung SCS, Sunderland GT, Leong HT, Li AKC. Thoracoscopic vagotomy: a new use for the laparoscope. Br J Surg 1992;79:254. 42. Laws HL. Naughton MJ, McKernan JB. Thoracoscopic vagectomy for recurrent peptic ulcer disease. Surg Laparosc Endosc 1992;2:24-8. 43. Legrand M, Detroz B, Honore P. Jacquet N. Laparoscopic highly selective vagotomy. Br J Surg 1992;79 Suppl:S68. 44.Weerts J. Highly selective vagotomy: Laparoscopic approach. Br J Surg 1992;79 Suppl:S68.
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45. Nathanson LK, Easter DW. Cuschieri A. LaDaroscooic reDairl peritoneal toilet of perforated peptic ulcer. Su& Eidosc 1990;4:232-3. 46. Mouret P, Francois Y, Vignal J , Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990; 77: 1006. 47. Edelman DS, Unger SW, Russin DR. Laparoscopic gastrostomy. Surg Laparosc Endosc 1991;1:251-3. 48. Alain JL, Grosseau D. Terrier G. La pylorotomie extramuqueuse par laparoscopie. Chir Pediatr 1990;31:223-4. 49. Reich H, McGlynn F, DeCaprio J , Budin R . Laparoscopic excision of benign liver lesions. Obstet Gynecol 1991;78:568. 50. Krivitskii DI, Palamarchuk VI. Puncture drainage of abscess of the liver and abdominal cavity controlled by echotomography and laparoscopy. Klin Khir 1990:49-50. 51. Paterson-Brown S, Garden OJ. Laser-assisted laparoscopic excision of liver cyst. Br J Surg 1991;78:1047. 52. McMahon MJ. Laparoscopic oesophagectomy. Kansas City: International Minimal Access Surgery Symposium, 1991. 53. Buess GF, Becker HD, Naruhn BM, Mentges BR. Endoscopic oesophagectomy without thoracotomy. In: Berci G, Sackier JM, editors. Problems in general surgery: laparoscopic surgery. Philadelphia: JB Lippincott, 1991:478-86. 54. Shimi SM, Nathanson LK, Cuschieri A. Thoracoscopic long oesophageal myotomy for nutcracker oesophagus: initial experience of a new surgical approach. Br J Surg 1992;79:3M. 55. Whiteley GSW, Nair RG, MacLennan I, McCloy RF. Pleuroscopic technique for oesophageal seromyotomy for achalasia. Jersey: Annual conference of the Society for Minimally Invasive General Surgeons. 1992. 56. Waldschmidt J, Schier F. Laparoscopic surgery in neonates and infants. Eur J Pediatr Surg 1991;l: 145-50. 57. Attwood SEA, McGrath J , Hill ADK, Stephens RB. Laparoscopic approach to Meckel’s diverticulectomy. Br J Surg 1992;79:211, 58. Birns MT. Inadvertent instrumental performation of the colon during laparoscopy: nonsurgical repair. Gastrointest Endosc 1989;35:54-6. 59. Espalieu P, Boulez J . Experience in colonic laparoscopic surgery. Br J Surg 1992;79 Suppl:S69. 60.Cooperman AM, Katz V, Zimmon D, Botero G. Laparoscopic colon resection. J Laparoendosc Surg 1991;1:221-4. 61. Lange V, Meyer G, Schardey HM, Schildberg FW. Laparoscopic creation of a loop colostomy. J Laparoendosc Surg 1991;1:307- 12. 62. Miller R, Roe AM, Eltringham WK, Espiner HJ. Laparoscopic fixation of sigmoid volvulus. Br J Surg 1992;79:435.
England
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Whiteley G, Nair R, McCloy R. Laparmpic gastrointestinal surgery. Scand J Gastroenterol 1992;U Suppl 192:136141. The growth and scope of laparoscopic gastrointestinal surgery are outstripping the ability of medical journals to print series and reports of experience, and much data remain anectodal and preliminary. Laparoscopic cholecystectomy has become established, although, unfortunately, peroperative cholangiograpty has not yet become normal practice, despite convincing published evidence that it is likely to reduce the increased number of bile ducts that are damaged by laparoscopic surgeons. Imaging the bile ducts and the overall management of choledocholithiasis need re-evaluation, and the approach will change as more surgeons explore the bile ducts laparoscopically. Laparoscopic hiatal anti-reflux surgery will soon be routine, and a whole range of laparoscopically assisted operations on the oesophagus, colon, and rectum will become commonplace. Operations on the liver remain anecdotal. Throughout this rapid progress, surgeons must not forget the principles of (open) surgical practice, whilst carefully kept registers and regular audit of operations will provide new surgical standards. Key words: Appendicectomy; biliary bypass; cholangiography; choledocholithiasis; colorectal surgery; gastric surgery; laparoscopic cholecystectomy; laparoscopic surgery; laparoscopy; oesophageal surgery
R. F. McCloy, University Depr. of Surgery, Manchester Royal Infirmary, Manchester, V .K . M13 9WL
In recent years the explosion of interest in laparoscopic surgery has seen minimal-access techniques being applied to different branches of surgery. The aim of this review is to highlight the recent developments in laparoscopic surgery as applied to the gastrointestinal tract. The crucial issues of training and accreditation are beyond this remit. As with any innovation, the techniques must be fully explored and evaluated. At this early stage most of the applications of laparoscopic or pleuroscopic surgery are anecdotal or the subject of very small series with little or no follow-up, and controlled trials are notable by their absence. The rapid and prolific development of new instrumentation will continue to open new horizons in the field of laparoscopic and thoracoscopic surgery. LAPAROSCOPIC CHOLECYSTECTOMY The popularity of this technique can be gauged from the fact that in the United States, 87.9% of all cholecystectomies are currently being performed laparoscopically (1). In Europe, the figure ranges from 66% to 97% in different centres (2). Data from the Confidential Comparative Audit Service of the Royal College of Surgeons of England (3), which provides data on 3988 open cholecystectomies (from 185 surgeons) and 2131 laparoscopic cholecystectomies (from 105 surgeons) performed during 1991, indicates how rapidly the practice of laparoscopic cholecystectomy has grown since its inception in the U.K in 1990. The cost savings per case done laparoscopically amount to USD700 per patient in the United States (4), and GBP900 per patient in England (2).
It has been estimated that if all the 30,000 cholecystectomies performed annually in the U.K. were done laparoscopically, the resultant saving to the National Health Service in terms of bed-days would be GBP 21 million (5). The mortality for laparoscopic cholecystectomy has been low-1 death in 1518 patients (0.07%) (1) and no deaths in 1203 patients (2). Figures for the U.K. from the Royal College of Surgeons Confidential Comparative Audit Service show a lower mortality for laparoscopic cholecystectomy (3 of 2131 patients, or 0.16%) than open cholecystectomy (32 of 3988 patients, or 0.9%) (3). Respiratory complications were commoner with open cholecystectomy (3.4%) than laparoscopic cholecystectomy (1.2%), whereas intraoperative bleeding was more frequent with laparoscopic cholecystectomy (1.3%) than open cholecystectomy (0.7%) (3). Overall, these figures may favour the laparoscopic operation owing to surgeons selecting patients who are fitter and less at risk for this approach during the early phase of their experience of laparoscopy. As surgeons become more experienced in the performance of laparoscopic cholecystectomy, the rate of conversion to an open procedure has fallen. It now stands at 5.7% in the U.K. (3), 3.6% in Europe (2), and 4.7% in the United States (1). The Confidential Comparative Audit Service data suggest that the mortality for patients requiring conversion to open cholecystectomy was similar to that for open surgery (0.1%). However, the mean rate of complications for the converted patients may be higher than for primary open cholecystectomy (18.6% versus 12.9%, respectively) (3). It is appropriate that the mortality and morbidity for the
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Laparoscopic Gastrointestinal Surgery
converted cases be added to the risks of the laparoscopic operation. but this is usually not the case in published series. The widespread performance of laparoscopic cholecystectomy has led to concern about the incidence of bile duct injuries, which is higher with laparoscopic cholecystectomy than with open cholecystectomy. In a large American series. the incidence of bile duct injuries was 0.5% at laparoscopic cholecystectomy ( I ) , whereas in Europe the incidence was 0.33% (2) and in the U.K. 0.31% (3). At open cholecystectomy the incidence of bile duct injury is only 0.1% (6) and was recently reported as 0.18% of 3988 cholecystectomies (3). Published reports to date demonstrate that the rate of bile duct injury is unacceptably high in series i n which peroperative cholangiography has not been done and that performance o f an operative cholangiogram during laparoscopic cholecystectomy can reduce the rate of bile duct injuries to zero. Ferguson et al. (7) reported 5 bile duct injuries in 315 cases (1.58%1), and Qureshi et al. (8) 2 bile duct injuries in 300 cases (0.67%) in their series in which peroperative cholangiograms had not been done. In contrast. Petelin (9) and Corbitt & Cantwell (10) have reported a 0% incidence of bile duct injuries i n series comprising 444 and 300 patients, respectively, in which peroperative cholangiography was routinely performed. Many authorities have emphasized that the incidence of bile duct injuries can be reduced by performing peroperative cholangiography, both at laparoscopic cholecystectomy ( 1114) and at open surgery (1s-17). At open cholecystectomy X4-90f% of surgeons perform operative cholangiograms (18. 19). yet 25-50%1 o f surgeons surveyed said that they did not d o s o at laparoscopic cholecystectomy (3. 19). The reluctance of surgeons to perform peroperative cholangiograms with the laparoscopic approach is probably complex. stemming from their philosophy that there may be no point in performing a roentgenogram to identify stones that the majority of surgeons still cannot tackle laparoscopically. Other reasons may include the technical difficulty of the cannulation and a feeling that they should learn to d o .the operation first’ and perhaps attempt operative cholangiography ‘later’ and when it is ‘necessary’. With practice. most surgeons become adept at performing laparoscopic cholangiography, and the stereotactic proficiency achieved will stand them in good stead for any other delicate laparoscopic manoeuvres learned subsequently. Success rates for cholangiography of 9(j-Y8% have been reported by Berci et al. (6). Bagnato et al. (12), and Corbitt & Cantwell ( l o ) , in contrast to failure rates of 20-30% reported by others (20, 21). An average time of 1&30 min is required for peroperative cholangiography ( 12). and the expense has t o be balanced against the cost of repairing bile duct injuries and removing retained stones by endoscopic retrograde cholangio-pancreatograph y (ERCP). It is more important to perform a peroperative cholangiograni primarily for the anatomy of the biliary tree and only secondarily t o identify stones. The position of the clips,
I31
the length of the cystic duct beyond the clip, and the presence of anatomic abnormalities can be judged, information that is vital in preventing bile duct injury and which is missed if the cholangiogram is not done. Operative cholangiography can show up anatomic abnormalities such as a short cystic duct, which was seen in 22 of 516 cases, or 4%, in the series of Sackier et al. (13), or a cystic duct parallel to the common bile duct. Furthermore, bile duct injuries occurring before imaging is achieved can be detected by operative cholangiography and occurred in 1 of 516 cases in the same Sackier series (13). The use of preoperative E R C P or intravenous cholangiography can only provide a ‘road map’ of the ductal system before surgery. Instead ‘sign posts’ during surgery, in the form of peroperative cholangiogram/clip landmarks, are required if the surgeon is to know, for certain, where his/her scissors are on ‘the road’. CHOLEDOCHOLITHIASIS More and more surgeons are becoming proficient in laparoscopic bile duct exploration. The incidence of bile duct stones in patients undergoing cholecystectomy is 8-16% (22), and 5-9% of patients undergoing laparoscopic cholecystectomy without peroperative cholangiography are likely have retained stones (13). Currently, bile duct stones are usually removed at laparoscopy by a transcystic duct approach. A flexible choledochoscope or a nephroscope can be used to confirm complete clearance of the bile ducts and to remove any stones left behind. Petelin (9) has reported complete clearance of the bile ducts in 87%’of cases, Bagnato et al. (12) in 69% Helms & Czarnetzki (23) in 70% Gelin (24) in 61%~,and Sackier et al. (13) in 60%) of cases. However, laparoscopic clearance of the bile ducts with the equipment currently available is more likely to fail if there are multiple bile duct stones or if stones are impacted and lying in the common hepatic duct, since the cystic duct approach directs any instrumentation down the common bile duct. I t is rarely possible to explore the hepatic ducts via this route. However, fornial choledochotomy to enable the usual open techniques of duct exploration is now being practised laparoscopically. but not commonly. Medical and surgical gastroenterologists appear to have been confused by the impact of laparoscopic surgery on the management of bile duct stones and are failing to practice appropriate risk management of their patients. We present a simple algorithm (Fig. 1) for the management of bile duct stones on the basis of the age of the patient and the ability or the lack of ability of the surgeon to perform laparoscopic exploration of the ducts. We assume that the surgeon is capable of performing a peroperative cholangiogram. Age is important since endoscopic sphincterotomy at the time of ERCPcarries a significant mortality of about 1% irrespective of the patient’s age (25). Prelaparoscopic E R C P as a routine in every case cannot be justified but should be performed selectively in patients ‘at-risk’ of choledocholithiasis, on the
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C. Whiteley et al. no history of jaundice abnormal LFTs dilated ducts or CBD stones on U/S
U/S shows gallbladder stones only, ducts normal
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1
age < 55
on gallbladder
+ peroperative cholangiography
open CBD exploration
age > 55
no action
combined PTC + ERCP
Fig. 1. Algorithm for the management of choledocholithiasis with the availability of laparoscopic procedures for cholecystectomy. operative cholangiography, and exploration of the bile duct.
basis of a history of jaundice, abnormal liver function tests, or dilated bile ducts (26). The mortality of open exploration of the common bile duct is significantly less than that of endoscopic sphincterotomy in younger patients. When considering appropriate management protocols for patients with stones in their bile ducts it is essential to add the mortality and morbidity of any diagnostic or therapeutic ERCP performed pre- or post-operatively to those for laparoscopic cholecystectomy. Only then will comparable risk-benefits with open surgery be obtained.
LAPAROSCOPIC BILIARY BYPASS Laparoscopic cholecysto-jejunostomy, using a hand-sewn anastomosis has been described by the Dundee group (27) and by St. Mary's Hospital, London (R.D. Rosin. Persona: communication, 1992). At Manchester Royal Infirmary we have performed a hand-sewn laparoscopic side-to-side choledochoduodenostomy for gross choledocholithiasis. Refinement in laparoscopic needle holders, knotting techniques, and intracorporeal stapling devices are making these procedures, hitherto regarded as impossible, increasingly easy for the more advanced laparoscopic surgeon to perform.
LAPAROSCOPIC APPENDICECTOMY Laparoscopic appendicectomy was described by Semm in 1983 (28) but has not been practised as widely as laparoscopic cholecystectomy. The laparoscopic approach has several advantages. First, the wound infection rate for laparoscopic appendicectomy (2.3% (29)) may be less than that for conventional open appendicectomy ( 4 7 % (30)). The use of a bag to remove the appendix laparoscopically may reduce the wound infection rate even further. Second, the rate of intraabdominal adhesion formation is likely to be less after laparoscopic appendicectomy than after open appendicectomy . De Wilde (31), who performed 'second-look' laparoscopy on patients subjected to conventional and laparoscopic appendicectomy, found adhesions in 80% of the former but in only 10% of the latter. Third, the laparoscopic approach results in an earlier discharge from hospital and return to full activity. After open appendicectomy the average hospital stay is 4-6 days (32), whereas laparoscopic appendicectomy hospital stays of 2-3 days (29) and 1-2 days (33) have been reported. The diagnosis of acute appendicitis was possible in 97% of cases with suspected acute appendicitis in the series of Nowzaradan et al. (34). The average operating time was 15-20min (28, 32). A 2% conversion rate to open
Laparoscopic Guslroinieslinal Surgery
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appendicectomy was reported by Pier et al. (29), whereas Cristalli et al. (35) reported no conversions. Furthermore, an unnecessary laparotomy can be avoided in a patient with undiagnosed right iliac fossa pain by using the laparoscopic approach. If appendicitis is diagnosed, the appendix can be removed immediately by a laparoscopic technique. If the appendix is not inflamed, the whole abdomen can be inspected laparoscopically , and an alternative diagnosis may be confirmed. This is an important advantage, since inspection of the whole abdomen is not possible through any of the conventional incisions for appendicectomy should a normal appendix be discovered at open surgery. LAPAROSCOPIC ANTIREFLUX SURGERY Nissen's fundoplication by a laparoscopic approach has been described by Dallemagne et al. (36) and Cuche et al. (37). The essential features of the operation reported by these authors include the use of a 60-French bougie in the oesophagus and the use of Teflon pledgets to hold the sutures. Dallemagne reported successful performance of the operation in 38 of 41 patients, and Cuche in 12 of 14. Reasons for failure included oesophageal shortening, making the fundoplication difficult, and dense adhesions between the or the gastric fundus with the peritoneal sac oesophagus . of the hiatal hernia, which proved impossible to dissect laparoscopically. Cuche performed 9 of 12 fundoplications using a stapler. A laparoscopic ligamentum teres cardiopexy has been described by the Dundee group (38) for the repair of hiatal hernia. In this procedure the ligamentum teres is dissected out. anchored to the gastro-oesophageal junction by sutures, and passed to the anterior wall of the stomach, to which it is sutured, deepening the angle of His. The gastric fundus is then sutured to the lower oesophagus. Good results have been reported in all the three series quoted above, but the follow-up period is short. ranging from 6 to 8 months. LAPAROSCOPIC GASTRIC SURGERY Elective operations for chronic peptic ulcer disease performed laparoscopically include anterior seromyotomy with posterior truncal vagotomy (31)). selective vagotomy (40), and transthoracic vagotomy for recurrent peptic ulcer after previous gastric surgery, reported by Chisholm et al. (41) and Lawset al. (42). At Manchester Royal Infirmary we have developed a technique for a formal laparoscopic proximal gastric vagotomy (R. G. Nair, G. S. W. Whiteley, T. H. Brown, R. F. McCloy. Unpublished observations); acid secretion studies showed an 86% reduction in postoperative basal acid output, and modified sham feeding-stimulated acid output did not rise above basal levels, confirming the completeness of the vagotomy. Reports of laparoscopic proximal gastric vagotomy have also been made by Legrand et al. (43) and Weerts (44). Anecdotal reports of laparoscopic gastrectomy are now being discussed and should be published shortly.
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Laparoscopic surgery for perforated peptic ulcer has been described, using either a technique of laparoscopic oversewing (45) or an omental patch held in place by fibrin glue to seal the perforation (46). Gastrostomy by a laparoscopic approach has been described by Edelman et al. (47). They emphasize that this technique is appropriate in patients unsuitable for percutaneous endoscopic gastrostomy because of head or neck malignancy or large hiatal hernias in which an endoscope cannot be passed. The laparoscopic approach also obviates possible damage to other structures that may occur when percutaneous gastrostomy is performed by interventional radiologists. Ramstedt's pyloromyotomy has been performed laparoscopically by Alain et al (48). LAPAROSCOPIC SURGERY OF THE LIVER Superficially located benign liver lesions have been resected (49), and laparoscopic-guided drainage of superficially located liver abscesses has also been performed (50). A laparoscopic technique for the resection of liver cysts associated with polycystic liver disease has been described by Paterson-Brown & Garden (51). THORACOSCOPIC OESOPHAGEAL SURGERY Thoracoscopic oesophagectomy has been described by McMahon ( 5 2 ) , and the technique has been described in detail by Buess et al. (53). Motility disorders of the oesophagus have been treated by thoracoscopic means. Cuschieri's group (54) has performed long oesophageal myotomy for nutcracker oesophagus, and we have performed cardiomyotomy for achalasia pleuroscopically ( 5 5 ) . No reports of resection of oesophageal diverticula have as yet reached the literature, but a thoracoscopic approach to this problem is inevitable with the development of stapling devices. OTHER LAPAROSCOPIC GASTROINTESTINAL PROCEDURES A wide range of laparoscopic operations in neonates and infants, including removal of the appendix, gallbladder, congenital cysts, and tumours and adhesiolysis have been reported by Waldschmidt & Schier (56). A laparoscopic approach to Meckel's diverticulectomy has been described by Attwood et al. (57). and repair of instrumental colonic perforation during laparoscopy has been described by Birns (58). LAPAROSCOPIC COLORECTAL SURGERY Laparoscopic procedures on the colon and rectum have been approached in various ways. The bowel may be mobilized laparoscopically and then externalized through an appro-
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G. Whiteley el al.
priately placed minimal-access incision, which most often is only about 5 cm long, to enable resection and anastomoses. Other workers have adopted an entirely laparoscopic approach with intracorporeal anastomoses being performed, usually with stapling devices. This can lead to problems as to how to remove the specimen and various routes, including the transanal route or placing the specimen in a bag for morcellation before removal, have been described. The fully laparoscopic techniques are far more time-consuming and are, as yet, less commonly practised. It is likely that the former, laparoscopically assisted resections, are the most appropriate at present. Espalieu & Boulez (59) have performed diverse operations such as colectomy , reversal of Hartmann’s operation, drainage of diverticular perforation, and colostomy transposition by a laparoscopic route. The technique for colectomy included a 30-mm abdominal incision for delivery of the specimen and an extracorporeal anastomosis. Their conversion rate was 1 of 17 colectomies. One anastomotic leakage led to an open operation. Cooperman et al. (60) have described a technique for laparoscopic colonic resection, and Lange et al. (61) have described the laparoscopic creation of a loop colostomy. A technique for laparoscopic fixation of sigmoid volvulus has been described by Miller et al. (62). At present, surgeons are content for perform colonic resections laparoscopically for benign conditions. Yet right, transverse, left, and sigmoid colectomies are being performed for cancer, as are anterior resection and abdominoperineal resection of the rectum. However, series with significant numbers have yet to be reported, and doubts have been raised about the ability to perform an adequate ‘radical’ clearance of all involved lymph node territories when malignant lesions of the colon are resected laparoscopically. Enthusiasts of the technique claim that full clearance is still possible. It will probably remain for appropriate follow-up studies to settle these issues, since it is difficult to initiate controlled trials in this new field of surgery. As with other areas of minimal-access surgery, critical audit of individual and pooled results will be necessary if outcomes are to be improved. National and multicentre ‘registers’ of procedures such as cholecystectomy, oesophagectomy, and colorectal resections could play a useful role towards this end. CONCLUSIONS Minimal-access gastrointestinal surgery can and is being performed from the neck to the anus for a wide spectrum of conditions. However, the philosophy of this burgeoning field should be ‘a new approach to old operations’. In other words, the tried and tested principles of gastrointestinal surgery, hard won in years past, should not be lost in the tidal wave of current enthusiasm. At present, this ‘new’form of gastrointestinal surgery is being limited by the rate at which new instruments and technology can be developed
and produced, but in the future the only limits may be those of the surgeons’ imagination or, possibly, their foolishness.
REFERENCES
I. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:10758. 2. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161: 385-90. 3. Dunn DC, Fowler S. Analysis of 1991 general surgery data. London: Confidential Comparative Audit Service. The Royal College of Surgeons of England, 1991. 4. Peters JH, Ellison EC, Innes JT, et al. Safety and Efficacy of laparoscopic cholecystectomy. A prospective analysis of lo00 initial patients. Ann Surg 1991;213:3-12. 5. Wastell C. Laparoscopic cholecystectomy. Br Med J 1991;302: 303-4. 6. Berci G , Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiogram during laparoscopic cholecystecomy . Am J Surg 1991;161:355-60. 7. Ferguson CM. Rattner DW, Warshaw AL. Bile duct injury in laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:17. 8. Qureshi A, Leahy A, Osborne H, et al. Routine cholangiography is unnecessary for laparoscopic cholecystectomy. Gastroenterology 1992;102 Suppl:A330. 9. Petelin JB. Laparoscopic approach to common duct pathology. Surg Laparosc Endosc 1991;1:33-41. 10. Corbitt JD, Cantwell DV. Laparoscopic cholecystectomy with operative cholangiogram. Surg Laparosc Endosc 1991;1:229-32. 11. Deyo GA. Complications of laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:41-8. 2. Bagnato VJ, McGee G E , Hatten LE, Varner JE. Culpepper JP. Justification for routine cholangiography during laparoscopic cholecystectomy. Surg Laparosc Endosc 1991;1:8993. 3. Sackier JM, Berci G , Phillips E, Carroll B, Shapiro S, PazPartlow M. The role of cholangiography in laparoscopic cholecystectomy. Arch Surg 1991;126:1021-5. 4. Rossi RL, Schirmer WJ, Braasch JW, Sanders LB, Munson JL. Laparoscopic bile duct injuries. Risk factors, recognition and repair. Arch Surg 1992;127:596-602. 15. Mossa AR, Mayer AD, Stabile B. Iatrogenic injury to the bile duct. Arch Surg 1990;125:1028-30. 16. Andren-Sandberg A, Alinder G , Bengmark S. Accidental lesions of the bile duct at cholecystectomy. Ann Surg 1985; 201:328-32. 17. Kelly CJ, Blumgart LH. Peroperative cholangiogram and post cholecystectomy strictures. Ann R Coll Surg Eng 1985;67:93-5. 18. Cahill CJ, Pain JA. Current practice in biliary surgery. Br J Surg 1988;75:1169-72. 19. Aldridge MC, Super P, Horner J . Perioperative cholangiography during laparoscopic cholecystectomy: does it still have a role? Jersey: Annual meeting of the Society of Minimally Invasive General Surgeons, 1992. 20. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB. Jones RS. Laparoscopic cholecystectomy-treatment of choice for symptomatic cholelithiasis. Ann Surg 1991 ;213:665-76. 21. GravesHA, Ballinger JF, Anderson WJ. Appraisal of laparoscopic cholecystectomy. Ann Suutg 1991;213:655-62. 22. Nahrwold D. The biliary system. In: Sabiston DC, editor. Textbook of surgery. Philadelphia: WB Saunders, 1991:1045. 23. Helms B, Czarnetzki HD. Complete laparoscopic therapy of gallbladder and common bile duct stones. Br J Surg 1992;79 Suppl:S68. 24. Gelin M. Laparoscopic treatment of common bile duct stones. Br J Surg 1992;79 Suppl:S69. 25. Cotton PB. Endoscopic management of bile duct stones (apples and oranges). Gut 1984;25:587-97. 26. Cotton PB, Baillie J, Pappas TN, Meyers WS. Laparoscopic
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 11/20/14 For personal use only.
Laparoscopic Gastrointestinal Surgery cholecystectomy and the biliary endoscopist. Gastrointest Endosc 1991;37:74-94. 27. Shimi S, Banting S, Cuschieri A. Laparoscopy in the management of pancreatic cancer: endoscopic cholecysto-jejunostomy for advanced disease. Br J Surg 1992;79:317-19. 28. Semm K. Endoscopic appendicectomy. Endoscopy 1983;15:5964. 29. Pier A. Gotz F, Bacher C. Laparoscopic appendicectomy in 625 cases: from innovation to routine. Surg Laparosc Endosc 1991;1:b13. 30. Krukowski ZH, Irwin ST, Denholm S, Matheson NA. Preventing wound infection after appendicectomy: a review. Br J Surg 1988;75:102.3-33. 31. de Wilde RL. Goodbye to late bowel obstruction after appendicectomy. Lancet 1991;338:1012-7. 32. Loh A, Taylor RS. Laparoscopic appendicectomy. Br J Surg 1992;79:28%90. 33. Saye WB. Rives DA. Cochran EB. Laparoscopic appendicectomy three years experience. Surg Laparosc Endosc 1991; 1 :109-15, 34. Nowzaradan Y, Westmoreland J . McCarver CT, Harris RJ. Laparoscopic appendicectomy for acute appendicitis: indications and current use. J Laparoendosc Surg 1991;1:247-57. 35. Cristalli B. Cayol A, Izard V, Levardon M. Appendicectomie per celioscopie. Resultats preliminaires d’une nouvelle technique. J Chir Paris 1991;128:302-5. 36. Dallemagne B, Weerts J , Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen’s fundoplication. Xansas City: International Minimal Access Surgery Symposium, 1991. 37. Cuche F, Pelissier EP, Girard JF. Preliminary results of laparoscopic Nissen’s fundoplication. Br J Surg 1992; 79 Suppl:S68. 38. Nathanson LK. Shimi S, Cuschieri A. Laparoscopic ligamentum teres cardiopexy. Br J Surg 1991;78:947-51. 39. Katkhouda N, Mouiel J . A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocelioscopy. Am J Surg 1991;161:361-4. 40. Bailey RU’, Flowers JL, Graham SM. Zucker KA. Combined laparoscopic cholecystectomy and selective vagotomy. Surg Laparosc Endosc 1991;1:45-9. 41. Chisholm EM, Chung SCS, Sunderland GT, Leong HT, Li AKC. Thoracoscopic vagotomy: a new use for the laparoscope. Br J Surg 1992;79:254. 42. Laws HL. Naughton MJ, McKernan JB. Thoracoscopic vagectomy for recurrent peptic ulcer disease. Surg Laparosc Endosc 1992;2:24-8. 43. Legrand M, Detroz B, Honore P. Jacquet N. Laparoscopic highly selective vagotomy. Br J Surg 1992;79 Suppl:S68. 44.Weerts J. Highly selective vagotomy: Laparoscopic approach. Br J Surg 1992;79 Suppl:S68.
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45. Nathanson LK, Easter DW. Cuschieri A. LaDaroscooic reDairl peritoneal toilet of perforated peptic ulcer. Su& Eidosc 1990;4:232-3. 46. Mouret P, Francois Y, Vignal J , Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990; 77: 1006. 47. Edelman DS, Unger SW, Russin DR. Laparoscopic gastrostomy. Surg Laparosc Endosc 1991;1:251-3. 48. Alain JL, Grosseau D. Terrier G. La pylorotomie extramuqueuse par laparoscopie. Chir Pediatr 1990;31:223-4. 49. Reich H, McGlynn F, DeCaprio J , Budin R . Laparoscopic excision of benign liver lesions. Obstet Gynecol 1991;78:568. 50. Krivitskii DI, Palamarchuk VI. Puncture drainage of abscess of the liver and abdominal cavity controlled by echotomography and laparoscopy. Klin Khir 1990:49-50. 51. Paterson-Brown S, Garden OJ. Laser-assisted laparoscopic excision of liver cyst. Br J Surg 1991;78:1047. 52. McMahon MJ. Laparoscopic oesophagectomy. Kansas City: International Minimal Access Surgery Symposium, 1991. 53. Buess GF, Becker HD, Naruhn BM, Mentges BR. Endoscopic oesophagectomy without thoracotomy. In: Berci G, Sackier JM, editors. Problems in general surgery: laparoscopic surgery. Philadelphia: JB Lippincott, 1991:478-86. 54. Shimi SM, Nathanson LK, Cuschieri A. Thoracoscopic long oesophageal myotomy for nutcracker oesophagus: initial experience of a new surgical approach. Br J Surg 1992;79:3M. 55. Whiteley GSW, Nair RG, MacLennan I, McCloy RF. Pleuroscopic technique for oesophageal seromyotomy for achalasia. Jersey: Annual conference of the Society for Minimally Invasive General Surgeons. 1992. 56. Waldschmidt J, Schier F. Laparoscopic surgery in neonates and infants. Eur J Pediatr Surg 1991;l: 145-50. 57. Attwood SEA, McGrath J , Hill ADK, Stephens RB. Laparoscopic approach to Meckel’s diverticulectomy. Br J Surg 1992;79:211, 58. Birns MT. Inadvertent instrumental performation of the colon during laparoscopy: nonsurgical repair. Gastrointest Endosc 1989;35:54-6. 59. Espalieu P, Boulez J . Experience in colonic laparoscopic surgery. Br J Surg 1992;79 Suppl:S69. 60.Cooperman AM, Katz V, Zimmon D, Botero G. Laparoscopic colon resection. J Laparoendosc Surg 1991;1:221-4. 61. Lange V, Meyer G, Schardey HM, Schildberg FW. Laparoscopic creation of a loop colostomy. J Laparoendosc Surg 1991;1:307- 12. 62. Miller R, Roe AM, Eltringham WK, Espiner HJ. Laparoscopic fixation of sigmoid volvulus. Br J Surg 1992;79:435.
