1992 Scientific Session of the Society of American Gastrointestinal Surgeons (SAGES) Washington,...

A hxtra.ctx Surgical Endoscopy

Surg Endosc (1992) 6:85-110 �9 Springer-Verlag New York Inc. 1992

1992 Scientific Session of the Society of American Gastrointestinal Surgeons (SAGES) Washington, D.C., USA, April 11-12, 1992

Oral presentations SO1 THE USE OF LAPAROSCOPY IN THE EVALUATION OF ABDOMINAL PAIN. Barry Salky, MD, Joel .Bauer , MD. Depar tment of Surgery, The Mount Sinai Medical Center. New York. New York.

One thousand one hundred and seven gastrointestinal laparoscopic procedures were performed by the authors between 1979 and 1991. Included in this group were 205 procedures for abdominal pain syndromes (19%). Slxty-nine pat ients were evaluated for acute abdominal pain. There were pat ients in whom the usua l physical e x a m i n a t i o n , l a b o r a t o r y tes t s , and radio logica l evaluat ion left the diagnosis in doubt. Laparoscopic examina t ion revealed the d iagnos is in 68 pa t ien ts (98%). Unnecessa ry laparotomy were avoided in 41 pa t i en t s (60%). The rapeu t i c p rocedures via the laparoscope were possible in 11 of 12 pat ients in whom i t was attempted. One hundred and forty-four patients were evaluated for chronic abdominal pain syndromes. These were pat ients in whom multiple gastrointest inal e v a l u a t i o n s (endoscopies , CT scans , sonograms , con t ras t radiographs) were nondiagnos t i c . A firm diagnosis was made laparoscoplcly in 96 patients (67%). In 47 pat ients , definitive laparascoplc surgery was possible. Local anes thes ia was used in 190 patients (92%) for the diagnost ic procedure . Eighty-eight p a t i e n t s had p rev ious a b d o m i n a l su rge ry (43%). Laparoscopy is a highly accurate diagnostic procedure in the evaluation of both acute and chronic abdominal pain syndromes. As therapeutic laparoscopy surgery is frequently possible in both acute and chronic abdominal pa in syndromes , l aparoscopy shou ld be s t rongly considered before open laparotomy in this setting.

S02 LAPAROSCOPY FOR THE EVALUATION OF ABDOMINAL NEOPLASMS. DW Easter, MD*, A Cuschieri, MD**, M Lavelle-Jones, MD**, L Nathanson, MD**~ Departments of Surgery: UCSD, San Diego, CA*, and Ninewells Hospital, Dundee, Scotland**.

To assess the value of elective diagnostic laparoscopy in patients with suspected or known abdominal neoplasms, we reviewed our experiences in 42 patients studied between 1/88-10/91. In 16 female and 26 male patients aged 23-78 years, the areas or organs of specific interest were:

liver (19), abdomen (9), colon and liver (4), pancreas (4), stomach (3), lymphatics (2), and gallbladder (i). Despite complete preoperative evaluations, 27 patients (64%) had proven cancer yet unsatisfactory staging or biopsy results.

After laparoscopy, ii patients (26%) had an increase in the preoperative cancer stage, 3 (7%) had no stage change, 26 (62%) had cancer excluded, 1 (2%) had a decrease in cancer stage, and I had an equivocal exam. Of 19 patients with liver disease, findings included: metastatic neoplasia (6), cirrhosis (5), hemangioma (3), cysts (2), normal (2), and lymph nodules (i).

Results for the entire group included 13 true positives (31%), 28 true negatives (67%), and one equivocal result due to adhesions (2%). Following the equivocal exam, laparotomy revealed an anastomotic colon- carcinoma recurrence that was unseen by all antecedent testing. Close surveillance for neoplasia continues in patients with negative examinations, and no false results are known to date.

We find laparoscopy to be safe and accurate for the diagnosis, staging or exclusion of abdominal neoplasms, and advocate its use where less invasive testinq leaves unsolved c[uestions.

S03 DIAGNOSTIC LAPAROSCOPY IN THE INTENSIVE CARE PATIENT: AVOIDING THE NON-THERAPEUTIC LAPAROTOMY. C o ~ , P.P. Priebe, MD, M.L. Eckhanser, MD, and Department of Surgery, Case Western Reserve University, MetroHealth Medical Center, Cleveland. Ohio.

Evaluation of the acute abdomen in patients who require intensive care for concurrent medical~urgicalproblems may present the general surgeon with a diagnostic dilemma due to ambiguities ]n the physical examination and ancillary diagnostic testing. Diagnostic uncertainty can delay appropriate sur~cal intervention for intra-abdominal disease, an~ non-therapeutic laparotomy may increase morbidity and mortality. Between Ahgust, 1990 and October 1991, 16 critically ill patients underwent diagnostic laparoscopy under general anesthesia in the operating room to evaluate a suspected acute abdominal process. Age ranged from 30 years to 81years (mean, 57.6) and all were in an intensive care unit from 1-77 days (mean, 13.3 days) prior to general surgical consultation and laparoscopy. Nine patients (56%) underwent taparotomy following laparoscopy, while seven patients (44%) had a negative laparoscopy and were observed. There were no false positive or false negative examinations as demonstrated by suSsequent laparotomy, clinical course, or autopsy findings. Clinical management was altered in 8 patients

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.(50%)by laparoscopic findings: four pat ients who would have been observed had operat ive in tervent ion on the basis of a positive laparoscopy. Four patients who would have had laparotomy were observed on the basis of a negative laparoscopy. In the remaining eightpat ients , laparoscopy served to confirm prior management decisions. There were two technical complications dur ing . . laparoscop,r but nei ther affected pat ient outcome. Seven deatias occurred (44%), three had negatwe lap aroscop~,, and dea th was unrela ted to intra-abdominal aisease. Four patients had positive laparotomies which confirmed laparoscopict ' indings. Laparoseopy is a safe and effective guide for managing these complex patients, since it may preclude non- therapeut ic laparotomy in some patients and confirm the need for operat ive in tervent ion m others.

S04 LAPAROSCOPIC CREDENTIALS IN A RESIDENCY PROGRAM

Horace F. Henriques IE, M.D. Department of Surgery, George Washington University

Washington, D. C.

As latmroscopic surgery has become an integral component of surgery, appplicafion of Iraining criteria in a residency progrmn is pav, m~ot~t to the development of latgroscopic surgical techniques. Criteria to establish credentials for graduating residents should be dtTferent from certification requirements for practicing surgeons who gain new techniques in post- graduate courses. Residents should be graduated from programs as lalxu-o- sco~e c competent surgeons.

model we developed for acquiring credentials is based on previously published recommendations from SAGES and a review of criteria for lalxtro- scopic privileges at local institutions, qhe requirements for certification are: (1) completion of six hours of didactic laboratory experience; (2) txarficipation in 10 cases as camera operator and 10 cases as first assistant before assuming the surgeon's role; and(3) performance as surgeon in 10 cases which are independently reviewed for outcomes and upon which the resident is evaluated by the attending surgeon.

To test the validity of the above criteria, we prospectively evaluated 47 consecutive cases in which a resident assumed the surgeon's role with the attending surgeon as first assistant, qhere were no complications, and in only two cases was conversion to an open procedure necessary. Upon certificanon, a second series of 14 conseculave cases were followed in which a resident assumed the role as surgeon, another resident as first assistant, and the attending surgeon as camera operator. In this latter series there were no complica- lions and no conversions.

Using strict training criteria, residents can acquire compet~lcy in lalxtro- ~ c techniques and avoid the learning curve complicalaons. The aca- uemic mad didactic -background is k,',sured while super~s.'xl pmcti~.l tminin.,, is offered. We suggest that by utilizing this training model competent lap~Yo - scopic surgeons are graduated.

slightly to 20.3• (p>.05). Post-LC, the proportion of OCs by PGY5 residents increased (43% vs. 18%, p<.01) while that by PGY1 residents decreased (4% vs. 16%, p<.01). A trend toward fewer OCs by PGY4 residents was also evidenced (31% vs. 42%, p=.08).

Conclusions: LC can safely be integrated into surgical resident training and qualify trainees to perform LC. The initial impact of LC has been to decrease resident OCs while maintaining total number of cholecystectomies and to shift operative experience with both LC and OC away from junior level residents toward the chief residents.

S06 LAPAROSCOPIC CHOLECYSTECTOMY UNDER EPIDURAL ANESTHESIA - AN IDEAL COMBINATION OF MINIMAL INVASIVE SURGERY AND MINIMAL INVASIVE ANESTHESIA.

G.W. Lexer M.D. I, G.Ch. Lexer M.D. 2, F. Lehofer M.D. 3,

G. Meiser M.D. I, O. Boeckl M.D. 1

ist Dept of Surgery, LKA Salzburgl; Depts. of Surgery 2

and Anesthesiology 3, Friesach; Austria

Epidural anesthesia (EPA) has been reported to exert beneficial effects in surgical procedures. In this retrospective study we evaluated the outcome of EPA in patients undergoing laparoscopic cholecystectomy (lap. CHE). Unselected 61 patients (39 female, 22 male), mean age 46.9 years (20/86 a), mean weight 71.7 kg (46/125) with symptomatic gallstone disease were admitted to our lap. CHE-program maintaining analgesia with EPA. Pre- operative patient selection and indication for lap. CHE were unchanged.

Ventilatory measurements and arterial blood gas analyses were performed preoperatively (I) in the hori- zontal supine position with T5-TlO-level of analgesia, (2) after intraabdominal insufflation of CO9 for pneumoperitoneum and (3) at the end of the procedure. During the procedure the patients were maintained with oxygen insufflation of 3 i/min through an anesthetic face mask. Intraoperative sedation was given if necessary.

No significant changes of minute ventilation or arterial blood gas measurements were observed. Further- more, no intra- or postoperative either anesthetic or surgical complications occurred.

In review, our experience shows that EPA in lap. CHE is associated with almost no risk and is an acceptable anesthesiological technique even for unselected patients.

S05 THE IMPACT OF LAPAROSCOPIC CHOLECYSTECTOMY ON THE OPERATIVE EXPERIENCE OF SURGICAL RESIDENTS

Daniel J. Deziel, M.D., Keith W. Millikan, M.D., Edgar D. Staren, M.D., Ph.D., Steven G. Economou, M.D.,

Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.

The integration of laparoscopic cholecystectomy (LC) into training of surgical residents and the impact of LC on operative experience with open cholecystectomy (OC) were prospectively assessed during an initial 15 month experience with LC. Comparisons were made to residents' experience with OC preceding implementation of LC.

From 6/90 through 8/91, 324 LCs and 231 planned OCs were performed at a university medical center training seven categorical general surgery residents annually. Following a planned program of integration, residents participated in a graded clinical experience with LC under the guidance of qualified faculty. Residents participated as operating surgeon in 116 LCs (36%) and 210 OCs (91%). The level of training of residents performing LC included PGY5 (76 cases), PGY4 (24 cases), and PGY3 (16 cases). Chief residents who completed training in the first year of LC performed a median of eleven LCs (range 4-19). Operative time, cholangiography rate, conversion rate and complications were not adversely affected by resident operators.

Compared to OC experience in the 6 months preceding LC, the mean number of OCs per month performed by residents decreased from 18.3• to 14.0• (p<.05) but the mean total number of resident cholecystectomies increased

S07 LAPAROSCOPIC INSUFFLATION OF THE AB DOMEN DEPRESSES CARDIOPULMONARY FUNCTION. Mark D. Williams, M.D., Peter C. Murr, M.D., Department of Surgery, Saint Joseph Hospital, Denver, Colorado.

Introduction Recently the laparoscope has been used to remove the gallbladder in critically ill patients with c o m p r o m i s e d cardiopulmonary function in order to spare them the operative trauma of laparotomy. However, increasing intra-peritoneal pressure (IPP) may have deleterious effects. The purpose of this study was to investigate these cardiopulmonary effects.

Materials, Methods and Procedures Ten mongrel dogs were anesthetized, intubated, and placed on constant volume controlled total mechnaical ventilation. Intra-peritoneal insufflation trocars, femoral artery catheters, pulmonary artery catheters and bladder catheters were inserted. Baseline data were obtained and then the abdomen was insufflated. Significance of any changes were tested using Student 's t-test after correct ing for baseline differences.

Results An IPP of 15mmHg significantly decreased the mean cardiac output by 24% (p<0.05). This depression was aggravated by reverse trendelenburg and occurred without a change in mean arterial pressure. Insufflation of the abdomen with CO2 caused a significant rise in the mean arterial pC02 (31.6 to 44.8mmHg, p=0.003). Mean peak airway pressure rose from 13.4mmHg to

16.0mmHg at 15mmHg IPP and to 19.3mmHg at 30mmHg IPP (<0.0005).

Conclusions Laparoscopic insuffiation of the abdomen causes a significant but mild cardiopulmonary depression which is of doubtful clinical signifcance in the vast majority of patients. However, to extend the benefits of laparosocpic cholecystectomy to patients with decreased cardiopulmonary reserve the surgeon should be aware of these effects and invasive hemodynamic and continuous C02 monitoring should be used. Measures to improve venous return, augment cardiac output, lower pC02 and counteract the increase in peak airway pressure may be required.

S08 PERIPHERAL VENOUS PRESSURE ANALYSIS IN THE LOWER LIMB DURING PNEUMOPERITONEUM IN CLINICAL LAPAROSCOPIC CHOLECYSTECTOMY Kazuvuki Shimomur~ MD, Yumiko Ohtomo MD, Yoichi Ishizaki MD, -Tamaki Noie MD, Hideki Abe MD, Sarder Abdun Nayeem MBBS, Yasutsugu Bandai MD, Yasuo Idezuki MD. Second Department of Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan.

The effect of pneumoperitoneum on hemodynamics and cardiovascular system during laparoscopic cholecystectomy is still a matter of discussion. The possibility of the lower limb venous stasis, hence formation of deep vein thrombosis still remains. We monitored and analyzed the peripheral venous pressure in the lower limbs in different body positions during clinical laparoscopic cholecystectomy under pneumoperitoneum.

Ten cases (3 male and 7 female) of an average age of 48.7 years (37-58 yrs.) were undergone this investigation. Eight patients had cholecystolithiasis, 1 had both stone and polyp and the rest a big liver cyst. After induction of general anesthesia we performed a venous puncture and maintained the line for monitoring the pressure.

Before the pneumoperitoneum the average venous pressure was 10.9 mmHg (8 N 13 mm Hg) and during pneumoperitoneum of 12 mmHg of intraabdominal pressure the average venous pressure goes up to 18.5 mm Hg (15 - 23 mmHg). The difference between before and during pneumoperitoneum ranged 7 to 13 mmHg. Just after the withdrawal of the pneumoperitoneum the pressure went down to the normal range simultaneously with the lowering of the intraabdominal pressure. After achieving the full pneumoperitoneum we found venous pressure got a peak rise and went down gradually in the first thirty minutes in six patients with a range -2 - -5 mmHg (average - 3.3 mmHg) and maintained a stable level.

As we found a stable level of venous pressure even little higher than the normal during pneumoperitoneum we suggest that the chance of deep vein thrombosis is very low due to a continuous return of blood. The slight decrease in the pressure at the beginning might suggest formation of some collaterals for venous return.

S09 FLUORESCEIN ASSISTED LAPAROSCOPY IN THE IDENTIFICATION OF MESENTERIC ISCHEMIA David Kam M.D., David Scheeres M.D., Department of Surgery, Michigan State U./Butterwcrth Hospital, Grand Rapids, MI

The purpose of this study was to evaluate the accuracy of fluorescein assisted laparoscopy (FAL) in acute arterial mesenteric ischemia. Angiography is the most accurate screening tool available for ischemic small bowel (ISB) but is time consuming, potentially nephrotoxic, and only defines vascular pathology. The use of fluorescein has been established in open surgery to demarcate ISB and fluoresces when illuminated by ultraviolet light or argon laser.

A canine mesenterio arterial ischemia model was used, preparing an ischemic small bowel segment in eleven mongrel dogs. Following a 2.5 hour delay, laparoscopy was performed and the ischemic segment identified and marked. Confirmation of the ischemic segment was by initial observation with a standard light source and then with an .argon laser light source while injecting fluorescein intravenously. These findings were then compared with immediate open inspection with and without fluorescence.

# ischemic segments correctly identified (Nmax=l 1) Method without fluorescein with fluorescein open* 1 0 8 laoaroscoov* 1 1 9 *no difference, Fisher's exact test

The combination of laparoscoDic inspection with and without fluorescein dye allowed accurate identification of small bowel ischemia in all subjects. Laparoscopy alone is an accurate means of identifying ischemic small bowel. Fluorescein is able to identify ISB as well and can be used laparoscopically when there is a question of ischemia. FAL may be preferable to angiography for the screening of ISB. Clinical trials to evaluate the efficacy of FAL for acute mesenteric insufficiency are warranted.

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S10

A NEW METHOD OF LAPAROSCOPIC CHOLECYSTECTOMY AND OTHER ABDOMINAL SURGERY: AN ABDOMINAL WALL-LIFT TECHNIQUE NOT UTILINZING PERITONEAL INSUFFLATION Hideo Nagai, M.D., Yasuo Kondo, M.D., Toshihiko Yasuda, M.D., Kogoro Kasahara, M.D., Kyotaro Kanazawa, M.D. Dpt. of Surgery, Jichi Medical School, Tochigi, Japan

Laparoscopic chelecystectemy is being performed with peritoneal insufflation of C02 gas, which limits free use of conventional surgical techniques and is accompanied by operative risks resulting from hypercapnia and increased intra-abdominal pressure. We have improved the lapare- scepic procedure by using an abdominal wall-lift technique which does not utilize peritoneal insufflatien, and have applied this method to other abdominal surgery.

Two wire loops are anchored in the skin, one in the upper portion of the umbilicus and the other in the right mid-clavicular line at the costal margin. Both loops are then raised upwards by means of chains. A laparoscope is inserted through an umbilical trocar, and three additional holes for manipulating instruments are made at the same sites as in the insufflation method. The operative field is almost the same as in the pneumoperitoneum method. Since air-tightness between manipulating instruments and the abdominal wall is net required, we are able to use conventional surgical instruments and techniques in addition to those specialized for laparoscopic surgery.

Laparoscopic cholecystectomy was done in 29 patients with this method only and in 3 patients with a transient combination (ca. 10 min.) of this method and peritoneal insufflation. Only one patient underwent open cholecystectomy due to severe adhesion of Calot's triangle. We also have successfully applied this method to choledecho- tomy and choledechoscopy in one patient, and to splenec- tomy in five dogs.

The abdominal wall-lift method enables us to perform laparoscopic surgery more easily and safely than the pneumeperitoneum method.

S l l

AN ANALYSIS OF THE IMPACT OF DISCRETIONARY EQUIPMENT DECISIONS ON HOSPITAL COST

An analysis of surgeons choice of surgical instrumentation on hospital costs is done from the billing statements of approximately i00 cholecvstectomy cases done in three rural hospitals. Professional surgical and anesthesia fees are not included. The median hospital costs for elective electro-cautery laparoscopic cholecystectomy was $4679, for open cholecystectomy $4036, and for laser laparoscopic cholecystectomy $6586. The most expensive hospitalization was incurred due to the conversion from laparoscopic to open cholecystectomy.

Discretionary equipment accounted for from 0% to as much as 38% of the total hospital cost. For non-laser elective laparoscopic cholecystectomy, on average discretionary equipment accounted for 7% or $363 of the total bill. This

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compares to open cholecystectomy with an average of $23 or less than 1% of the hospital bill constituting discretionary equipment. Discretionary equipment used in laser-laparoscopic cholecystectomy cases accounted for 35% or $2171 of the total costs.

The cost of discretionary items for electrocautery laparoscopy can approach that of laser laparoscopy consuming

over $2000 per case. The pricing policy for equipment varied enormously between these hospitals. To make a)de - cision on the cost/benefit ratio of these items, the surgeon must therefore know the specific pricing policies of his institution.

Surgeons should act responsibly by using only technology that is necessary to the conduct of the operation and beneficial to their patients.

laparotomy. The 1 death and 2 bile duct injuries in our series occurred in non-acute patients. Complications for the 2 groups are shown in the table.

Misc Wd Infn UTI Rasp Bile leak Pancreatitis Acute 0.9% 3.9% 0.9% 1.9% 1.9% 0.9% Non-acute 1.7% 2.3% 0.9% 0.3% 0.7% 0.2%

Although patients with acute cholecystitis requircd conversion from laparoscopy to laparotomy more often than non-acutcs, most acutes could be managed by LC with few complications, short hospital stay and early return to full activities. Conversion to laparotomy was usually required because of inabi!ily to c!e:-,_r!y d,'!i~,'a!e the anatomy, rather than duu to intraoperative complications. A low threshold tbr conversion to laparotomy will result in a low risk of complications. We recommend that LC be attempted routinely in patients with acute cholccystitis.

S12 CHOLECYSTECTOMY: WHICH PROCEDURE IS BEST FOR THE HIGH RISK PATIENT? C.M. Wittqen, M.D., J.P. Andrus, M.D., C.H. Andrus, M.D., D.L. Kaminski, M.D. Dept. of Surg., St. Louis University Hospital, St. Louis, MO.

With less postoperative pain, disability and scarring, laparoscopic cholecystectomy (LC) has become an attractive alternative method of surgical management for the ambulatory patient with gallbladder disease. The best procedure for se- verely ili patients (pts) who are a poor operative risk but require cholecystectomy, however, is unknown since the operative morbidity and mortality of LC in this group of pts has not been extensively studied.

All pts undergoing cholecystectomy at one institution during the last year were evaluated. Based on their preoperative state of health as defined by a modified acute physiologic score (APS), pts were divided retrospectively into two groups [APS<10, APSZl0 (multiple medical risk factors for operation)]. Selection for either procedure was made independently of their preoperative status. Pts past medical history, demographic, physiologic and laboratory data, and operative complications (comps) were obtained from hospital records. A Chi-square analysis with a Yates correction factor or a Student's t test were utilized for evaluation of the collected data.

APS < i0 APS ~ I0 SC LC P value SC LC P value

Number of Pts. 47 81 29 20

Pt. Age 52.7 ! 47.3 ! 61.4• 56.8! (Years) 16.9 18.8 0.ii 17.3 22.0 0.43

Days in 9.5 ! 2.6~ 26.2• 8.5~ Hospital 8.7 2.6 0.0001 27.1 ii.0 0.01

Intraoperative Comps. 1 5 0.54 2 2 0.067

Postoperative Comps. 7 Ii 0.97 12 5 0.37

Mortality 0 0 -- 5 2 0.67 As shown in this study, the overall morbidity and mor-

tality of cholecystectomies are a function of the pts perioperative state of health and not related to the operative technique utilized. Although the major morbidity and mortality rates are no better than for SC, LC remains an acceptable surgical alternative for those patients with significant other illnesses.

S13

MANAGEMENT OF ACUTE CHOLECYSTITIS BY LAPAROSCOPIC CHOLECYSTECTOMY. G.M. Fried M.D.. H.H. Sigman M.D., J.L. Mcakins M.D., E.J. Hinchey M.D., J. Garzon M.D., J.S. Barkun, M.D,, J. Mamazza M.D., M.J. Wexler M.D., Dcpt of Surgery, McGill University, Montreal, Ouebec

Acute cholccystitis may be associated with hypervascularity, dense adhesions, and obscured anatomy. We prospec-~ive!y cva!w~led ~mr experience with lapamscopic cholccystcctomy (LC) in patients with acute cholecystitis (acutes) compared to patients without acute cholecystitis (non-acutcs). Over 16 months, 804 patients underwent LC, 102 (12.7%) lbr acute cholecystitis. Mean age of acute patients was 48, of non-acute paticnts 49 yrs, and 35% patients in each group had previous abdominal surgery. Median duration of operation was increased to 85 rains in acutes compared to 74 rains in non-acutes. Mudian postop hospital stay was 24 hr in non-acutcs, and 48 hr in acutes, but both groups were able to return to their usual activity at a median of 7 days after surgery. Of acutes, 21% rcquired laparotomy to complete the cholccystcctomy, whereas only 3% non-acutes required

S14 LASER VERSUS ELECTROCAUTERY IN I,APAROSCOPIC CHOLECYST- ECTOMY: A PROSPECTIVE, RANDOMIZED TRIAL. BM B0rdelon MD, KA Hobday CST, JG Hunter MD Dept of Surgery , U n i v e r s i t y of Utah School of Medicine , Sa l t Lake Ci ty , Utah.

While much of the clamor has d ied as to the opt imal i n s t r u m e n t ~or d i s s e c t i o n of the g a l l b l a d d e r from the l i v e r bed, the re remains no p r o s p e c t i v e compara t ive da ta con ce rn ing t h i s i s s u e . We under took a p r o s p e c t i v e randomized t r i a l comparing c o n t a c t Nd:YAG l a s e r with monopo]ar e l e e - t r o c a u t e r y d i s s e c t i o n in ]00 p a t i e n t s undergo ing l a p a r o - s cop ic c h o l e c y s t e e t o m y . E ] e c t r o s u r g i c a l d i s s e c t i o n was performed with "L" hook and s p a t u l a e l e c t r o d e s at ?SW c o a g u l a t i o n c u r r e n t . Nd:YAG l a s e r d i s s e c t i o n was per formed with an o rb - shaped con t ac t t i p (1200 pm t ip ) at 15W c o n t i n u o u s . A combina t ion of l i g h t touch thermal d i s s e e - t ion and b h m t d i s s e c t i o n was used for both p a t i e n t g roups . A s i g n i f i c a n t d i f f e r e n c e was found in the t ime r equ i r ed for d i s s e c t i o n of the g a l l b l a d d e r from the l i v e r bed, 19.2 + 8 .5 minu tes fo r "e lect r o c a u t e r y v e r s u s 23.6 • 9.6 minutes fo r l a s e r (mean • s t a n d a r d d e v i a t i o n , p < 0 .05 ) . E s t i - mated blood l o s s was s i g n i f i c a n t l y I e s s in the e l e c t r o - c a u t e r y group (p ~ 0 .01 ) . No s i g n i f i c a n t d i f f e r e n c e s were noted between the groups in the number of g a l l b l a d d e r p e r f o r a t i o n s , l i v e r i n j u r i e s , sern , , amylase , l i v e r chem- i s t r i e s , or b e m a t o c r i t change. In s i x i n s t a n c e s , l a s e r m a l f u n c t i o n n e c e s s i t a t e d comple t ing the d i s s e c t i o n with electrosurgery. We conchlde that electrosurgerv appears to have significant advantages for dissection of the gallbladder during laparoscopic cholecystectomy, and that the expense n e c e s s a r y to purchase and ma in t a in a l a s e r s p e c i - f i c a l l y for l a p a r o s c o p i c cho l ecys t ec tomy does not appear j u s t i f i e d .

S15 IS O U T P A T I E N T L A P A R O S C O P I C C H O L E C Y S T E C T O M Y WISE? C.J. Saunders, M.D., B. Gardiner , M.D., B.F. Leary, F.N.P., C.F. Frey, M.D. and B.M. Wolfe, M.D. Depa r tm en t of Surgery, Universi ty of California, Davis, C A

The authors repor t a compute r a ided prospect ive analysis of their experience with 421 consecutive laparoscopic cholecystectomies to examine the appropr ia teness of hospital discharge within 8 hours of operat ion. Four issues were found to be pert inent: 1) adverse ou tcome result ing f rom delayed diagnosis and t rea tment of complications, 2) dehydrat ion result ing f rom postoperat ive intestinal motility disturbance, 3) impai red postoperat ive ventilation, and 4) postoperat ive pain. Twenty-five pat ients (6%) experienced at least 1 postoperat ive complication. The complication was clinically evident or suspected in 3 of these 25 patients (12%) within 8 hours following operat ion. Seven additional complications were evident by 24 hours, 8 by 48 hours, and 7 complications were not detected until more than 48 hours postoperatively. The course of 2 pat ients was prolonged as the result of a delay in detect ion of the complication. One patient died at h o m e of a potentially reversible complication, and 1

patient developed life threatening ARDS 24 hours postoperatively. Nausea and vomiting occurred among 32% of all patients on the day of operation and extended into the first postoperative day in 10%. Two patients required readmission for dehydration. Vital capacity was 40_+26% (mean + SD) below predicted 1 hour postoperatively and 34-+32% 6 hours postoperatively in the 22 patients studied. Postoperative analgesic medication requirement was determined in 220 patients who were provided with a patient controlled intravenous morphine infusion with no basal rate. Consumption of morphine was highly variable but substantial on the day of operation: 17- + 16 mg. Conclusion" Hospital discharge less than 8 hours following laparoscopic cholecystectomy should be avoided or done only in highly selected cases due to the potential for delayed recognition of complications, impaired gastrointestinal motility, decreased pulmonary ventilation, and analgesic requirements.

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routine oD.cholanqioqraDh V to diagnose C.B.D. stones. Of those with possible C.B.D. stones, 75% had passed the stones bv the time of operation, i.e. preop. E.R.C.P. would have been unnecessary. Of those that did not, plus 8% who had unsuspected C.B.D. stones (on clinical, LFT, U/S grounds), 70% bad their stones removed by laparoscopie trans cystic balloon dilation of sphincter and flushing the stones to the duodena. There was no pancreatitis. The 30% with retained stones had a postop. E.R.C.P.

We conclude, there will be a temporary increased demand for E.R.C.P. • ES during the introduction of LC whilst surgeons learn lap. cholangiography and duct exploration following which ES will be as before LC, reserved for retained stones (possible increased incidence) and recurrent stones (stone retrieval and duct drainage to prevent further recurrence). A~knowledgements Upper G.I. Section, R.A.C.S. (audit data), R.M. Jones, Surgical Colleague.

S16 E~SCOPIC RETROGRADE CHOLAI{GIOPAI~CREATOGRAPHY (ERCP) AFTER LAPAROSLDPIC CHOLECYSTECTOHY (LC) AT A REPATOBILIARY REFERRAL CENTER R.A. Kozarek, M.D., L~W. Traverso, M.D., T.J. Ball, N.I)., J. 8rundabur, H.D., P.C. Jolly, }tD., D.J. Patterson, R.D., J.A. Ryan, }LD., R.C. ThirlbL M.D., D.G. Wechter, M.D., J~A. Hunter, Virginia Mason Medical Center, Seattle, Washington

The objective was to assess the use of ERCP after LC at our hepatobiliary referral center. Included are post-LC problems from outside institutions. Between May 1990 and October 1991 we performed 273 LC and 1,021 ERCP. Forty-two of the ERCP exams (4%) involved post-LC patients. In regards to in- house (~C) patients intraoparative ch01~gi~ams were obtained in 80% and 3% showed stones. The CBD ston~ were successfully treated and were e~ally divided between observation, open exploration, or ERCP papill0t0my (EP). Results of the p0st-LC ERCP exa~ and of n0nsurgical treatment were:

Reason for ERCP V~C Referred Total PD ~ E Stent

Stones/Pancreatltis 2 16 18 0 16 2

Papillary sten0sis 2 5 7 0 5 1

Cystic duct le~ 1 1 2 1 1 2

CBD injury 2 a 13 b 15 7 9 I0

Total 7 35 42 8 31 15

a. No transecti0ns; b. 6 transecti0ns status-past s~gical repair; P.D. percutane0us drainage; E.Stent = endoscopic CBD stent

Surgery was re~ired in 1/7 WRC patien~ when an E.Stent could not placed and in none of the referred patients. Conclusions: ERCP is a valuable diagnostic and theraputJc aid avoiding sur~ry in most cases, although it was infrequently used in W~C patients (2.6%). In contr~t referred cases bad more acute or complicated pr0ble~. Other than direct repair of trans~ti0ns, almost every past-LC problem was treated n0nsurgically. Long-ten stri~ure rate is ~kn0wn.

S18 IS LAPAROSCOPIC BETTER THAN OPEN APPENDECTOMY? Robert G. Molnar, M.D., Keith N. Apelgren, M.D., John M. Kisala, M.D., Department of Surgery, Michigan State University, East Lansing, Michigan

Laparoscopic Appendectomy (LA) is becoming increasingly popular as surgeons strive to manage surgical problems via minimally invasive techniques. LA has potential advantages over Open Appendectomy (OA), such as decreased hospital stay, hospital costs, wound infection rate, post-operative pain, and convalescence. LA also allows better visualization of the pelvis and peritoneum thus providing enhanced diagnostic accuracy. To assess some of these factors, we compared our early experience with LA to standard open appendectomy with regards to demographics, operative time, hospital costs, hospital stay, and normal appendix rate.

Age* Sex OR Time* Wound Appen N (Years) ~/~ (Min) Infec Lap Ii 24.2• 7/4 119.4• 0 Open 22 21.9• 12/10 68.5• 0 =========================================================

Hosp. Cost* Hosp. Stay Neg. Appen N ($) (DAYS) App7. Lap ii 6679+2041 4.2• - 3(27%) Open 22 5655• 4.1• 4(18%) * MfS.D. ** p<0.05 by unpaired t test

We found an increase in operative time and in hospitalization costs, with no decrease in hospital stay. Our surgical fee for LA is $1200 while it is $700 for OA. Anesthesia fees are based on OR time and are thus higher for LA in this study. Preliminary data suggest an earlier return to normal activity for LA, but the data are incomplete.

We conclude from this pilot study that, at present, LA is not clearly superior to OA. With further experience and new instruments Laparoscopic Appendectomy may replace the open technique. Further studies are needed.

S17 iAPABOSCOPIC CHOLECYSTECTOMY-IMPACT ON ERCP IN AUSTRALIA. D.P. Fletcher, FRACS, Uni.Melb., Austin Hospits], Melbourne, 3084

This studv assesses the impact of the introduction of laparoseopic cholecystectcmy (LC) in Australia on the practise of E.R.C.P. utilising national and institutional data. LC began in Australia in February, 1990. In May, 1991, under the auspices of the Royal Australasian College of Surgeons, a national audit of outcome of LC was performed. 171 surgeons performed 3498 operations on a selective basis (uncomplicated cases). Laparotomy was required in 7%, injurv to C.B.D. 0.2%, bowel 0.2% and postop, fistula 0.9%. Most did not do routine operative cholangiogram, using preoD. E.R.C.P. to screen for and treat C.B.D. stones by endoscopic sphincterotcmy (ES). This increases the demand on E.R.C.P. • ES and therefore incidence of complications. We assessed the proportion of patients in whom E.R.C.P. or ES would have been unnecessarv by attemDting LC in all comers and using

S19 Laparoscopic Treatment of Liver Cysts Lawrence W. Way, M.D., Albert Wetter, M.D., Department of Surgery, University of California, San Francisco, CA.

Simple cysts of the liver should be treated when symptomatic, and although percutaneous sclerotherapy is sometimes effective, large cysts do not usually respond to this approach. Surgery is curative if the cyst can be excised or permanently unroofed. In the past year we have treated 9 patients with benign simple cysts of the liver laparoscopically. Two patients had congenital polycystic disease, 5 patients had large solitary cysts at the surface of the liver, and 2 patients had large solitary intrahepatic cysts. The large surface cysts were treated by excising 30-50% of their surface area and tacking omentum over the residual cyst lining. The intrahepatic cysts were opened and drained by removing a small portion (eg, 10%) of their surface area. A pedicle of omentum was tucked inside the cavity

90

and tacked in place. The patients with polycysfic disease were treated by unroofing as many cysts as possible (eg, 50 cysts). Results have been excellent except in the patients with polycystic disease, although they too experienced palliation. The 7 others are asymptomatic, and CT scans have demonstrated only one recurrence (for technical reasons). Thus, although more followup is needed, laparoscopic surgery produced a result equivalent to what is accomplished by open surgery. In every case the postoperative course was uncomplicated, and the patient left the hospital within 1 or 2 days of surgery.

Many patients with symptomatic liver cysts are elderly. Since laparoscopic therapy is so effective and well tolerated, we suspect it will become the treatment of choice for most of these lesions.

and sigmoid colon resections (2) were performed. Indica- tions for surgery were malignant polyp (2), carcinoma (3), benign stricture (i), rectal prolapse (i).

The operative procedure consisted of the laparoscopic mobilization of the portion of bowel to be resected with evisceration of this portion via an oversized trocar, division of the mesentery with resection and anastomosis performed extracorporeally.

The operative times ranged from 70 to ii0 minutes. There were no intra-operative complications. One patient developed a post operative ileus. The total length of stay (including pre-operative day) ranged from 4 to 8 days (average 5.7). Hospital charges were approximately 50% of those for traditional open procedures in this age

group. The use of laparoscopic access for the mobilization

and the traditional techniques for resection of the intestine allows for enhanced recovery without inordinate increases in operative time or cost.

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TAILORED HERNIA PROSTHESIS FOR TRANSPERITONEAL LAPAROSCOPIC REPAIR OF INDIRECT AND DIRECT INGUINAL HERNIAS Joseph J. Pietrafitta, M.D., Leonard S. Schultz, M.D., John N. Graber, M.D., David F. Hickok, M.D.

Laparoscopic hernia repair has attracted a considerable amount of attention recently. A number of different techniques have been utilized by various investigators for the repair of both indirect and direct inguinal hernias. The original technique that was employed by us has evolved over time as additional experience has been obtained in over 150 cases. In an effort to standardize the procedure and eliminate recurrences, a tailored prosthesis was developed and used. The prosthesis was fashioned at the time of surgery. Its size and shape were based upon a standard set of measurements that were taken at the time of the operation. These measurements were obtained using a pair of pre-measured open dissecting forceps. Marlex mesh was used as the prosthetic material. The initial configuration that was used consisted of a simple elliptical shape. This was subsequently modified by adding a lateral projection that was designed to keep the prosthesis in place. The projection of the prosthesis was also made of marlex mesh. It was attached to the body of the prosthesis using vicryl suture. The projection was inserted into the inguinal canal. A medial reinforcement was also subsequently added. This was also made of marlex mesh. It was designed to repair a recognized direct defect while preventing protrusion of the prosthesis. In addition, it would reinforce the direct space in patients with an unrecognized weakness, thereby preventing direct recurrences. The design of the prosthesis is discussed as well as the results of its use. It is felt that use of a hernia prosthesis will contribute significantly to the effectiveness of transperitoneal laparoscopic inguinal hernia repair.

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LAPAROSCOPIC HIGHLY SELECTIVE VAGOTOMY. M. keqrand MD, B. Detroz MD, P. Honore MD, N. Jacquet MD. Dept. of Abdominal Surgery -

CHU Liege - BELGIUM INTRODUCTION We argue for laparoscopic highly selective vagotomy as the surgical treatment of chronic duodenal ulcer. M_A_T_E_R_LAJ_ AND M_E[._H_QD.S A consecutive series of 9 patients (8 males and 1 female) with documented chronic duodenal ulcer were treated between february and september 1991. The mean age was 36 years (range 27-56). Indication for surgery was failure of medical treatment. The mean duration of the disease was about 9 years (range 3-13). PROCEDI,IRE Patients were operated under general anesthesia with endotracheal intubation. A Faucher tube was inserted into the stomach to stretch the greater curvature. Pneumoperitoneum was obtained by umbilical puncture. Four ports were needed. First, the endoscope was inserted through a 10mm port sheath at the upper limit of the umbilicus. The procedure began with abdominal visual exploration and the nerve of Latarjet was easily identified. A 5-mm port was introduced to the right of th~ Xyphoid process and allowed the placement of an irrigator-aspirator cannula which helped to retract the left hepatic lobe. Two other 10 mm ports were placed beneath each costal margin to introduce the grasping forceps, scissors hook coagulator and clip applier. The dissection proceeded upward from the Crow's foot. The anterior leaf was divided close to the lesser curvature. The main vessels were doubly clipped and divided whilst the smaller generally higher ones were coagulated. The separation of the posterior leaf was facilitated by opening the lesser sac. The lower 6 cm of oesophagus was completely bared. To make this critical step easier a rubber s!ing was placed around the oesophagus. RESULTS There was no mortality nor operative morbidity. All patients were discharged after 4 day~ (range 3 - 5). I he mean operattve time wa= 186 ,hill. The acid secretion test under insulin stimulation confirmed the completeness of the vagotomy. CONCLUSION Laparoscopic highly selective vagotomy promises to be as efficient and safe as its laparotomy counterpart. Moreover, it benefits from the advantages of the laparoscopic approach within a reasonable operative time.

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LAPAROSCOPICALLY ASSISTED EXTRACORPOREAL COLON RESECTION D. CONGREVE, M.D., H. ZINNECKER, M.D., J. LOHMULLER, M.D. DEPARTMENT OF SURGERY, ST. LUKES HOSPITAL, DAVENPORT, IOWA

The application of laparoscopic visual access to traditional abdominal procedures such as cholecystectomy,

appendectomy and inguinal hernia repai~, has stimulated

the investigation of its use in intraperitoneal colon surgery. The initial phase of the project was the development of appropriate instrumentation to manipulate the intestine and allow for the evisceration of the portion of intestine to be reseeted.

Seven patients ranging in age from 70 to 93 years underwent laparoscopically assisted colon resections. Right hemicolectomy (4), transverse colon resection (I),

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LAPAROSCOPE GUIDED INTRACORPOREAL ULTRASOUND ACCURATELY DELINEATES HEPATOBILIARY ANATOMY M. Yamamoto, MD, G. Stiegmann, MD, J. Durham, MD, R. Berguer, MD, Y. Fujiyama, MD, Y. Oba, MD, J Downey, MD, O Miho MD. Departments of Surgery, Jikei University School of Medicine, Tokyo, and University of Colorado, Denver, Colorado.

Intracorporeal ultrasound (ICU) examination of the cystic and extrahepatic bile duets at laparoscopy may provide rapid delineation of anatomical relations and expedite detection of common duct stones. The purpose of this study was to determine if ICU could demonstrate ductal and porta hepatis vascular anatomy and provide accurate intraductal images.

METHODS: Five pigs had general anesthesia and placement of ports for cholecystectomy. Laparoscope guided ICU was done with a 7.5 MHz linear array l I ram. diameter probe (Tetrad Inc.) equipped with doppler flow detection capability. ICU was done by direct

contact with portal structures without water bath or contact gel. Identification of relationships between cystic and common/hepatic ducts and visualization of the extra_hepatic biliary system and portal vasculature was attempted. Measurements o f duct size with ICU were compared with cholangiograms and wi th anatomical measurement at necropsy.

RESULTS: ICU successfully visualized relationships between cystic and common/hepatic ducts using transverse, oblique, and longitudinal images. Portal vein and hepatic artery were identified and easily differentiated from duct structures using doppler signals. The entire intraductal extrahepatic biliary system could be seen including entry of the common duct into the duodenum. Ductal measurements obtained from ICU images correlated well with those from cholangiogmms mid with direct anatomical measurements.

CONCLUSIONS: 1) ICU imaging of the biliary system is readily performed; 2) Determination of anatomical relationships and complete visualization ofextrahepatic bile ducts and portal vessels is possible; 3) ICU may supplement or obviate cholangiography i f results of recently initiated clinical trials parallel these observations.

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TELEPRESENCE: ADVANCED TELEOPERATOR TECHNOLOGY FOR MINIMALLY INVASWE SURGERY

P. Green*, R. Satavat, ]. Hill*, and I. Simont" * SRI International, Menlo Park, CA 94025 USA i- Silas B. Hays Army Hospital, Monterey, CA 93941 USA

The minimally invasive surgeon's video view is detached from his physical relationship to the instruments and to the operating field itself. Hand motions required to maneuver the instruments are unlike those used in open surgery and are unnaturally correlated to the instrument tip motion, requiring deliberate rather than sponta- neous action. Moreover, force and tactile feedback are diminished as compared to open surgery. Our research is directed to the development of telepresence technology, which will bring to minimally invasive procedures the same intimate involvement, certainty, and dexterity that open surgery affords. Telepresence is enhanced teleop- eration; it provides to a remote operator the same hand control and visual, tactile, proprioceptive, and auditory feedback that he would have were he actually at the worksite, carrying out the operation directly. Eventually, minimally invasive procedures requiting great dexterity will be performed indirectly, by surgeons sitting at telepresence work-stations that recreate all of the motor, visual, and sensory responses that the surgeon would experience were his head and hands actually inside the patient. We have assembled a telepresence demonstration system consisting of two modules: a worksite module, in which the actual object manipulation takes place, and an operator module, which contains a strikingly realistic, virtual work- space. The operator reaches into this space and grasps and operates instruments that look and feel as if they are performing the task tight in front of him. This illusion enables the operator to carry out complex tasks with quick, sure motions. We describe the principles of operation of our telepresence system and demonstrate, via video tape, the deftness that can be achieved with it. A new system, specif- ically configured for laparoscopic surgery, is under development.

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CHOLANGIOGRAPHY AND LAPAROSCOPIC CHOLECYSTECTOMY: THE SAGES OPINION SURVEY. RJ Brodish, AS Fink. Dept. of Surgery, University of Cincinnati Medical Center, Cincinnati, OH and the SAGES Standards of Practice Committee, Los Angeles, CA.

With the increased use of laparoscopic cholecystectomy (LC), the roles of preoperative ERCP and intraoperative cholangiography (IOC) may be changing. To define opinions regarding adjunctive cholangiography in association with LC, SAGES members were surveyed regarding actual LC experience. In addition, hypothetical clinical scenarios were posed for ~40 and z65 year old patients. Responses were compared with Chi

91

Square test. 447 of 1220 (37%) surveys were returned. Most respondents (83%) performed LC, reporting data on 19,747 LC. Conversion to laparotomy was required in 803 (4%) of cases. Complications were reported in 340 (1.7%) patients. IOC was attempted in 10,102 (51.2%) cases and was successful in 7,384 (73%). When presented with normal liver function tests (LFTs), preoperative ERCP was selected by only 2% of respondents. Routine IOC was recommended by approximately 50% of respondents (44% patients s 40; 49% patients > 65). However, 80% recommended IOC for patients with multiple small gallstones and a dilated cystic duct. With elevated LFTs (bilirubin 1.8, alkaline phosphatase 1.5 x nl), only 56% of respondents recommended preoperative ERCP. However, 73% of respondents would obtain preoperative ERCP for more severe LFT abnormalities. Most (85%) recommended endoscopic sphincterotomy followed by LC for choledocholithiasis demonstrated by preoperative ERCP. Only 30% of respondents recommended laparotomy for a positive laparoscopic IOC. Response frequencies did not statistically differ in the two patient age groups. These opinions will be helpful in establishing practice standards for LC. However, they are likely to change as technical improvements are introduced.

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R OUTINE VERSUS SELECTIVE I N T R A O P E R A T I V E C H O L A N G I O G R A P H Y D U R I N G L A P A R O S C O P I C CHOLECYSTECTOMY. Nathaniel J. Soper. MD, Deanna L. Dunnegan, RN; Department of Surgery; Washhagton University School of Medicine; St. Louis, Missouri, U.S.A.

It is unclear whether intraoperative cholangiograms should be performed routinely or on a selective basis during laparoscopic eholecysteetomy. We therefore conducted a prospective randomized trial, studying 99 consecutive patients undergoing laparoscopic cholecystectomy at our institution. Excluded were 17 patients in whom eholangiograms (C) were indicated by preoperative or intraoperative findings. Of the remaining 82 patients, 40 were randomized to the C group and 42 patients were in the no cholangiogram (NC) group. Static images were obtained with a GE portable X-ray machine while injecting 30% Hypaque into the cystic duct. Results: Mean age, weight and stone burden were similar in the two groups. No complications due to C occurred, and there was no mortality. Cholangiography was not performed in one patient in the C group (2.5%) due to an obliterated cystic duet. No filling defects were demonstrated in the common bile duct with C, and no retained stones have been documented in either group. Cholangiographie findings altered operative therapy in 4 patients (10%): in 2, contrast entering the gallbladder led to placement of a drain and in 2 other patients cystic duet stones were demonstrated and removed. Operative time for NC was 76-+3 minutes (SEM) vs. 95-+3 rain for C (p<0.05). The time to obtain C was 24-+1 min and the mean total cost of C was $444. There were no injuries to the common bile duct or postoperative bile leaks in either group, and mean postoperative interval to discharge (1 day) and return to work (9 days) were identical in the two groups. Conclusions: Static C obtained during laparoseopie eholecysteetomy is safe, but time consuming and expensive. Findings on C may dictate a change in operative tactics. If C is not performed, the cystic duet should be opened and "milked" to remove calculi. With appropriate selection criteria, static C need not be performed routinely during laparoscopic eholecystectomy. If more rapid fluoroscopic techniques are available, routine performance of cholangiography may be worthwhile.

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LAPAROSCOPIC CHOLECYSTECTOMY; RESULTS OF A POLICY OF SELECTIVE CHOLANGIOGRAPHY. Jeffrey H. Peters, M.D., Jeffrey T. Innes, M.D., Mary E. Front, R.N., and E. Christopher Ellison, M.D. Depts. of Surgery, USC, Los Angeles, CA, and Grant Medical Center, Columbus, OH.

Routine cholangiography during laparoscopic cholecystectomy (LC) as has been advocated by some, is time consuming, costly and can be difficult. Selective cholangiography was performed on 347 patients undergoing LC and outcome data recorded prospectively. Criteria for

92

cholangiography were; i) an elevated alkaline phosphatase, 2) an elevated bilirubin, 3) a history of jaundice or panereatitis, 5) a common bile duct (CBD) >10mm on ultrasound examination and 6) unclear anatomy. Seventy two (72/347, 20.7%) underwent some form of cholangiography. Preoperative endoscopic retrograde cholangiograms (ERCP) were performed upon 32 (32/72, 9.2%) patients. Four (4/32, 12.5%) demonstrated choledocholithiasis, 19 (19/32, 59.3%) were normal, 8 (8/32, 25%) demonstrated other non-stone pathology, and I (3.1%) was unsuccessful. All patients with stones had successful endoscopic extraction of thier stones followed by uncomplicated LC. Forty (40/357, 11.5%) patients underwent intraoperative cholangiography (IOC). Eight patients had a positive IOC (8/40, 20%). Two patients underwent open laparotomy and stone extraction, one laparoscopic transcystic CBD exploration and stone extraction, and the remaining five had uneventful and successful postoperative ERCP and stone extraction. There were no major complications of ERCP in either the preoperative or the postoperative groups.

Three patients have presented with retained stones (3/347, 0.86%). Each had successful ERCP and stone extraction. All patients have been followed for more than 6 months and 253 for more than 1 year post procedure. One minor bile duct injury occurred in the 21st patient. An anterior tear was made in the CBD during initial dissection, cholangiography would not have prevented this injury.

It is concluded that routine cholangiography during LC is unnecessary. A policy of selective cholangiography can result in an acceptably low incidence of bile duct injuries. In addition patients returning with symptoms secondary to stones retained in the CBD are both uncommon and easily managed by ERCP and stone extraction.

A new technique for laparoscopic common bile duct exploration, flexible choledochoscopy and T-tube drainage (CBDE) is described. Comparison to traditional open CBDE is made.

During a 12 month period (10/90-9/91) 15 patients underwent LCBDE. The technique involves a longitudinal incision in the common duct, choledochoscopy with stone extraction using a basket or balloon catheter and T-tube drainage using laparoscopic suture of the choledochotomy. Open CBDE carried out in 31 patients is used for comparison. The post-operative length of stay (LOS), operative time (OT), hospital charges (HC) and complications are examined.

Results: Laparoscopic CBDE Open CBDE Number of Patients 15 31 Age (Years; Mean + SD) 50 + 23 71 + 15 OT (Minutes; Mean + SD) 176 + 49 123 + 34 LOS (Days; Mean + SD) 3.9 + 1.9 6.5 + 5.2 HC (Dollars; Mean + SD) 7,693 + 1,755 8,105 + 6,184 Complications 1 4

The single complication in the LCBDE group was a retained stene impacted at the ampulla. There was no mortality in either group. After a mean follow up of 7 months all LCBDE patients were asymptomatic.

LCBDE as described herein is quite similar to Open CBDE. Although longer and more technically demanding it is a safe and effective method for treating common duct calculi at the same operative setting as laparoscopic cholecystectomy.

$28 LAPAROSCOPIC CHOLEDOCHOSCOPY

Lee Swanstrom, M.D., William Sangster, M.D. Legacy Medical Systems, Portland, Oregon

Hypothosis is made that, as in open cor~non duct exploration (CDE), choledochoscopy should be the gold standard for laparoscopic CDE. A clinical experience in LCDE is presented under a protocolized approach to establish the feasibility, safety, efficacy and advantages of laparoscopic choledochoscopy.

An algorithm is presented as applied to 350 consecutive laparoscopic cholecystectomies. There were 28 positive cholangiograms (8%). The algorithm involved placing a guide wire via the cholangiocath, balloon dilating the cystic duct and inserting a 9.8 Fr. flexible choledocho- scope into the CBD. Stones are then either retrieved with baskets, fractured with pulse dye laser or pushed into the duodenum. If no endoscope can be passed, a 5 Fr. helical stone basket is introduced and "blind" retrieval is<~ attempted. If all attempts fail, then laparoscopic choledochotomy is performed if the duct is greater than 1.0 cm, or the patient is opened and standard CDE is performed.

Transcystic choledochoscopy and stone clearance was accomplished 23 times (82%) choledochotomy and choledochoscopy in 1 case (4%), blind basket retrieval in 2 cases (7%) for a total success rate of 93%. Both failures were opened and ducts cleared with no sequeli. Complica- tions of choledochoscopy includes persistent bile drainage in the choledochotomy/T-tube patient, perforation of the duct with a stone basket with no clinical sequeli, 1 ampulary laceration and 1 retained CD stone. There was no mortality, pancreatitis, cystic duct leaks or infections.

In conclusion, we feel that laparoscopic choledochoscopy is feasible, efficient in clearing ducts and has a low incidence of complications. It also has the advantage of finding occult pathology not available to blind techniques.

$30 THE MANAGEMENT OF SUSPECTED COMMON BILE DUCT STONES E. Phillips, M.D., B. Carroll, M.D., H. Fallas, M.D., L. Daykhovsky, M.D. Dept. of Surgery, Cedars-Sinai Medical Center, L.A., CA

Laparoscopic cholecystectomy (LC) has become the plat- inum standard for treatment of symptomatic gallstones. The optimum management of conmon bile duct stones (CBDS) en- coi ultered dui-Ji%~ T~C ov suspected ~,, ..... ~p~+~"~7,~. ~ ~: remains controversial.

Two patient groups were studied. 650 consecutive patients undergoing LC and 292 patients with CBDS treated laparoscopically are reviewed. Our technique of transcystic duct CBD exploration and laparoscopic choledochotomy and T-tube placement are presented. Our radiographic technique of balloon dilation of the ampullae will also be presented.

Preoperative indicators of CBDS were imprecise. Only 33% of patients with abnormal liver function tests had CBDS at the time of surgery. 4% of patients undergoing LC had unsuspected CBDS. There were ii complications (4%) in the 292 cases of CBDS treated laparoscopically. There were 2 deaths (0.9%), both patients were over 60 years of age and suffered myocardial infarctions postoperatively. There was one patient with a retained stone. Average hospitalization was under 3 days.

Pre and postoperative EBCP/ES should be restricted to the elderly, critically ill or high risk patient. Laparo- scopic choledochotomy is usually required when the stones are larger than 9~m or are proximal to the cystic duct junction. The transeystic duct technique is applicable in ~"~ Of' CaSes and o b v i a t e s ~ . . . . . ~ f o r a ,r~ t t lbe , me, con - c l u d e l a p a r o s c o p i e t e c h n i q u e s h a v e t h e a d v a n t a g e o f t r e a t - i n g p a t i e n t s w i t h CBDS a t one s e s s i o n ( s h o r t e n i n g t h e h o s - p i t a l s t a y ) w h i l e b e i n S s a f e and e f f e c t i v e .

$29 COMPARISON OF OPEN VS. LAPAROSCOPIC

COMMON DUCT EXPLORATION WITH T-TUBE DRAINAGE Mark E. Stoker, M.D. Division of General Surgery

The Fallon Clinic, Worcester, Massachusetts The treatment of common bile duct stones in the era

of laparoscopic cholecystectomy is a controversial topic.

S31 THE EFFECT OF RESIDENCY TRAINING ON ENDOSCOPY SUITE UTILIZATION. B. Murphy, D.O., Ph.D, S. Miller, M.D., and N. Keiter, R.N., Dept. of Surgery, Wright State University School of Medicine and Endoscopy Unit, Miami Valley Hospital, Dayton, Ohio.

Gastrointestinal endoscopy has become an important phase of residency training. It has been suggested

that procedures performedby residents lengthen endoscopy time and therefore reduce the total time available for daily procedures. This study was undertaken to compare the procedure durations between attending and resident perfomed EGDs, flexible sigmoidoscopies, and colonoscopies.

From January through March, 1991, a total of 740 GI endoscopy procedures were performed. Of these, 185 (25%) were performed by residents with attendings present. Durations were recorded by procedure type. Differences were evaluated by student's T-tests. The mean duration for all procedures was 25.3 and 28.5 minutes for attendings and residents respectively (p<.Ol). When analyzed by specific procedure, the mean duration times for colonoscopies, flexible sigmoidoscopies, and EGD were 32.1", 21.5, and 19.6" minutes for attendings and 44.2*, 23.7, and 24.6* minutes for residents (*=p<.01). The average time differences between attendings and residents were 12.1, 2.2, and 5.0 minutes for these procedures.

In conclusion, residents took significantly longer to perform EGDs and colonoscopies. However, the actual time differences should not effect scheduling except for colnnoscopies. These results indicate that effective resident endoscopy training can be conducted in the community-based hospital setting without interruption of the endoscopy schedule.

$32 APPLICATION OF ENDOSCOPIC INJECTION SCLEROTHERAPY (EIS) TO GASTRIC VARICES (GV). Norman B. Halpern, M.D., Angel Escudero-Fabre, M.D., Jonathan Sack, M.D. Department of Surgery, UAB, Birmingham, Alabama 35294-0007.

EIS is the primary method of management of bleeding esophageal varices. Presence of GV, however, is gener- a l l y regarded as a predictor of therapeutic f a i l u re , despite sparse data to substantiate the concept. This review was undertaken to assess our EIS experience in this unique subset of patients. Methods: from September 1982 through January 1990, 84 patients were treated by EIS. GV were manifest i n i t i a l l y or subsequently in 42 (50%) and 3 patients (4%), respectively. Five were lost to follow-up within two months. Median follow-up in the remaining 40 patients was 42 months (range 3-92). Conven- t ional, f lexible endoscopic techniques were used, speci- f ica l ly not l imiting injections only to an identif iable bleeding source. Usually 2-3 sessions were accomplished in the f i r s t week followed by outpatient elective ses-

"sions at monthly intervals. Intervals were lengthened as variceal obliteration became apparent. Rebleeding was managed by urgent endoscopy as indicated. Results: 21 patients never developed c l in ical ly apparent rebleeding. In the 19 patients who rebled, endoscopic findings classi- fied the source as: clearly esophageal (E) in 11, clearly gastric (G) in 3, or i f identification of the responsible varix was not possible, nonlocalizable (NL) in 5. Bleeding deaths occurred in only 2 patients, both NL sources. There were 7 operations for significant rebleeding, 6 shunts (al l E) and i varix l igation (G). Ten patients sustained minor rebleeding episodes (5 E, 3 NL, 2 G), all controlled by repeat EIS. Summary: Even i f all NL bleeding is combined with and considered to be G source, the risk of GV causing death is only 5%; requiring operation 2.5%, and only 12.5% wil l modestly rebleed during EIS. Conclusions: GV are not a direct cause of poor results from EIS.

which endoscopic features are associated with continuous or recurrent bleeding and thus requires active management. A retrospective review of 110 pts. with bleeding peptic ulcers who initially underwent conservative therapy was carried out. There were 62 females and 48 males and their ages ranged between 37 and 84 (mean 69.4). There were 42 gastric and 68 duodenal ulcers. Thirty four pts. presented with hematemesis, 49 with melena and 27 with hematemesis and melena. Fifty two pts. were in shock (BP < 90 MM Hg). All pts. were initially treated conservatively; N/G tube, IV fluids, Cimetidine or Ranitidine. Specific notation was made of continuous or recurrent bleeding. Endoscopy was carried out within 12 hrs. of admission to hospital and the following stigmata of bleeding were noted: spurting vessel, oozing blood clot, non-bleeding visible vessel. All 4 gastric ulcers with spurting vessels and 24 of 34 with oozing blood clots continued to bleed or had recurrent hemorrhage. All 4 gastric ulcers with non-bleeding visible vessels stopped bleeding. All 9 duodenal ulcers with spurting vessels and 11 of 53 with oozing blood clots continued to bleed or had recurrent hemorrhage. Only one of 6 duodenal ulcers with non- bleeding visible vessels had recurrent bleeding. We conclude that gastric and duodenal ulcers with spurting vessels and gastric ulcers with oozing blood clots require urgent treatment. The majority of duodenal ulcers with oozing blood clots are effectively treated by conservative therapy and as well gastric and duodenal ulcers with non-bleeding visible vessels.

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$34 COLONOSCOPIC IMPACTION IN LEFT COLON STRICTURES RESULTING IN RIGHT COLON PERFORATION Luchette, F., M.D., Doerr, R., M.D., Kulaylat, M., M.D., Stephan, R., M.D., and Kelly, K., M.D. State UniVersity of NY at Buffalo, Buffalo, NY Buffalo General Hospital and Veterans Administration Medical Centcr

Colonic perforation during flexible colonoscopy is a rare but recognized complication. We describe four cases of right colon perforation following impaction of the colonoscope in tight left colon lesions.

We reviewed 4,593 colonoscopies performed from 1984- 1989. The perforation rate for diagnostic colonoscopy was 0.28% (6/3,538), and for therapeutic colonoscopy was 2% (21/1,055). During colonoscopy, four perforations of

the right colon occurred at a site proximal to the level of the impacted colonoscope. The lesions being evaluated were obstructive in nature: two diverticular strictures (sigmoid colon), one ischemic stricture (descending colon) and one annular carcinoma (descending colon). The four perforations occurred in the right colon and manifested as distension with pneumoperitoneum in three patients and retroperitoneal emphysema in one patient. Operative management included total abdominal colectomy in three patients (ileoproctostomy in two and ileostomy in one) and right colectomy with ileostomy in one. Outcome was favorable in all cases.

We postulate that in patients with an obstructive left colonic lesion and a competent i!eoceca! vs!ve~ eYe~ss~ve air insufflation may lead to an acute closed loop obstruction. Overdistension, stretching and perforation may occur in the right colon. Combined definitive resectional surgery of the lesion and the right colon is a safe approach.

$33 ENDOSCOPIC INDICATORS OF RECURRENT OR CONTINUOUS BLEEDING PEPTIC ULCERS. H.S. Himal, M.D., Dept. of Surgery, University of Toronto, Toronto, Ontario, Canada.

Endoscopic control of bleeding gastric and duodenal ulcers is now an accepted therapy. Controversy exists as to

$35 EFFICACY OF COLONOSCOPIC SNARE RESECTION Of LARGE COLON

AND RECTAL ADENOMAS Dennis L. Fowler, M.D. and Sharon A. White, R.N.

Olathe Medical Center, Olathe, Kansas

Many pat ients with large adenomas (>2.0 cm) of the colon or rectum are referred for colectomy or transanal

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resect ion because of concern about adequacy of resect ion and r isk of complicat ions. The purpose of t h i s repor t is to review the resu l ts of colonoscopic snare resect ion of large adenomas. Forty pat ients had at least one large adenoma, and 3 pat ients had 2. Th i r t y -e igh t polyps were sessi le and 5 were pedunculated. Al l but 2 adenomas were 4.0 cm or less in size but those 2 were very large carpet- l i ke adenomas in the r e c t u ~ Th ! r t y - f i ve adenomas were benign (11 adenomatous, 3 v i l l ous , 20 tubu lov i l l ous and I hyperplast ic polyp). Five pat ients had carcinoma i n s i t u and 2 had s u p e r f i c i a l l y invasive carcinoma. Although a l l pat ients were advised to return for fol lowup, 7 pat ients did not re turn . Of the 33 who returned, 18 (55%) had no residual or recurrent adenoma. Fi f teen (45%) had residual or recurrent adenoma, but 7 had completion of the resect ion at fol lowup exam. Of the remaining 8, 4 are await ing fol lowup a f te r re - resect ion . Three others at the ages of 84, 86 and 90 have opted for repeated colonoscopy rather than colectomy for pers is tent adenoma on mul t ip le subsequent exams. Only I pa t ien t underwent colectomy a f te r his t h i r d colonoscopy documented residual disease. Hence,only 4 of 33 pat ients (12%) had documented pers is tent adenoma a f te r mul t ip le colonoscopic snare resect ions. Complica- t ions were inf requent. Two pat ients (5%) bled requ i r ing hosp i ta l i za t i on but ne i ther pa t ien t required t ransfus ion. There were no per forat ions and no deaths. In no pat ient was there malignant t ransformat ion in a lesion which was i n i t i a l l y benign. We conclude that colonoscopy and snare resect ion is safe and e f fec t i ve (88%) treatment for large adenomas of the colon and rectum.

$36 ANCILLARY TECHNIQUES FOR COLONOSCOPE INSERTION: HOW OFTEN ARE THEY EFFECTIVE? James M. Church, M.D., Colorectal Surgery Dept., Cleveland Clinic Foundation, Cleveland, Ohio.

Certain maneuvers may be used to facilitate advancement of the colonoscope. This study was performed to see how often these maneuvers were used and which were more helpful.

Methods: Data was collected prospectively from a series of colonoscopies performed solely by the author(n=159) or completed by him after a trainee had been unsuccessful(n=61).

Results: Colonoscopy was incomplete in 7 patients because of stricture(4), colitis(I) or tortuosity(2). Mean time of insertion was 15+/-2(95%CL) minutes and withdrawal 12+/-1 minutes. The 4 ancillary techniques used and their effectiveness are given in Table 1.

n %Helps %No Help Turn on left side 74 58 42 Turn on right side 32 81 18 Hold breath 133 31 69 Abd. Pressure 148 64 36

All 4 techniques were used in 23 patients. Three were used in 44, 2 in 62, and i technique only in 37.

Conclusion: Insertion of the colonoscope can be helped by a variety of techniques. Turning the patient on their right side is least often required but most frequently effective, usually in moving the scope down the ascending colon into the cecum. Abdominal pressure was the technique most often used and was effective in 2/3rds of cases.

through the laparoscope. 8 patients presented with stones larger than the cystic duct, thus precluding their retrei- val through this route. A intraoperative cholangiogram and a 3.6mm flexible ureteroscope were used to explore the common duct. A 3 Fr electrohydraulic lithotripsy probe was introduced through the cystic duct and the stones were fra~ mented under direct visualization. This was done in 3 patients with a total of 5 stones(maximal diameter of 1.3cm). The 3.6mm mechanical lithotriptor was also introduced '' through the cystic duct and the stones were fragmented under fluoroscopic control in 5 patients, with a total of 9 stones(maximal diameter of 1.6cm). In 2 of these patients a laparoscopic transcystic sphincterotomy was performed b! cause of papillary stenosis and fragments larger than 5mm. They were all pushed through the papilla. All of the stones were successfully fragmented, allowing subsequent extrac-- tion with the aid of ballon and basket catheters and clearance of the common bile duct. No complication occurred.

We conclude that laparoscopic transcystic mechanical/ electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with stones in the common duct that are larger than the cystic duct, that can be done during routine laparoscopic cholecystectomy,and that a new procedure, as laparoscopic transcystic sphincte rotomy, may be employed to treat concomitant papillary ste nosis or to allow pushing large fragmented stones after me chanical lithotripsy through the papilla.

$38 IAPAROSCOPIC REPAIR OF SMALL B(TWEL, COLON AND RECTAL ~fENOYOMIES: REPORT OF 26 CASES

WL Ambroze Jr MD, C Nezhat MD, F Nezhat MD, G OrangioMD, Atlanta, Georgia

As it has yet to be determined whether enterotomies created during laparoscopic dissection can be repaired safely without laparotcmy, our aim was to determine the efficacy and safety of laparoscopic enterotormy repair. Methods: A retrospective review of enterotcmies created during therapeutic or diagnostic laparoscopy in 26 (mean age 37, range 25 to 65 years). All patients had mechanical and antibiotic bowel preparation preoperatively. The indication for laparoscopy was endometriosis in 18 patients, severe abdominal adhesive disease in 7 patients, and adhesions with Crohn's disease in one patient. Enterots were secondary to CO2 vaporization of endcmetriosis or adhesions in 23 cases and trocar insertion in 3 cases. The injuries included 9 small bowel enterotcmies, 4 colotomies, and 13 rectotcmies. All were single layer suture repair with either 4-0 PDS or 3-0 silk. Results: There were no clinical ccrmplications related to enterotomy repair. All patients were placed on regular diets, when nausea, if any, abated. 23 patients were discharged one day after surgery, one patient was discharged on postoperative day two, and two patients on postoperative day three. Conclusions: Small and large bowel enterotomies can be repaired safely with minimum morbidity in patients with prepared bowel using the laparoscope. This may have implications for enterotcmies created during other procedures such as gastrointestinal endoscopy.

$37 LAPAROSCOPIC MECHANICAL/ELECTROHYDRAULIC LITHOTRZPSY FOR CHOLEDOCHOLITHIASIS - A. L. DE PAULA, M.D. , K. HASHIBA, M.D. - HOSPITAL SAMARITANO - GOIANIA - GOIAS - BRAZIL.

The objective of this study is to demonstrate the safety and efficacy of laparoscopic transcystic mechanical and electrohydraulic lithotripsy during routine laparoscopic cholecystectomy to treat choledocholithiasis. From 02 to 09/91, 33 patients with choledoc~oiithiasls were ~reated

$39 M A N A G E M E N T OF BILE LEAKS F O L L O W I N G LAPARO- SC OPIC C I t O L E C Y S T E C T O M Y . DC Brooks MD, JMBecker MD, PJ Connors MD, DL Carr-Locke, MD. Depts of Surgery and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Post-operative bile leaks (BL) are uncommou following open ci~olecyste~.tomy but may occur more fre~L~etaIly ai'ter lap:~rosCL}l~it: cholecystectomy (LC) because of haexact clip application to the cystic

duct or interruption of accessory ducts during dissection of tile gallbladder from the liver bed. We reviewed 475 LC to determine the incidence, clinical presentation, diagnosis and optimal management of BL. BL were identified in 6 patients (1.2%). There were 4 women and 2 men (mean age: 42, range 26 - 72). Presentation occurred at a mean of 5.6 days (range: 3 - 8 days) after LC with low grade fever, abdominal pain, nausea and vomiting. All patients demonstrated signs of ileus with localized right upper quadrant tenderness, leukocytosis and elevated liver function tests. Ultrasound demonstrated fluid collections in 5 of 6 studied. Extravasation was identified by hepatobiliary scintigraphy (DISIDA) in 5 of 5 patients studied and ERCP demonstrated the site of leak in 3 of 4 patients (2 cystic duct, 1 duct of Luschka). CT examination was confirmatory in 4 patients studied.

Two patients with cystic duct leakage were successfully treated with naso-biliary stenting, 1 patient with a small collection and positive DISIDA was treated expectantly after inability to place a nasobiliary stent. Her symptoms resolved in 5 days. One patient with retained common duct stone and leakage from a duct of Luschka underwent papillotomy and stone retrieval. The leak closed without further intervention. Two patients underwent surgical placement of closed suction drains, one via laparotolny and one via laparoscopy, both witi, leak closure in 7 days.

We conclude that BL occurs in under 2% of LC and the most common etiology is misapplication of cystic duct clips. Diagnosis is best accomplished by a combination of ultrasonograpy, DISIDA and ERCP. Appropriate treatment can be achieved by either naso-biliary stenting or laparoscopic placement of closed suction drains.

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cecal landmarks, alone and in combination were evaluated to precisely define their reliability.

Materials and Methods - Over an eight month period, 601 consecutive colonoscopic examinations to the cecum were studies. After confirming cecal intubation with fluoroscopy, the presence of three cecal landmarks were recorded: appendiceal orifice (A), ileocecal valve (V), and transillumination (T).

Results - Presence of Landmarks in all Cases: * Ileocecal Valve 98% * Appendiceal Orifice 87% * Transillumination 74%

Landmarks in Combination: (A) All 3 Present 64% (B) When Missing 1 Landmark 31%

* Ileocecal Valve Missing 2% * Appendiceal Orifice Missing 28% * Transillumination Missing 70%

(C) When Only 1 Landmark Present 5% * ileocecal Valve Present 77% * Appendiceal Orifice Present 4% * Transillumination Present 19%

Conclusion - In summary, transillumination through the abdominal wall is often not possible and an indentifiable appendiceal orifice is likewise unpredictable. The ileocecal valve is themost reliable cecal landmark and is invariable visualized, even when all ether landmarks are obscured.

$40 COMMON BILE DUCT INJURY AT LAPAROSCOPIC CHOLECYSTECTOMY. *DB Adams M.D., *MR Borowicz M.D., +FT Wootton I l l M.D., +JT Cunningham M.D. Departments of *Surgery and +Medicine, Medical University of South Carolina, Charleston, South Carolina.

Injuries to the common bile duct (CBD) represent the Achilles' heel of laparoscopic cholecystectomy (LC). To identify injury patterns, management, and outcome, a retrospective review and analysis of patients referred to the Division of Gastroenterology and the Department of Surgery with CBD complications after LC was undertaken.

14 patients were identified over a ]2 month period. 5 patients had major injury [(complete transection (4), obstruction by metallic cl ip ( I ) ] . g patients had minor CBD complications [str icture (3), cystic duct leak (4), obstruction due to retained stones (2)] which were diagnosed and managed endoscopically. No patients had intraoperative cholangiogram. Bleeding and inflammation in Calot's triangle were observed in ] patient. Surgeon LC inexperience (<13 LC) occurred in 3 cases.

Major CBD injuries were unrecognized at LC in three patients; three had repair of major CBD injuries with unconventional techniques, complicated by anastomotic stricture (2) and bile leak with per i toni t is (1).

In this study, diagnosis and management of major CBD injury at LC was characterized by diagnostic delay and unsuccessful attempt at operative repair. Minor CBD injuries were diagnosed endoscopically and successfully managed with non-operative techniques. Operative cholangiogram may prevent many of the CBD complications of LC. CBD complications occur after LC by experienced and inexperienced surgeons.

$41 THE RELIABILITY OF CECAL LANDMARKS DURING COLONOSCOPY.

W. C. Cirocco, MD, and L. C. Rusin, MD; Dept. of Surgery, State University of New York Health Science Center, Brooklyn, NY, and Dept. of Colon and Rectal Surgery, Saint Vincent Health Center/Hamot Medical Center, Erie, PA

Introduction - Confirming colonoscopic intubation of the cecum during colonoscopy can be a laborious, time-consuming and often frustrating endeavor. Anatomic landmarks may offer visual clues of cecal intubation, but how reliable is this evidence? The presence of three

$42 3D RECONSTRUCTION OF E N D O S C O P I C GASTROINTESTINAL ULTRASOUND Dido Franceschi. M,D.. Timothy Pritcharcl, M.D., and Marc Eckhauser, MD. Dept. of Surgery, Case Western Reserve University, Metro- Health Medical Center, Cleveland, Ohio

Endoscopic ultrasound evaluation has recently become a useful tool for the diagnosis and staging of rectal and esophageal neoplasms. Interpretation by clinicians can be difficult since a considerable amount of experience is required for three-dimensional (3D) mental reconstruction from two dimensional visual images. To address this problem we have developed a novel computerized approach that allows the creation of realistic 3D images from two dimensional contiguous slices obtained from an endoscopic ultrasound scan.

All manipulations are done on an IBM/AT compatible computer equipped with appropriate hardware. Cross sections from a continuous transverse scan of the intestinal segment are digitized with a resolution of 512 x 480 pixels, and a dynamic range of 8 bits/pixel (256 gray scale). The dynamic range of the pixel gray levels is digitally enhanced and edge detection and enhancement are performed with convolution filters through the original binary data. The in- traluminal and outer edges of normal and pathologic segments are traced and converted to a polygon vector within a defined 3D space. Serial cuts, 2 mm apart, are then "stacked" by connecting the contours to form a 3D mesh structure. The model is then rendered to a high resolution display frame buffer where the normal intestine and the pathologic segment (tumor) can be represented by different colors. Once created, angles of rotation around the X, Y and Z axes are assigned for image reconstruction, allowing the operator to obtain the best perspective. Furthermore, the model can be "cut" and cross sections recreated in any plane. Hardcopy of the model can be obtained from a photographic unit or a graphics printer. The 3D model data !s etored on the hard disk.

Utilizing the described technology, it is feasible to perform 3D reconstruc- tions of gastrointestinal endoscopic ultrasound on a personal computer, with detailed and accurate surface information. This permits an improved under- standing of the normal and pathologic anatomy as well as provides a useful tool for teaching and research.

$43 TECHNIQUES FOR IN UTERO ENDOSCOPIC SURGERY: A NEW APPROACH FOR FETAL INTERVENTION JM Estes MD. Z Szabo PhD*, and MR Harrison MD From The Fetal Treatment Program, Department of Surgery, University of California, San Francisco, CA and The Microsurgical Institute*, San Francisco, CA.

in utero open surgery can salvage many fetuses with life-threatening anomalies but carries substantial risks, mostly from preterm labor caused by the large

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hysterotomy incision. In an effort to decrease the risks of open fetal surgery and hysterotomy, we developed techniques for endoscopic fetal manipulation and applied them to a model of congenital cleft lip.

Four fetal lambs at 80 days gestation were used (term=145 days). The uterus was exposed via a laparotomy incision and insufflated with CO 2 to 5 cm 1-120. The fetal position was determined by palpation and a 5 mm trocar was placed for the telescopic lens and insufflation. Additional 5 mm instruments were placed and all ports were secured with a purse-string suture. A simulated cleft lip was created by incising the upper lip and alveolar plate. The wound was immediately repaired with interrupted 6-0 nylon sutures using intracorporeal suturing and knot-tying methods.

We designed and created several instruments necessary for successful fetal surgery. These instruments featured a curved micro-tip grasper and coaxial handle which facilitate precise suturing and knot-tying in a highly magnified surgical field. The techniques for microscopic knot-tying were adapted to this procedure and practiced in a trainer for approximately 20 hrs prior to use in animals.

The techniques of intra-amniotic endoscopy were worked out in 6 fetal lambs prior to this study. Gas insufflation was required as direct visualization through amniotic fluid was unsatisfactory due to excessive light scatter. Proper fetal positioning prior to trocar placement is also important as the surgical field is greatly constrained within the resulting small gas pocket.

The procedure was weli tolerated and there was no fetal or maternal morbidity. Fourteen days later the fetuses were removed and the wounds examined. There was no gross or histologic evidence of scar using hematoxylin/eosin and Mallory's trichrome stains.

The novel techniques of endoscopic fetal surgery described here offer an alternate approach to fetal intervention. These methods may facilitate earlier and safer fetal surgery. Our future goals include the application of these techniques to a non-human primate model and the development of percutaneous access methods.

sis. Aim: Use the laparoscope to mobilize the left colon and rectum, to perform a transperineal proctosigmoidectomy with primary end-to-end anastcmosis and to assess surgical margins, anastomotic integrity and ca~plications in the porcine model. Methods: In 8 pigs, under general endotracheal anesthesia , we placed the operating laparoscope and four operating trocars. Tne left colon was mobilized, the inferior mesenteric artery ligated at its origin on the aorta, the inferior mesenteric vein (IMV) ligated as it crossed the left colic artery and the rectum mobilized to the levator ani muscles by electrocautery. The rectum and sigmoid colon were prolapsed through the anal canal, transected and anastomosis performed using an EEA stapler. Transanal methylene blue was used to determine anast~notic integrity. Fluoroscene was used to determine colonic vascular integrity. Following the procedure, laparotcnry was performed to estimate blood loss and to record visceral injury. The specimen was examined for extent of resection. Results: Resection and anastomosis were performed in all animals with an average time of 87 + 7 minutes (+ SEM). Average blood loss 13 ~ 3cc. Average IMV length 6 + ic~. Average n~ber lymph nodes removed were 6~+ i. There were no injuries to ureters, bladder or spleen. A cautery burn to a fallopian tube was the only visceral injury. There was no anastomotic ischemia. All anastcmoses were patent and intact. Conclusion: Using the laparoscope in the porcine model a low anterior resection and anastomosis can be performed safely with adequate surgical margins without an abdominal incision.

S44 COMPUTER-AIDED GEOMETRIC MODELING OF LARGE INTESTINE AS VISUALIZED DURING COLONOSCOPY S.M. Krishnan, Ph.D., P.M.Y. Goh, M.Med, FRCS (Glas)

The graphic display features and manipulation capabilities of Computer-Aided- Design (CAD) System offer several useful and valuable methods for studying the anatomical forms and physiological functions. CAD techniques have been extensively used in modeling the Cardiovascular, Respiratory, Orthopaedic and other systems as well as for simulating complex surgical procedures. This paper describes work done by the researchers by application of CAD and computer vision technologies to model the large intestine uptu the ileococal valve, simulating what the endoscopist would sr162 during a diagnostic eolonoecopie procedure. The main purpose of this work is to aid the surgical residents perform computer simulated endoscopy, which would prove to be an essential and valuable tool during their training in endoscopic procedures.

Geometric data for defining the computer model of the large intestine are obtained by reviewing radiographic images of several Barium enema studies as well as published data on normal and abnormal colon anatomy. A three dimensional model of the large intestine is reconstructed using the collected data and making cuts of serial sections in parallel planes both in anterio-posterior and lateral views. The large intestine is divided into several geometric.ally significant segments and associated anatomical form-defining equations are developed. A central path of movement of an endoscope through the colon model is considered and corresponding mathematical relationships am derived. Using a CAD system, images are generated on a screen simulating what the endoecopist would see through a colonoscope during a procedure such as one for colonic cancer screening.

Based on the three dimensional model of the large intestine and simulated endoscopic capabilities, several computer-aided colonoscopie runs have been made. Preliminary results are obtained with normal colon eases. Work is in progress for the simulation of polyps and other abnormalities.

We conehide that the 3-D computer model of large intestine and endoscopic movement is a valuable training aid for the residents. The technique forms the basis for a possible future application as in robotic colonoscopy.

Poster presentations IAPAROSCOPIC PROC~OSIGMOIDECIDMY WITH EXTRA-CORPOI~EAL TRANSAk~L AI~AS%X)MOSIS : A PILOT STUDY W.L. Ambroze Jr., M.D., G.R. Orangio, M.D., J.G. Tucker, M.D., D. Baird, M.D., M. Herndon, D.V.M., G.W. Lucas, M.D., Georgia Baptist Medical Center, Atlanta, Georgia

Laparoscopic colon resections have required an abdominal incision to remove the specimen and perform the anastomo-

L A P R O S C O P I C C H O L E C Y S T E C T O M Y : ITS I N D I C A T I O N , L IMITATION A N D T R A I N I N G SYSTEM B A S E D ON JAPANESE SYSTEM Yasutsu~u Bandai MD, Kazuyuk i Sh imomura MD, Y u m i k o Ohtomo MD, Sar-der Abdun Nayeem MBBS, Yasuo Idezuki MD. Second Depar tmen t of Surgery, Facul ty of Medic ine , Univers i ty of Tokyo, Tokyo, Japan.

Laparoscopic cholecystectomy, which was ini t ia ted in the western countries, was in t roduced in Japan in 1990 and soon became popular. Difference of med ica l sys tem in some aspects be tween here and the western countries virtually influences laparoscopic cholecystectomy of Japan. This paper wi l l ref lect the indicat ion, l imi ta t ion and t ra in ing system of this procedure in Japan based on our own experience.

Unt i l S e p t e m b e r 1991, 73 ca se s u n d e r w e n t l a p a r o s c o p i c cho lecys tec tomy in our department . The indicat ions of this operation were cholecystol i th ias is , ga l lb ladder polyps and adenomyomatos i s in 62, 9 and 2 cases respec t ive ly . A v e r a g e ope ra t ing t ime was 153 minutes and ave rage pos topera t ive hospi ta l s tay was 5.1 days. No serious compl ica t ion during operation was exper ienced but there were 2 cases conver ted to l aparo tomy because of uncont ro l lab le bleeding from peripheral branch of the hepatic vein in one and another due to hematoma of the mesenter ium. Int raoperat ive cho lang iography was per formed rou t ine ly for check ing res idua l s tones and ana tomica l variat ions of the bile ducts. At init ial stage of our experience, patients with rather low grade inf lammat ion of the ga l lb ladder were selected and after pe r fo rming 31 cases we a lso inc luded the pat ients with chronic cholecys t i t i s even with negat ive cho lecys togram. However , acute cho lecys t i t i s is st i l l pend ing as cand ida te of this procedure because sys temic inf luence of insufflat ion under purulent condition is not yet clarif ied. Dur ing this per iod a total o f seven operators were produced, and transferring of technique was neatly accomplished.

Finally, laparoscopic cholycys tec tomy was introduced smoothly in our depar tment and pe r fo rmed wi thou t severe compl ica t ion . This unique m e t h o d for cho l ecys t ec tomy wi l l be f i rmly es tab l i shed in Japan.

I M M E D I A T E C Y S T I C D U C T O C C L U S I O N U S I N G A N E N D O L U M I N A L A B S O R B A B L E P O L Y G L Y C O L I C A C I D SCREW.

R.C.W. Bel l MD. G.V. S t iegmann MD, J. Sun MD, J. K im MD, J. Durham MD, M.S. Luc i a MD; Depar tments of Surgery, Radiology, and P a t h o l o g y ; U n i v e r s i t y o f C o l o r a d o and D e n v e r Veterans Hospitals , Denver , Colorado.

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Endoscopic in situ ablation of the cystic duct and gallbladder could be a valuable alternative to cholecystectomy in certain instances. This study examined endoluminal occlusion of the cystic duct using a biodegradabe polyglycolic acid screw, and simultaneous gallbladder in situ mucosal ablation with a sotradecol-ethanol mixture.

Eight domestic pigs (average weight 20 kg) had the gallbladder exposed via a right subcostal incision. Through a cholecystotomy, an endoluminal screw of polyglycolic acid (Davis and Geck), 3mm by 8 mm long, was twisted into the cystic duct. A closed suction drain was brought out the fundus. Following closure of the cholecystotomy, Sodium Sotradecol 2% mixed 1:1 with Renograffin were instilled up to a pressure of 20 cm H20. Immediate radiography showed occlusion of the cystic duct in all pigs. Chemical ablation of the gallbladder mucosa was done by instilling absolute alcohol and 2% sotradecol, to a pressure of 20 cm H20 into the gallbladder. Instillation time was 4 minutes each, 20 minutes total. The drain was placed to suction, and the wound closed. Animals were sacrificed on days 14, 21, and 42.

All animals survived operation and suffered no adverse sequelae. At sacrifice, radiography confirmed occlusion of the cystic duct in 6 of 8 pigs (75%). In two, the screw had migrated into the gallbladder. Histopathologic examination showed the following: Areas of mucosal necrosis mixed with regions of chronic granulomatous reaction. However, islands of gallbladder mucosa remained intact and epithelial regeneration was seen. The cystic ducts also showed small areas of mucosal preservation. Common bile duct mucosa showed no injury.

We conclude that immediate occlusion of the cystic duct is possible using an endoluminal polyglycolic acid screw. Modification to permit endoscopic insertion is feasible. Effective mucosal ablation may require multiple treatments.

welght of 154.8 pounds. Stones were seen on ultrasound (US) in 96.4% & 97.1% had chronic symptoms with 1.1% described as acute. Previous abdominal surgery (PAS)was recorded in 26% & 15 patients (1.7%) were jaundlced. History of myocardial infarction (MI) was present In 3.6% & dlabetes In 3.2%. ERCP was used preoperatively In 2.1%. Intrsoperstlve cholanglogram (IOC) was performed In 51.2% and this talled In 10%. Average surglcal Ume was 113.5 minutes & 3.2% were converted to open cholecystectomy (OC). There was a 12.2% Incldence of blle leakage with one ductal Injury (0.1%) & a total 8 cases required re-exploration (0.9%). There were 2 deaths, one due to unknown causes & one subsequent to a trocar injury. Patients were discharged mostly by the 3rd post-operative day (80.8%). Prospective Study: 22 Institutions gathered data on 1771 patients between 1/90-3/91. The female:male rstlo was 3.5:1 with average age o1 47.1 & welght of 167.8 pounds. Stones were detected by US In 96.6% & 88.1% had chronlc symptoms with 1% presenting acutely. In 32.,5% there had been PAS & 37 patients were jaundiced (2.1%). MI was noted In 3.7% & diabetes In 4 .3%. The duct was assessed by ERCP preoperatively In 4.6%, another 4.6% had attempted oral dlssolutlon therapy & 2.0% had failed extracorporeal lithotripsy. IOC was performed In 53.9% & felled In 29.3%. Average operating time was 105 minutes, 4.6% were converted to OC. There were 4 bile duct injuries (0.2%). Re-exploration was required in 13 patients (0.7%). One patient dled (0.06%) due to a CVA. Dlecharge from hospital was by the 3rd day in 88.7%. Additional demographics will be included & direct comparlsons between both studies will be drawn. The names of all the partlclpatlng InstltuUons & surgeons will be Included in the presentation.

DIAGNOSTIC LAPAROSCOPY IN CRITICALLY ILL INTENSIVE CARE UNIT PATIENTS. J.S. Bender, M.D. and M.A. Talamini, M.D. Department of Surgery, The Johns Hopkins University, Baltimore, MD

Introduction: Despite major advances in non- invasive testing, unexplained sepsis or abdominal pain in critically ill patients remains a major diagnostic challenge. In order to limit the amount of time spent in often poorly monitored settings, we have hypothesized that taking the sickest patients directly to the operating room for diagnostic laparoscopy and possible definitive surgery may improve outcome. Patients: This has been done thus far in five patients, four of whom were mechanically ventilated preoperatively (two patients following CABG; and one each with major burns; COPD and pneumonia; and possible myocardial infarction).

Results: Laparoscopy has revealed acalculous cholecystitis in two patients (one removed laparoscopically), gangrenous colon in one, cirrhosis and liver infarction in one, and in one patient was normal. Two patients died postoperatively: the burn patient from multisystem organ failure and the patient with cirrhosis and COPD from liver failure. The other three patients (including the patient with negative findings) recovered uneventfully. Laparoscopy itself was well tolerated in all patients.

Conclusion: Because of its ease and accuracy, diagnostic laparoscopy should be considered in all critically ill patients suspected of having intraabdominal pathology.

SAGES LAPAROSCOPIC CHOLECYSTECTOMY STUDY Coordinators: G.Bercl & J.M.Sackier, Cedars Sinai Medical Center

In view of the lack of data on laparoscoplc cholecystectomy (LC), SAGES sponsored retrospective & prospectivestudies. Retrospective study: 12 Institutions retrieved data on 900 patients from 6/90-1/91. The female:male rstlo was 3.5:1 with an average age of 46.7 and

LAPAROSCOPIC JUDD FORCEPS FOR PLACEMENT OF PURSE- STRING SUTURES

Marc Bessler MD, Michael R. Treat MD Department of Surgery, Columbia University CoJlege of Physicians & Surgeons and the Columbia- Presbyterian Medical Center, New York, New York

For advanced laparoscopic gastrointestinal procedures, it would be useful to have a simple means of placing a purse-string suture. We have developed and constructed a working prototype of an instrument to facilitate purse-string placement. The laparoscopic Judd forceps sets up the bowel wall in such a way as to allow for two stitches to be placed with one pass of a needle. In addition to reducing the time needed to place a row of sutures, the forceps improves the evenness of the suture line as equal bites of tissue are taken with each stitch. We have used the forceps in-vivo to laparoscopically place purse-string sutures in the ends of divided bowel prior to anastomosis with an end-to-end stapling device. Comparative time measurements of the time required to place a purse- string with the new instrument show that a 50% reduction can be achieved compared to standard free-hand laparoscopic suturing techniques. We feel that this simple instrument will render laparoscopic purse-string placement within the technical capabilities of most surgeons.

INCISION EXTENSION IS THE OPTIMAL METHOD OF DIFFICULT GALLBLADDER EXTRACTION AT LAPAROSCOPIC CHOLECYSTECTOMY. BM Bordelon MD, KA Hobday CST, JG Hunter MD. Dept of Surgery, University of Utah School of Medicine, Salt Lake City, Utah,

An unsolved problem of ]aparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Methods conceived to reme dy this situation include fascial dilatation, stone crushing, ultrasonic lithotripsy, and high speed rotary lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. To prove this hypothesis we reviewed the narcotic require-

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ments of 107 patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and fifty-five patients did not have their fascia] incision enlarged. Intramuscular meperidine use averaged 39.5 • 63.6 mg in the patients requiring fascial incision extension, as compared with an average meperidine use of 66.3 • 79.2 mg ia those not requiring faseial incision extension (m~an • standard deviation). Oral narcotic requirements were 1.1 • 1.5 doses versus 1.3 • 1.7 doses in patients with and without incision extension, respectively. While it appears that less pain medication was required by patients who underwent incision enlargement, the wide range of narcotic use in both groups makes this apparent difference not significant from a statistical standpoint. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscepic cholecystectomy.

EXPERIENCE OF 559 DIAGNOSTIC AND THERAPUETIC COLONOSCOPIES IN THE PRIVATE OFFICE. J.Canady, M.D., Dept. of Surgery, McKeesport Hospital E.Nicolo, M.D., Dept. of Surgery, McKeesport Hospital C.Jagdeo, M.D., Dept. of Medicine, Georgetown Univ. Hospital J.McQueen, M.D., Dept.of Anesthesia, National Orthopedic Hospital F.Foutaua, M.D., Dept.of Surgery, McKeesport Hospital

R.Dewltty, M.D., Dept.of Surgery, Howard Univ. Hospital Fiheroptlc colonoscopy has a well known diagnostic and therapeutic benefit. This procedure is usually performed in a hospital setting. The authors report their initial experience of 559 colonoscopies performed in a private office. There were 350 females and 209 males ranging in age from 30-92 (median age of 62). All colonoseopic procedures were performed using a combination of intravenous sedation (Demerol, Versed or Feutauyl) and continuous cardiac monitoring, oxygen saturation measurements. Major indications for colouoscopy were: occult rectal bleeding 58.3% (u=326), previous pathology or family history 10.3% (n=58), a b d o m i n a l pain 10.5% (u=59), and chronic constipation 8.5% (n=48). Findings on eolouoscopic examination revealed carcinoma 3.5% (n=20), single polyps 12.5Z (n=70), synchronous polyps 5.9% (n=33), and diverticulosis 51.8Z (n=290). The average colouoscopic procedure was twenty-two minutes. Of these 559 cases there were no morbidity or mortality. In sm,mary this data demonstrates the efficacy and safety of diagnostic and therapeutic eolonoseopy performed in a private office under well cardiac monitoring and balanced intravenous sedation.

DIAGNOSTIC LAPAROSCOPY IN AN OFFICE SETTING M. Castellano, M.D., E. M. Elmann, M.D. and

V.J. Lobbato, M.D. Department of Surgery, Cabrini Medical Center, New York, NY

Introduction: In this article, laproscopy was performed in an office setting under local anesthesia for the diagnosis of abdominal pain.

Material and Methods: Ten patients with a history of acute and chronic pain underwent diagnostic laproscopy. A 5nm, 0-degree single fiber laparascope, local anesthesia with sedation, and minimal insufflation (2 liters) were used in all cases.

Results: Five patients had indirect inguinal hernias. Three patients were found to have no pathology. One patient had acute appendicitis, and one patient had a ovarian cyst. There were no complications.

Conments: It is our conclusion that the role of laparoscopy should be expanded to

one involving diagnosis and can be performed rapidly and safely under local anesthesia in the office setting

ENDOSCOPIC APPROACH TO UPPER GASTROINTESTINAL HEMORRHAGE ON A SURGICAL SERVICE

JOHN M. COSGROVE, M.D., HOWARD FRANKLIN, M.D., IRVING B. MARGOLIS, M.D. Department of Surgery, Long Island Jewish MedicalCenter, Affiliation at Queens Hospital Center, Jamaica, NY Albert Einstein College of Medicine

The purpose of this study was to evaluate the protocol of admitting patients with upper gastrointestinal hemorrhage to a surgical service.

We believe in a policy of admitting patients directly to the surgical service from the Emergency Room. All patients on whom we were consulted by the Emergency Room attendings were admitted, resuscitated, started on H2 blockade, and, endoscoped early in their hospital course. Ninety-nine consecutive patients with upper gastrointestinal bleeding were analyzed.

Endoscopic intervention was performed in 8 patients, surgical intervention in 19 patients and endoscopic and surgical therapy in three. The majority of patients were managed non-operatively. There were 4 operative deaths and 9 non-operative deaths. Five of these deaths were due to advanced carcinoma, two were due to cirrhosis, four to multiple organ failure and one respiratory arrest. Only one appeared to be attributed to continued bleeding. The overall survival was 87 percent and the operative mortality was 18 percent. These statistics compare quite favorably with reported series in the literature.

We conclude that most patients with gastrointestinal hemorrhage do well. Those with a poor outcome generally have cirrhosis or advanced carcinoma. We further suggest that aggressive resu~cination and early endoscopy by the surgery service may lead to improved survival statistics that are, comparable, if not better than previously reported series.

OPEN TROCAR INSERTION FACILITATES LAPAROSCOPIC CHOLECYSTECTOMY AND DECREASES MORBIDITY. R de la Torte BSE, DC Brooks MD, JM Becker MD. Div of General and GI Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA.

Laparoscopic cholecystectomy(LC) haa t,c,'ome a siguificant alternative to conventional cholecystectomy except in patient.3 v.,ho have undergone prior abdominal operations. Our aim was to investigate the efficacy of open trocar placement in circumventing complications not only in this population but in all patients undergoing LC. 108 patients who underwent open LC were retrospectively compared to 130 patients who underwent closed LC. The study populations were comparable: (mean__SD age) 49.2_+ 14.7 with 19.3% men and 40.2_+ 15.4 with 21% men, respectively. Past surgical history and operative complications (cpx) were as below.

Open Closed total(complicatons) total(complications)

No Past Sur Hx 49 (8) 80 (10) Append only 9 (1) 6 (1) Pelvic Sur x i 21 (0) 23 (0) Mult Pelvic Sur I5 (0) 15 (3) Up abd Sur x 1 7 (0) 6 (2) Mult up Abd 7 (0) 0 (0)

Total 108(9) 130(i6)

Cpx ranged from incisionaI infection to Verres needle puncture of small bowel and aorta. Of 16 complications encountered with closed LC, 6(37.5% of cpx and 4.6% of al! procedures) were believed to be technique-dependent. No cpx could be directly attributed to the open technique. Three infections were noted in the closed group, 2 in the open. Also, patients undergoing open LC had a significantly greater number of prior abdominal operations while decreasing overall operative morbidity. We advocate the standard use of open trocar placement as a first attempt for all patients undergoing laparoscopic cholecystectomy regardless of surgical history.

ENDOSCOPIC ULTRASOUND DEMONSTRATES EXTENT OF ENDOSCOPIC SCLEROSIS OF GASTRIC CARDIA AS TREAT- MENT FOR REFLUX DISEASES.

P~ Donahue, M.D,, P 8chlesinger, M.D., K 81uss, M.D.,

B Attar, M.D., LM Nyhus, M.D.,K Anan, M.D. Dept. of Surgery, Cook County Hospital and University of Illinois at Chicago, Chicago, Illinois.

In previous report we demonstrated that endoscopic sclerosis of the gastric cardia (ESOC) controls experimental gastroesopha- geal reflux by improving the competence of the esophag6gastric junction. The present study was performed to determine whether endoscopic ultrasound (EUS) would detect the effect and extent of ESOC. METHODS: Endoscopic morrhuate

Injections were performed in seven dogs, at five week intervals; injections were made 1.0-2.0 cm distal to the squamo-columnar junction. Endoscopic ultrasound (EUS) was performed at times 0,8,11,16, and Z1 weeks after beginning treatment. SIF, expressed as the area(s) of sonographically visible echo-dense reaction (mmZ), was compared at each stage of treatment.

RESULTS: Transmural EUS echo-dense lesions were noted in all animals by the fifth week. The area of sonodense lesions encounted ranged from 30 to 380 square millimeters, and were maximal at ZI weeks. Histologic examination of the cardia revealed transmural fibrosis and disruption of the architecture of the submucosa and muscularis propria.

CONCLUSION: ESOC effects are transmural, and the extent of the fibrosis can be estimated with the useu of EUS. EUS can he used to determine the efficacy of ESOC in clinical trials of this treatment.

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of the technique and to suggest a role for operative cholangiography during laparoscopic cholecystectomy. 194 cholangiograms were attempted in 425 patients who underwent laparoscopic cholecystectomy from September 1989 through July 1991(46%). 173/194(89%) of attempts were successful. 88%(153/173) of studies were normal and 12%(20/173) were abnormal. All 153 patients with normal studies remained asymptomatic (false-negative rate=0%). True-positive studies occured in 3.5%(6/173) of cases. False- positive studies (normal postop ERCP) occured in 2.3%(4/173) of all cholangiograms. Sensitivity of cholangiography was 100%, specificity was 97.6%, and positive predictive value was 60%. Overall, a total of 18/425(4.2%) patients had proven common bile duct stones. 8/18 stones were removed preoperatively with ERCP and sphincterotomy. 6/18 stones were found at cholangiography, 5 of which were unsuspected (5/173, 2.9%). 5 of 6 stones found at operation were removed by ERCP and 1 by open CBDE. Retained common duct stones were found in 4/252(1.6%) patients not undergoing cholangiography. One biliary injury occured(1/425, 0.2%), in a patient who did not undergo cholangiography. No morbidity or mortality occured as a result of cholangiography. Routine cholangiography during laparoscopic cholecystectomy is recommended at the present time to avoid biliary injury by clarification of anatomy, to detect the presence of cystic duct and common bile duct stones, and for training purposes, especially during the learning phase of laparoscopic cholecystectomy.

ENDOSCOPIC CUT DOWN AT E.R.C.P. FOR THE DIFFICULT COMMON BILE DUCT CANNULATION - INDICATIONS AND RESULTS

D.R. Fletcher, FRACS, Uni. Melb., Austin Hospital, Melbourne, 3084.

This presentation describes the technique and long term

follow up of direct cut down on the bile duct for biliary acc~s~ at E.R.C.P.

Endoscopic sphincterotomy has become the treatment of choice for the retained and the recurrent common duct stone. The technique however is not always successful in either achieving cannulation or extracting calculi. One approach is to make a "precut" in the papilla and return at a subsequent E.R.C.P. for bile duct cannulation. The luxury of this delayed approach is not always appro priate with acute obstruction. By using a needle diathermy "cut down" on the apex of the papilla, immediate cannulation can be achieved in the majority. The risks are perforation or inadvertant entry into the pancreatic duct. 52 cut downs have been performed 1983-90. Commonest indication was stenosis or oedematous pendulous papilla. Immediate bile duct cannulation was achieved in 87%. In only 5 patients was it not possible to achieve a cut down (Polya gastrectomy, duodenal diverticulum, ill defined apex), bringing overall success in cannulation to 97%. There were no perforations. The pancreatic duct was entered in two, one developing hyperamylasaemia. Another patient with a history of calculus pancreatitis despite

a straight forward cut down and bile duct cannulation/ sphincterotomy had a severe exacerbation, with pancreatic abscess and ultimate death from sepsis. There have been no other long term sequelae.

Endoscopic cut down can achieve access to the biliary tree in the difficult case, but should be used with caution, as it is possible there is added risk of pancreatitis.

LAPAROSCOPIC CHOLANGIOGRAPHY: AN UPDATE. JL Flowers MD, KA mucker MD, SM Graham MD, WA Scovill MD, AL Imbembo MD, RW Bailey MD. Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

The role of laparoscopic cholangiography remains undefined; our current experience is reviewed to elucidate the safety and efficacy

LAPAROSCOPIC PARTIAL HEPATECTOMY FOR LIVER TUMOR

M. Gagner, M.D., FRCSC; M. Rheault, M.D., FRCSC, FACS; O?-D-O-b--O-C~, M.D., FRCSC. Department of Surgery and Gynec- ology, HOtel-Dieu de Montr6al, Univers i ty of Montreal.

Laparoscopic guided l i v e r biopsy and laparoscopic asses- ment of l i v e r metastasis are performed for d iagnost ic purposes. L iver reser t ion can be performed safe ly with u l t r a - sonic d issect ion and high performance e lec t ro cauthery.

Two pat ients underwent a pa r t i a l hepatectomy, a hemiseg- mentectomy VI fo r a 6 cm focal nodular hyperplasia (suspected Adenoma) and a wedge of the segment V fo r a l i v e r metastasis from a colorecta l cancer. A hemodilution was performed during laparoscopic assessment of r e s e c t a b i l i t y and biopsy.

The dissect ion was performed with the use of percutaneous u l t rason ic d issector and high voltage monopolar cauthery and vessels cl ipped. Adequate margins were obtained. The tumors were extracted in a s t e r i l e p las t i c bag and a post- e r i o r colpotomy. One pat ien t necesitated transfusion of 2 uni ts . Hospital stay were 3 and 4 days. Laparoscopic Par t ia l Hepatectomy can be performed in se lect ive pat ients.

A NEW TECHNIQUE FOR COMBINED PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND JEJUNOSTOMY Rafik Ghobrial, M.D., Bruce V. MacFadyen, Jr., M.D., Mark Catalano, M.D., and Isaac Raijman, M.D. The University of Texas Medical School, Houston, Texas

Aspiration of gastric contents has been a frequent complication with intragastric feeding and therefore jejunal feeding has been preferred. However, endoscopic placement of jejunal feeding tubes has been difficult and therefore a new technique for tube placement was developed.

Twenty critically ill patients (average 56 years, range 17-98 years) at high risk for aspiration underwent concomitant percutaneous endoscopic gastrostomy-jejunostomy (PEG-PEJ) using general and local anesthesia and intravenous sedation. Initially, an Olympus GIF IT10 gastroscope was advanced into the third part of the duodenum and the PEJ tube (8 French nasobiliary tube) was advanced through the accessory channel at least 40 cm distal to the pylorus

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into the jejunum. The endoscope was withdrawn and the proximal PEJ tube was brought out the mouth while the distal end remained in the jejunu~. Th~ gastroscope was rein- troduced into the stomach, a needle and guide wire were advanced through the abdominal wall and stomach, the wire captured and pulled out the mouth. Externally, the PEJ tube was connected to the PEG tube, both tubes attached to the guide wire and pulled through the stomach and anterior abdominal wall and secured. A postprocedure radiograph was obtained to confirm the position of the jejunal feeding tube.

The procedure averaged 59.3 min. The only complication in the 60 day follow up period was one uneventful episode of pulmonary aspiration (5%). All but 2 patients (90%) maintained positive nitrogen balance. Four patients (20%) died from their underlying disease and no deaths were related to the technique.

This technique is easy to perform, accurately places the PEJ tube, and minimizes pulmonary aspiration.

Group I l l hospitals ranged in size from 15-159 beds (median 50) with al l but one having less than 100 beds. Of hospitals larger than 300 beds, 95% offered LC, whereas 18% of hospitals smaller than 100 beds performed LC. These smaller hospitals represented 54% of al l hospitals in the state; 21% of al l LC hospitals; and contributed 4.7% of the estimated 4550 cases performed. The corresponding figures for hospitals greater than 300 beds were 17%, 33%, and 59.6% respectively, Mapping demonstrated LC ava i l ab i l i t y in v i r t ua l l y every geographic region. Resurvey 10 months following i n i t i a l data collection revealed that nearly al l Group I I hospitals had indeed begun offering LC and that 8 of 29 Group I l l has reversed their ear l ier decision not to perform LC. Conclusions: LC is now available in 78% of Alabama hospitals, demon- strating the profoundly rapid and geographically side- spread prol i ferat ion of this procedure.

LAPAROSCOPIC TUBE CHOLECYSTOSTOMY by Barry N. Haicken~ M.D.

The purpose of this study was to determine if placement of a drainage tube in the acutely inflamed gallbladder, judged too inflamed for safe laparoscopic removal, would facilitate later laparoscopic cholecystectomy. Most large series of patients undergoing laparoscopic cholecystectomy describe an incidence between 1% and 8% of patients who require conversion of the laparoscopic procedure to an open cholecystectomy. The most comnon reason is acute inflmmmtion.

The author offered tube cholecystost~y with 6 weeks of bile drainage as an alternative to open cholecystectomy in all patients undergoing attempted laparoscopic cholecystectomy. One hundred patients enrolled in the study. Three patients were judged to require open cholecystectemy for acute cholecystitis. A drainage tube was placed in the gallbladder using the seme comnercially available kit which is used for percutaneous endoscopic gastrostomy. A #14 Foley catheter was placed in the gallbladder. The gallbladder was placed on closed drainage, as an outpatient for 6 weeks. The patients then returned to the hospital for laparoscopic cholecystectemy.

The result of the study is that the 3 patients underwent successful laparoscopic cholecystectomy.

It is concluded that tube cholecystostomy with gallbladder drainage represents a satisfactory alternative to open cholecystectomy for this difficult acutely inflamed gallbladder. This method will serve to reduce drsmatically the nunber of patients requiring conversion to open cholecystectomy.

LAPAROSCOPIC CHOLECYSTECTOMY: A NEW APPROACH WITHOUT PNEUMOPERITONEUM H~himoto DaiiolM.D., Sarder Abdun Nayeem2MBBS, Kajiwara Shuji 1 M.D. and Hoshino Takanobu 1 M.D., 1Department of Surgery, Tokyo Metropolitan Police Hospital, Tokyo, 2Second Department of Surgery, University of Tokyo, Tokyo, Japan

The high volume insuffletor is among the most important equipments which made the laparoscopic surgery possible to perform successfully. Insufflation is essential for a safe insertion of trocars as well as for a good operative field. In fact the idea of insufflation is to have a room in between the anterior abdominal wall and intraabdominal organs. So we devised an alternative to make the same room by lifting up the abdominal wall, by the help of subcutaneous wires and thick sutures.

Two 30 cm long and 2-3 mm diameter strong stainless steel wires were p~ssed under the skin, one parallel to the right costal margin and another transversely above or below the umbilicus. Then lifting of the anterior abdominal wall was done by anterior, upward and little outward traction of these rods using No.-5 dexon suture and the traction was maintained by the help of hooks, an arch and clamp bars used in Kent extension retractor set for open abdominal surgery. A fairly good room was produced intraabdominally which was enough for performing the cholecystectomy procedure. An open laparotomy was thought to be safer in this case. We have successfully performed 20 cases of laparoscopic cholecystectomy by this procedure.

Pneumoperitoneum, which is considered as the first step of any laparoscopic procedure is no longer an absolute necessity. It is widely accepted that pneumoperitoneum has a number of disadvantages and may give rise to a number of complications relating Veress needle introduction, gas, pressure etc. The new maneuver provided an excellent operative field and operative view in the monitor and we could perform the procedure in a considerable number of laparoscopic cholecystectomies safely. No complication was experienced with this method and moreover excess instrumentation, cost and complications related pneumoperitoneum could be avoided.

PROLIFERATION AND AVAILABILITY OF LAPAROSCOPlC CHOLE- CYSTECTOMY IN THE STATE OF ALABAMA. Norman B. Halpern, M.D., Department o f Surgery, UAB, Birmingham, AL 35294.

Laparoscopic Cholecystectomy (LC) represents one o f the most r e v o l u t i o n a r y developments in heal th care in the past several decades. The procedure was f i r s t performed in the State o f Alabama in the Spring o f 1989. #ppro~imately 20 months la ter , this survey was performed to assess the impact of the phenomenon in this state. Methods: Appropriate individuals were contacted at al l 112 hospitals. Fac i l i ty and cl in ical practice data were obtained and hospitals were placed in three groups: I - presently performing LC; I I - intending to perform LC when equipment arrives; I I I - not intending to perform LC. Results: LC was already available in 54 (48%); soon to be available in 29 (26%); not intending to be available in 29 (26%). Group I hospitals ranged in size from 50-808 beds (median 192) and had already performed from 1-700 cases per inst i tu t ion. Group I I hospitals ranged in size from 48-319 beds (median 82).

MOVABLE DISSECTING AND TYING SPATULAE: TWO NEW INSTRUMENTS FOR LAPAROSCOPIC CHOLECYSTECTOMY Hashimoto DaitolM.D., Sarder Abdun Nayeem2MBBS, Kajiwara Shujil M.D., H0shino Takanobu 1M.D.and Tsuneo Fukuyo 3 1Department of Surgery, Tokyo Metropolitan Police Hospital, Tokyo; 2Second Department of Surgery, University of Tokyo, Tokyo; 3Shinko Optical Co. Ltd., Tokyo, Japan.

We developed a new type of movable dissecting spatula (Ojigi spatula) and a tying spatula for proper dissection, identification and ligation of the cystic duct and artery in laparoscopic cholecystectomy.

The dissecting instrummt is a 1.5 cm long blunt headed spatula fixed in a 30 cm long handle which is 5 mm in diameter. The spatula can freely be moved from a straight to vertical direction with a smooth angulation with the handle. The movement of the spatula can easily be controlled by the surgeon by its hand piece and also can be fixed in any angulation or also used as a free one by a detachable rachet at the hand piece. Using this instrument w e satisfactorily could dissect the

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neck region before clipping of the duct and artery. We found that this instrument is benificial to dissect every aspect of the Callot Triangle especially the posterior of the duct and artery. Sometime, using two spatulae we performed a 'double Ojigi spatula maneuver ' which means dissection of the duct or artery passing two spatulae posteriorly from both lateral sides of the structure using both hands of the surgeon. It allowed excellent dissection to expose the structures upto a considerable length which was not possible by a conventional dissecting forceps.

We modified the same spatula to develop a tying device making two slits, one at the tip and another at left border, and two tiny boles, one at the center and another little posteriorly. We use 2-0 nylon as ligature and pass it posterior to the duct or artery from one side using the tip-slit and bring its end back from the other side of the structure using the lateral slit. Then a slip knot is performed outside the abdomen which is slipped into the abdominal cavity by the help of the central or posterior hole of the spatula. A perfect ligation of the duct or artery could be achieved by this instrument.

tic falciform ligament and pushed up to the right subcostal portion, under video visual control. After the correct position is confirmed by laparoscope, the U-shaped retractor is lifted up by the winch placed over the abdominal wall, providing a clear field of vision without infusing gas into the abdominal cavity. The smoke produced by electrocautery of tissues is readily ventilated by suction through openings in the middle part of the U-shaped retractor. Ordinary surgical instruments can be readily used because of the non-air tight conditions. Between April 1991 and June 1991, we used this new procedure on 40 patients. These procedures were well tolerated and there were no complications. The procedures provide a clearer field of vision than does the usual method because the falciform ligament is lifted along with the abdominal wall. We find that our U-shaped retractor provides a rapid and slfer method of performing laparoscopic cholecystectomy even in patients with a gallbladder difficult to dissect, since there is no need to insufflate the abdomen with gas.

THE ROLE OF ENDOSCOPIC OR PERCUTANEOUS DRAINAGE IN MALIGNANT OBSTRUCTION OF THE COMMON BILE DUCT. H.S. Himal, M.D., Dept. of Surgery, University of Toronto, Toronto, Ontario, Canada.

The relief of jaundice is one of the major goals in the treatment of malignant obstruction of the extrahepatic biliary tree. Currently choledochojejunostomy (C J), endoscopic papillotomy and stenting (EPS), and percutaneous transhepatic biliary drainage (PTD) are the treatment options. A retrospective study of 104 pts. with unresectable malignant lesions was carried out. There were 54 males and 50 females and their ages ranged between 51 and 89 yrs. (mean 71.6). C.T. scans, ultrasonography and E.R.C.P. documented the site and extent of the lesions. There were 84 pts. with unresectable carcinoma of the head of the pancreas or distal common bile duct. Fifty pts. underwent CJ. Jaundice resolved in 43 pts. Three pts. died in the postoperative period (multisystem organ failure, pulmonary embolus, myocardial infarction). Four pts. developed intraabdominal sepsis requiring multiple procedures to control the infection. Twenty four pts. had EPS. Jaundice resolved in 21 of the 24 pts. Three pts. developed cholangitis requiring antibiotics and changing of stents. Ten pts. had PTD. In 6 pts. jaundice persisted; cholangitis and bleeding were major complications. Twenty patients had obstruction of the proximal hepatic ducts: 12 with carcinoma of the proximal hepatic duct, and 8 with metastases to the porta hepatis. Eleven pts. had EPS; jaundice persisted in 10 and cholangitis developed in 7 pts. Nine pts. had PTD; jaundice resolved in all 9 pts. Cholangitis in 3 pts. treated with antibiotics, quickly resolved. We therefore recommend that for unresectable carcinoma of the head of the pancreas or distal common bile duct EPS should be the treatment carried out. For unresectable proximal hepatic duct lesions PTD should be the treatment of choice.

A NEWLY DESIGNED U-SHAPED RETRACTOR FOR LAPAROSCOPIC CHO- LECYSTECTOMY. 8.Kitano ~_, M.Moriyama MD, K.Sugimachi MD. Department of Surgery, Saiseikai Yahata General Hospital, Kitakyushu and Department of Surgery, Kyushu University, Fukuoka, Japan

Laparnscopic cholecystectumy is rapidly gaining accept- ance as a new modality. We describe herein a safe and simple technique to maintain a clear field of vision that does not require high pressure gas infusion into the abdominal cavity. The video laparoscope is inserted into the abdomen through the subumbilical trocar, in the usual manner following the initial pneumoperitoneum. The U-shaped retractor is introduced with the guide tube connected to a long vented needle which is inserted at the epigastric portion, passed at the dorsal of the hepa-

DEPRESSED TYPE OF EARLY COLO-RECTGAL CANCER. Shin-ei Kudo, M.D., Takashi Kusaka, M.D., Kouji Nakajima, Hiroyuki Kimata, M.D., Kouji Miura, M.D., Yukio Takano, M.D. Department of Surgery, Akita Red Cross Hospital, Akita, Japan.

Since April, 1985 the authors have diagnosed and treated 524 lesions of early cole-rectal cancers. Of those 524 lesions, 299 were protruded-type lesions, 123 were the slightly elevated type, 16 were a flat type, and 57 were depressed-type lesions.

Although the depressed-type lesion is very small, with a slight reddish change in the mucosa, it is often seen as an invasive cancer. Therefore, precise endoscopic observation, as well as careful endoscopic mucosal resection (strip biopsy) is required.

We have performed endoscopic strip biopsies, with fluid injection, on 771 lesions, including complete treatment for 45 lesions of depressed carcinoma.

THE NONOPERATIVE TREATMENT OF COLONIC MICROPERFORATION AFTER COLONOSCOPIC POLYPEC~OMY

Jonathan B. I_amphier M.D., Thomas Diflo M.D., and Edward S. Kondi M.D. uoston University, Boston, MA

The incidence of perforation following colonoscopy is between 0.2 and 2%, but is increased two-fold if polypectomy is performed. Symptoms following perforation range from n o n e

to those of an acute abdomen. Colonoscopic perforation has traditionally been treated operatively, however there is good evidence that certain carefuUy-selected patients can be managed nonoperatively with intravenous antibiotics and fluid, and bowel rest.

In this paper we present the only two perforations we have had in a 16-year experience with 7,890 colonoscopies. Although the clinical situations were different in each case, management was the same, consisting of intravenous fluids and antibiotics, nasogastric decompression and bowel rest.

The paper discusses the factors predisposing to perforation, the usual clinical presentation and the treatment options.

Colonoscopic perforation is uncommon, and its presentation quite variable. Theories for treatment range from immediate celiotomy to nonoperative management. We feel that in many, if not most situations patients wiU recover without sequelae, without requiring surgery.

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LAPAROSCOPIC CHOLECYSTECTOMY EXPANDS THE ROLE OF BILIARY ENDOSCOPY. G.M. Larson, M.D., G.C. Vitale, M.D., W. Voight, M.D., W. Cheadle, M.D., F. Miller, M.D., Dept of Surgery, University of Louisville, Lou., Ky.

The purpose of this study is to evaluate the indications and results of ERCP and sphincterotomy (ERS) since beginning LC. The indications for preoperative ERCP have been a suspicion of CBD stones based on lab tests, ultrasound assessment of CBD and patient history in 310 consecutive patients (10ts.).

Preoperative ERCP was performed in 17 pts. and was positive for stones in 6. The stones were successfully removed by ERS in each of the six. Five pts. had CBD stones identified during LC and these stones were removed by open CBD exploration in 3 pts. and by planned ERS the next day in 2 pts.

In the postoperative pedod, a CBD stone was identified in one additional 10t. and this was removed by ERS. Thus, in our total experience, 12 of 310 pts. (4%) have had CBD stones identified and 9 of 12 have been removed by ERS. Postop ERCPs have been performed in 6 other pts. for evaluation of a suspected CBD injury (1), postoperative pain (3), and bile leak (2) which was treated by ERS in one pt. and by laparoscopic placement of drains in another pt. In the 12 pts. with CBD stones, the CBD diameter by ultrasound was <5.0mm in 2 pts. and >5.0mm in 10 pts. (range 4.5 - 10mm). ERCP complications were 2 mild cases of pancreatitis - one after stone extraction and one after a normal ERCP.

In summary, in this series of 310 pts. ERCP/ERS procedures were performed in 25 pts. (17 preop and 8 postop). The CBD diameter by ultrasound appears to be an important predictor of CBD stones. We conclude that biliary endoscopy is a valuable diagnostic and therapeutic adjunct for LC both in the pre and postoperative period.

LAPAROSCOPICALLY ASSISTED TOTAL COLECTOMY PF I_em_hy MD,* RP Pennino MD,** RH Furman BS** * Yale University School of Medicine, New Haven CT ** University of Rochester Medical School, Rochester NY

A 24 year old female presented with disfunctionai megacolon. The laparoseope was introduced through a fight upper quadrant port Additional ports were introduced in the fight lower quadrant, left upper quadrant and left lower quadrant. The colon was dissected free from the peritoneum, and hepatic and splenic flexures to permit mobilization. A second laparoscope attached to a light source was introduced via the left lower quadrant pert. The mesentary was placed over this scope to outline the margins of the mesenteric vessels. The mesenteric vessels were dissected free, clipped, and divided. An Endo GIA 30 stapling device (U.S. Surgical Corp.) was used to transect the rectum. A 3cm incision was made in the abdomen just above the pubic symphisis. The distal ileum was mobilized out of the abdomen through this incision. The diseased colon was transected and the anvil of the CEEA stapling device (U.S. Surgical Corp.) was placed in the distal ileum. A purse string (U.S. Surgical Corp.) was applied to the ileum to anchor the anvil. The CEEA stapling device was introduced through the rectum and the trocar advanced. The trocar was disconnected from the CEEA instrument and carefully removed from the abdomen. The CEEA instrument was closed, fired and the anastomosis was visually inspected. The pataent was discharged ca post-operative day 4 ~qd was able to resume normal activities within 6 days.

LAPAROSCOPICALLY ASSISTED GASTRECTOMY PF Leahy, MD,* RH Furman, BS,** RP Pennino, MD** * Yale University School of Medicine ** University of Rochester School of Medicine

Whether laparoscopically assisted procedures will confer similar henefit~ to totally laparoscopic procedures remains unverified. The following report describes a laparoscopically assisted gastrectomy

performed for the treatment of eroding ulcer. A 62 year old female presented with abdominal pain. Upper gastro-intestinal investigation and endoscopy revealed an eroding ulcer at the cardio-esophageal junction. The trocars were placed as follows: A 10mm in the right upper quadrant, a 5ram in the left upper quadrant, a 12mm in the left midclavicular line, and a 10mm in the umbilicus. The greater omentum was grasped and suspended. Endo GIA stapling devices equipped with vascular cartridges (U.S. Surgical Corp.) were utilized to hemostatically seal the short gastric vessels and branches of the gastroepiploic arterie. The stomach was mobilized and transected using 3 Endo GIA stapling devices (U.S. Surgical Corp.) and removed through a 3cm incision. Gastric reconstruction was achieved by the Polya technique. The patient was able to resume early ambulation and required minimal analgesics. She was discharged within 6 days and made a rapid recovery. Based on this experience it is clear that laparoscopically assisted procedures will produce favorable results and should play a role in endoscopic surgery ,Ji u~e iutdi:e. As endoscopic technology ir/~provc~ i~ i~ ilk~l~" that procedures such as this may be performed totally laparoscopically.

LASER GLUE FIXATION OF POLYPROPYLENE MESH TO FASCIA: APPLICATION TO LAPAROSCOPIC HERNIA REPAIR

Steven K. Libutti MD, Marc Bessler MD, Mathew R. Williams, Michael R. Treat MD Columbia University College of Physicians & Surgeons and the Columbia-Presbyterian Medical Center, N.Y., N.Y.

We have performed a preliminary evaluation of laser activated tissue glue as a means of fixing polypropylene mesh to fascia. A 2x2 cm piece of mesh was-placed on the exposed abdominal wall fascia of anesthetized rats. The mesh was then coated with a liquid protein glue applied with a cannula. A 2.1 micron holmium:YAG laser was used to coagulate the glue, thereby fixing mesh to fascia. A tensiometer was then used to measure the shear force needed to separate the mesh from the fascia. The average result was 600 grams. For a typical human inguinal hernia, we estimate the surface area of mesh in contact with fascia to be 32 cm 2, which is eight times the area of the test square. Thus the total shear force required to dislodge the mesh in a human hernia repair would be 4.8 Kg (8 x 0.6Kg). This result suggests that the laser activated glue is strong enough to hold the mesh in place until healing and fibrosis occur.

This technique may have application in laparoscopic hernia repair. Advantages include technical ease of application and decreased risk of injury to or entrapment of adjacent structures.

RESPIRATORY FUNCTION AFTER IAPAROSOOPIC CHOLEL~STECIDMY D. Litwin~ M.D.; D. Johnson, M.D.; J. Osachoff, R.N.; C. Ccallagher, M.D.; D. Church~ R.T. Departments of Medicine~ Anaesthesia and Surgery, University of Saskatchewan, Saskatoon, Canada

Open cholecysteetomy causes changes in pulmonary function test (PFr) vol~es leading to respiratory complications of hypoxemia and atelectasis. There is little information on these changes after laparoscopic cholecystectomy (L.C.). Changes in functional residual capacity (FRC), vital capacity (VC), arterial PO9, and chest x-ray atelectasis were assessed in 31 patients undergoing L.C. Data was analyzed by paired t test with significance as p(O.Ol. Twenty-four females and seven males were recruited with age of 47 + 14 years and operative time of 55 _+ 26 minutes. ~mparing preoperative to postoperative PFr vol~nes, ~lall but

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significant decreases were found in VC (13 + 19%) and FRC (7 + 17%). Postoperative Pal:) 2 decreased from 89 + ll--to 82 + 14 mmHg and only one patient's PaO~ was less than 60 n~g postoperatively. Three patients ~ demonstrated new se~ental or lobar collapse on postoperative chest x-ray. We conclude that patients post L.C. demonstrate sm~all but significant changes in PFr volL~nesand corresponding low incidence of postoperative hypoxomia or major atelectasis. These changes in FRC, VC, PaD 2 and atelectasis are less than that expected with open cholecystectomy.

NEUROENDOCRINE STRESS RESPONSE AFFER MINIMALLY INVASIVE SURGERY IN PIGS M.A.Mansour, MD, G.V.Stiegmann, MD, M.Yamamoto, MD. Department of Surgery, University of Colorado, Denver, Colorado.

Minimally invasive (laparoscopic) procedures may be better tolerated by the organism because they are less stressful. The purpose of this study is to characterize the neuroendocrine stress response to laparoscopie cholecystectomy (LC) compared to conventional cholecystectomy (CC). METHODS: Halothane general anesthesia was induced in 15 pigs and a central line placed for unobtrusive blood draws. Group 1 (n=3) were controls, group 2 (n=6) had LC and group 3 (n=6) had CC. Serum levels of ACTH, Cortisol, Insulin and Glucagon were determined at baseline, and postoperatively for 3 days. RESULTS: There were no significant differences observed between groups or cohorts. Peak serum hormone levels measured two days postoperatively for LC and CC are shown here as percent increase from baseline (mean-+SEM).

ACTH Cortisol Insulin Glucagon

LC: 62+26 48_+8 919_+_354 229+_38

CC: 27• 83• 1200-+672 247-+48 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CONCLUSION: Serum levels of ACFH, Cortisol, Insulin and Glucagon were not significantly different after LC compared to CC. Other more sensitive surgical stress markers may be better indicators of possible hormonal differences between invasive and minimally invasive procedures.

quired reoperations. There were no major common bile duct injuries.

This retrospective review indicates that this new procedure can be introduced into a community setting by novice laparoscopic surgeons acting both as operators and assistant with a morbidity a~d mortality rate comparable to that reported for open cholecystectomy.

TOWARDS A SAFER LAPAROSCOPIC CHOLECYSTECTONY: THE PROGRADE R(J~TE. G. M iscus l , L. Masont, ivi. Gasparvfin5 and A. Flonic~-i Oept. Pa+-o]ogJa C h i r u r g i o a ~[ [ (Chairman Pro f . A. Montor'J) "La SapJenza" Urdvevs ' i t y , Rorr~ - I+-aly

Th, e f i r s t expevie~ees w i t h ]aparoscop ic cho]eeystec tomy (LC) have been perfovmed by "expev~ suvgeons fin qua- I i f i ed i n s t ' i l u t i c ~ s . The repovted success and s a f e t y o f the new method blare vapJd-ly appealed many o ther surgeons ai-pd seem to j u s t i f y +-he widespread d i f f u s i o n ot: LC. Nc~ethe-iess, fhe scenav io o f f eved by the mosf recen t mul+-i-ins+.' itu+_io- r',s] i n q u i v i e s on LC i s q u i t e di1:1:event and SOlT~ewha+: wovvy- some, showing +-hat the r i s k s o1: inadvev+_ent b i l e duct i rL iu r ies cam be as high as 1-2%. Since the ducts at-e ger-re~a']'iy non.--di]ated~ r e p a i r o1: such damages i s t e c h n i - c a l l y di f1: icu]+- and long tevm complica+-ic~-~s or f a i l u v e can be antieipa+-e~]. Inadverten+- i n j u v i e s o1: b i l e ducts in the course o f LC ave caused by mSs in fe rp re fa t ' l on o1: the so-- c a ] l e d C a ] o t ' s tvSang-le sb-uc+_ures. [he* 'e fe re , v o u t i n e use o f i n t r a o p e v a t i v e cho]ang iography (IOC) p r i o v to sevev ing o f +-he cys+-ic duct h~s beer, advoca+-ed by sGne Au+-hevs Nonetheless, we b e l i e v e t h a i v o u t i n e IOC i s time-consumJn9 and sometimes t e c h n i c a l l y d i t : f i c u ] t . Therefowe. we have mod i f ied the standavd +-echnique o f re+-vogvade LC by adop- f~n 9 the prograde r,~Jte, whfich we have o~.,n o1:+-er, ussng in +_he cases o f d i f f i c u l t oper', cho'iec_vs+-ec+-omy. Our technique i s based upon: - ide i -d: i f icat - ,on ot: the "pvesumed" c y s t i c duct and o f the cys+-ic a r t e v y a t the C a ] o t ' s b - i ang ]e ; - ciampfng and sec t io rHng o f +-he c y s t i c a v t e r y ; - mob i ] , za - s arid d i s s e c t i o n o f the g a l l b l a d d e r s tar �90 a t i t s s -- complet ion o f cho]ecysfeetomy ir, a prograde 1:ashion_ Hydvodf issecf ion g v e a i ] y facS-I f i ta tes t h i s v~neu- vet-; - sec+-Sc~-Hr)9 o f the c y s f i c duct after-P~omp]e't:e sepa .... v a t i o n o f +-he gallbqadder" from the l i v e r ( 'hangi r lg peav" apperance) . ]he CC~T~0ar'fison o1: ouv prelfinlJnar"y r e s u l t s o f pvogvade LP w i t h standavd re ivogr 'ade LC seeTis q u i t e p romi - sgrlg and has Jnduceci us to r~JtJr~e]y adop• t h i s new method.

SAFE LAPAROSCOPIC CHOLECYSTECTOMY IN A COMMUNITY SETTING, N=762

Matt B. Martin, M.D., & Drs. Abrams, Arkin, Ballen, Blievernicht, Bowman, Davis, Farley, Hoxworth, Ingram, Leone, Lindsey, Newman, Price, Streck, Weatherly & Young. Greensboro, N.C.

Laparoscopic cholecystectomy (LC) can be introduced into a community with morbidity and mortality rates equal to that of open cholecystectomy. The entire general surgical community of Greensboro, N.C., learned the technique of LC on animal models prior to offering this innovation to the community. Over the ensuing 12 months, they served as surgeons or assistant surgeons to each other on 762 LC with morbidity and mortality rates comparable to open cholecystectomy.

This retrosPective study examined the first one year experience beginning 8/13/90. This work represents all of the LC performed in Greensboro and all of the surgeons participated in this review. All of the surgeries were done with an electrocautery and utilized a zero degree forward viewing scope. Cases were performed at two hospitals with a surgeon as both operator and assistant and no effort was made to exclude high risk or elderly patients from this procedure.

Patients averaged 50 years of age and ranged from 14-96 yrs. Static cholangiograms were performed in 27% of patients. Conversion to open cholecystectomy was seen in 4.8%. There were two cardiac deaths (0.26%) and significant complications were seen in 3.4%. Seven patients re-

A NEW DEVICE FOR LAPAROSCOPIC INTRAOPERATIVE CHOLANGIOGRAPHY

Y. MUNAKATA S. KAWASAKI, Y. HASHIKURA, S. HASHIMOTO, K. HAYASHI, M. NUMATA and M. MAKUUCHI First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan

INTRODUCTION: We have performed routine intraoperative cholangiography to prevent biliary tract injury and to identify common bile duct stone and anatomical variants since the first case of laparoscopic cholecystectomy in March, 1991. We studied retrospectively to evaluate the usefulness of a cholangiogram catheter which we devised for laparoscopic cystic duct cholangiography. MATERIALS AND METHODS: Two types of catheter system for cholangiography were compared. One was modified ERCP catheter (5Fr. in diameter, 40cm in length) combined with a guide wire (TYPE-A). The other was TYPE-A catheter system with an air-tight- valve (TYPE-B). The subjects studied were 54 cases with laparoscopic cholecystectomy. Of these 54 patients, TYPE-A was used for intraoperative cholangiography in I l patients whereas TYPE-B in 43 patients. The cannulation time and the success rate of cholangiography were compared in both groups. RESULTS: The cannulation time in TYPE-B group (5.32_+3.04 minutes) was significantly shorter than that in TYPE-A group (9.30-+7.80 minutes, p<0.05). The success rate of cholangiography

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in TYPE-B group was 93% which was similar to 91% in TYPE-A group. CONCLUSIONS: TYPE-B catheter system prevents air influx into the catheter even if the guide wire is moved. It brings satisfactory success rate of cholangiography and makes the time of cholangiography shorter. We conclude TYPE-B catheter is very useful for laparoscopic cholangiography.

EArAI//A-q~C~ OF ~INTESTINAL H]D~DRRHAGE IN PATI~2~fS WITH N~F//~IS. IA Mclstafa, M.D., WP Reed, M.D., NPW Cue, M.D. Tufts University School of Medicine and Department of Surgery, Baystate Medical Center, Springfield, Massachusetts.

Over a three year period from 1987 to 1990, two patients aged 43 ~ 52 with neurofibromatcsis were referred to cur medical center for evaluation of repeated episodes of melena. Upper endoscopy was unrevealing in each case, as was colonoscopy. Artericgraphy during active hemorrhage suggested souroes of blood loss in the prox~l jejunum, but these studies were equivocal. At exploration, grossly prc~t neurofibrcmas were noted protruding frcm the serosal surface of the proximal jejunum. Hemorrhage had occurred as a result of erosion of zm/cosa stretc/hed over these t~m~rs. Local resection of the involved segments of jejunum resulted in long-term (1-4 years) control of hedge.

Neurofibromas producing gastrointestinal hemorrhage most frequently invDlve the jejunum. Upper e n d ~ is t/%erefore unlikely to reveal the site of bleeding in these cases. Since the lesions are easily seen at operation, surgical exploration offers the most definitive way to diagnose and treat this condition. Arteriography may identify the souroe of bleeding, but is probably u r ~ in most cases. Laparoscopic examination and resection could offer an alternative method of management provided that adequate exposure of the proximal jejuntml can be obtained.

A UNIQUE METHOD OF GUIDE WIRE INSERTION FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY LEIGH H. NADLER, M.D. University of Illinois College of Medicine, Champaign, IL.

Percutaneous endoscopic gastrostomy (PEG) is a coranon procedure, not without complication, to establish enteral feeding. A new method of guide wire insertion could con- ceivably minimize the complications of blind percutaneous gastric puncture. A preliminary report of a unique me~lod of guide wire insertion is presented whereby a sheathed needle-tip guide wire is passed through the endoscope, traversing the gastric and anterior abdominal wall.

The standard method of guide wire insertion involves percutaneous puncture of a distended stomach under direct endoscopic visualization. This technique may be compli- catedby needle dislodgement due to loss of intragastric air pressure prior to guide wire insertion, resulting in perforation and leakage of gastric contents.

A 260 cm guide wire was fashioned with a fixed 18 gauge needle tip enclosed in a standard sclerotherapy-type sheath. The endoscope is directed end-on against the anterior wall of the stomach firmly abutting it to the anterior abdominal wall. The tip of the scope is easily palpable through the abdominal wall. The guide wire is then advanced through the sheath until the needle tip emerges at the skin incision site. The endoscope is then removed, and the gastrostomy tube is inserted by the endoscopists method of choice. This technique has been used successfully in the canine laboratory.

This is a preliminary report of a new method of guide wire placen~nt during PEG in~eztion. This tedn~ique could minimize the morbidity associated with difficult needle placement, as may occur during standard PEG insertion. Further trials, including humans, are necessary before this technique can be shown to be safer than blind percutaneeus needle insertion.

HOW SECURE ARE LAPAROSCOPICALLY-PLACED CLIPS? AN IN VITRO AND IN VlVO STUDY. M.T Nelson, M.D., M. Nakashima, M.D. and S.J. Mulvihill, M .D . Department of Surgery, University of California, San Francisco, CA

Recently developed multiple clip appliers allow rapid and precise hemostatic control during laparoscopic procedures without the need for removal of the instrument after each firing for reloading. The security of these clips has not been rigorously evaluated. We compared the security of clips applied with Ligaclip (Ethicon Inc., Somerville, N J) and Endo Clip (U.S. Surgical Corp., Norwalk, CT) multiple clip appliers both in vitro and in vivo. The force needed to transversely dislodge clips (n = 72) applied to silastic tubing (outside diameter 2.4 mm) was greater with the Ligaclip than with the Endo Clip (2.68 -- 0.04 vs. 1.81 __+ 0.07 Newtons; p < 0.001, by unpaired t-test). Similarly, in testing for axial security the force needed to dislodge clips (n = 72) was greater with the Ligaclip than with the Endo Clip (4.78 __ 0.18 vs. 4.08 __ 0.20 Newtons; p < 0.05, by unpaired t-test). In vivo, on mesenteric vessels in 4 anesthetized pigs, clips applied with the Endo Clip were more often moved or dislodged compared to those applied with the Ligaclip (34% vs. 11%, n = 100 in each group; p < 0.001, 95% confidence interval for clifference is 11-35% by Comparison of Proportions). By subjective criteria there were no significant differences in clip visibility, ease or accuracy of clip placement, or in time required to place each clip. We conclude that laparoscopicaUy-placed vascular clips applied with the Ligaclip are more secure than those applied with the Endoclip. Laparoscopic surgeons should be aware of the relative ease with which all clips may be dislodged.

CLINICAL EXPERIENCE USING A BIPOLAR ELECTRUSURGICAL DEVICE FOR LAPAROSCOPIC CHOLECYSTECTOMY

Douqlas O. Olsen, M.D., Nashville, Tennessee John D. Corbitt, M.D., Atlantis, Florida David S. Edleman, M.D., Miami, Florida

Stephen Unger, M.D., Miami, Florida Harold Unger, M.D., Miami, Florida

INTRODUCTION: The debate of laser vs cautery continues to dominate discussions concerning laparoscopic cholecystectomy. We evaluated a new device that has promised to "harness" the technology of bipolar current offering an inexpensive, but safe alternative for the coagulation and hemostatic division of tissues during laparoscopic cholecystectomy.

MATERIALS, METHODS AND PROCEDURES: A prospective trial consisting of 50 patients chosen at random for laparoscopic cholecystectomy was the basis for this report. After completion of the procedures, the bipolar device was evaluated in comparison to monopolar cautery and laser using a series of clinical impressions which were designed to evaluate the device for:

I) it's ability to cut and coagulate tissues, 2) precision and safety of use, 3) and the ease with which the instrument could be use.

RESULTS: The fifty patients chosen for the trial contained a wide range of clinical presentations. There were 5 patients with acute cholecystitis, 4 morbidly obese patients, and 21 patients with previous surgery requiring adhesiolysis. 74% of the cases were comple%ed using only bipolar current. Those cases using a combination of energy sources where during the early experience of the investigators and felt to be due to the unfamiliarity with the new device. In each category, the bipolar device was felt to be equal to or superior when compared to monopolar cautery or laser.

CONCLUSION: The conclusion of the authors is that the bipolar device evaluated offers an effective alternative to both monopolar cautery and laser for performing laparoscopic cholecystectomy. With the cost efficacy of an electrosurgical device, and the precision and safety of bipolar current, it may become the instrument of choice for use in laparoscopic surgery..

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A MOBILE VIDEOENDOSCOPY UNIT: FIRST YEAR'S EXPER/ENCE BA Orkin MD, LE Smith MD.Division of Colorectal Surgery, George Washington University, Washington, D.C.

Our operating suite obtained a custom made mobile videoendoscopy unit in October of 1990. In the previous year, 7 intraoperative colonoscopies were performed. In the last 12 months 53 procedures have been performed on 50 patients. Thirty-seven procedures were performed intraoperatively, while 16 were performed either in the patient's room (10) or in the ICUs (6). Intraoperative procedures were performed for diagnostic purposes (incidental to another operation, to identify the site of a non- palpable lesion, to assess the extent of inflammatory bowel disease, to complete colonic screening for neoplastic lesions or to identify the site of gastrointestinal bleeding) or for minimally invasive surgery (PEGs, biopsies or polypectomies). Diagnostic procedures performed outside of the operating room included identifying the cause of GI obstruction, ruling out colonic ischemia, or to diagnose pseudomembranous colitis. Interventional procedures performed included volvulus reduction and colonic decompression colon for pseudo-obstruction. The procedures performed included colonoscopy (19), sigmoidoscopy (23), and upper endoscopy (10).

Access to this endoscopy unit has increased our ability to perform intraoperative and urgent endoscopy for both diagnostic and interventional purposes. Many procedures may be guided by the findings on endoscopy, and lesions that would have been missed are now being identified and appropriately treated. Advantages include easy accessibility in and out of the operating suite and clear visualization of the procedure by all personnel in the room. Also. the video recorder and print generator allow graphic documentation of the pathology identified. The addition of a mobile endoscopy unit for use in and out of the operating room has markedly improved our ability to care for our patients.

LAPAROSCOPIC CHOLECYSTECTOMY IN THE SETTING OF ADMISSION FOR ACUTE BILIARY SYMPTOMS Jeffrey H. Peters, M.D., John Miller, M.D. Kieth E. Nichols, M.D., and David Ollila, M.D. Departments of Surgery, Riverside Methodist Hospital, Columbus, Ohio and the University of Southern California, Los Angeles, California.

Laparoscopic cholecystectomy has become the standard of care for the elective management of cholelithiasis. Little information exists however, regarding the appropriateness of laparoscopic cholecystectomy in the setting of acute symptomatology. We retrospectively reviewed our experience with 516 laparoscopic cholecystectomies performed at a single institution from May 1990-May 1991. Fifty six (10.8%) of these patients were admitted from the emergency department with acute abdominal pain (100%) fever (9/56, 16%), and/or an elevated white blood count (WBC, 22/56, 39.3%). There were 47 females and 19 males with a mean age of 50• (range 17-89) years. All patients underwent attempt at laparoscopic cholecystectomy. Forty nine (49/56, 87.5%) underwent successful laparoscopic cholecystectomy. Seven (12.5%) were converted to open cholecystectomy because of difficulty in dissection, precluding safe laparoscopic cholecystectomy. The time from admission to surgery (mean 3.7• days), as well as the total hospital stay (mean 6.7Z0.73 days) were much longer than in the elective circumstance. Mean laboratory values for the group as a whole were as follows; WBC (mean 9.53• range 4.1- 19.5), alkaline phosphatase (mean 93.36• range 27- 306), and alanine aminotransferase (mean 79.63• range 15-701). Patients requiring open laparotomy were older (mean 62.16• vs. 48.58• were more likely to be febrile (3/7, 42% vs. 4/49, 8.2%) and have a significant leukocytosis (mean WBC 13.53• vs. 9.0• than did those undergoing successful laparoscopic cholecystectomy. Laparoscopic cholecystectomy can be performed safely in the majority of patients presenting with acute biliary symptoms. Patients with a triad of acute abdominal pain, fever and elevated white blood count, particularly the elderly, are more likely to require conversion to open cholecystectomy.

ADEQUATE TRAINING---THE BASIS OF A PROFICIE~WT OPERATING ROOM TEAM M. Paz-Partlow, M.F.A., G. Berci, M.D., J.M. Sackier, M.D., Surgery, Cedars-Sinai, Los Angeles, CA.

Since its introduction in 1987, laparoscopic cholecystectcmy has irrevocably changed general surgery. The field of minimal access surgery now encompasses over a dozen new procedures which surgeons must examine and possibly learn. As surgeons introduce new techniques into the operating room, allied personnel must also learn new ways in which to better assist them.

Because the n~r and complexity of instrumentation is growing, surgeons must rely more and more on their assistants. It is imperative that assisting personnel thoroughly comprehend laparoscopic procedures and instrt, uentation so that they may resolve incipient intraoperative problems in the O.R. in a timely fashion.

Laparoscopic courses concomitant with those taken by surgeons should be considered mandatory for operating room personnel. Didactics would cover anatomy,basic surgical approaches to various procedures, instrLunen- tat• and trouble shooting doc~uentation equipment. Instrumentation hands-on sessions would be interspersed between formal lectures and would reinforce didactic theory with practice. During inanimate and animate labs participants would begin todevelop hand/eye coordination and depth perception. Actual experience of the technical problems inherent in laparoscopic surgery would give assistants a new appreciation for the challenges which face surgeons at each procedure, reinforcing the need for a coordinated team approach. At course conclusion, students would be able to assemble appropriate iustrt~uentation for a variety of laparoscopic procedures; arrange in series and operate each component in a video cart; devise on the spot solutions to routine technical breakdowns during a procedure.

BILIARY SCINTIGRAPHY IN THE DIAGNOSIS OF BILE LEAKS FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY. Jeffrey H. Peters, M.D., David Ollila, M.D., Keith E. Nichols, M.D. Gregory E. Gibbons, M.D., Mark A. Davanzo, M.D., John Miller, M.D., Jeffrey T. Innes, M.D., and E. Christopher Ell• M.D. Depts. of Surgery, USC, Los Angeles, CA; Riverside Methodist Hospital and Grant Medical Center, Columbus, OH.

Having recognized that clinically evident bile leakage can be a troublesome complication following laparoscopic cholecystectomy (LC), we sought a simple, rapid and non- invasive test to help distinguish those patients with bile leaks, from those with non-specific abdominal pain but more benign conditions. Between January 1990 and April 1991, 854 patients who underwent LC for symptomatic gallstone disease, were prospectively followed. Ten of these patients (10/854, 1.17%), as well as five patients referred to us from elsewhere, were identified as having clinically significant biliary leakage. Typically, the patients presented in the first week following LC (mean 4.3• days, range 2-10) with worsening abdominal pain (16/16, 100%), nausea, and low grade fever (mean;99.6• F ~ range;96.8-102.2). Eleven (11/15, 73%) of these patients underwent technicium-99 imidodiacetic acid scanning (Tc-99 IDA) to determine the presence of a possible bile leak. All ii promptly demonstrated free intraperitoneal collections of bile. Ten of the ii patients with positive Tc-99 IDA scans underwent endoscopic retrograde cholangiography (ERCP) confirming the presence of biliary leakage (one patient underwent prompt laparctomy). ERCP confirmed the presence of bile leakage from the common bile duct in one patient (I/ii, 9%), the cystic duct in 4 patients (4/11, 36%), and small accessory ducts close to the gallbladder bed in the remaining 6 patients (6/11, 54%). Six patients presenting with similar signs and symptoms, also underwent Tc99-IDA scanning, all of which were negative, and did not undergo cholangiography. All six resolved thier symptoms within 24 hours and had no further difficulty. Tc-99 cholescinti- graphy appears to be useful to screen this relatively high risk, symptomatic population. As the complications of LC are being recognized, simple non-invasive testing allows rapid evaluation, and prompt appropriate treatment, thus minimizing further morbidity.

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ENDOSCOPY IN MASSIVE UPPER GI HEMORRHAGE Michael A. Polacek,M.D. St. Lukes Medical Center

Diagnostic endoscopy and therapeutic cautery endoscopy all have had an impact on the treatment and ~ortality rate of bleeding peptic ulcer disease.

This study is a clinical review of over llOO consecutive massive upper GI bleeders, following strict criteria, admitted to a 600 bed hospital over the last decade.

In spite of new modalities for treatment and diagnosis of peptic ulcer disease, the number of GI bleeders and the overall mortality rate has not decreased. Ninety percent of the bleeders were endoscoped, and 30% were coagulated for active bleeding. Coagulation was successful in 60% of the cases, resulting in a significant decrease in patients referred for emergency surgery from 38% to the current level of 13%. However, in the group requiring open surgery, the mortality rate has increased from 5% to 17%. Possible reasons for this increased mortality will be discussed.

In conclusion, massive upper GI bleeders from peptic ulcer disease and mortality have not shown a decrease in lO years. Endoscopy is now a standard procedure in all bleeders, and active bleeding was treated by coagulation in ~ of 3 cases endQscoped. This resulted in a decrease in emergency surgery by over 70%, but the mortality rate of patients undergoing surgery has increased from 5% to 17% mainly because of an older patient population base with associated multi-system disease.

LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY: A PROSPECTIVE ANALYSIS OF 108 PATIENTS IN A COMMUNITY, TEACHING HOSPITAL. R Pons, MD, K Grannan, MD, R Welling, MD. Dept Surgery, Good Samaritan Hospital, Cincinnati, OH

This study compared several variables for standard open and laparoscopic cholecystectomies in our hospital. These variables included cholangiograms performed, cost of hospital length of stay and surgery, length of stay, operative time, and length of unemployment.

Of 309 cholecystectomy patients reviewed, 54 open and 54 laparoscopic patients were matched according to age and sex. All 108 patients were electively scheduled and admitted 24 hours or less before surgery. Patients who stayed longer than 4 days and/or had a surgery complication were not considered for the match.

Variable Open Laparoscopic Cholangiogram (%) 57.4 13.0 Total Hospital Cost $3344 • 765 $3465 • 835 Total Cost of Surgery $1117 • 358 $1558 • 478 Operation Time (min) 73.0 • 22.3 81.3 • 30.6 Number Post-Op Days 2.5 • 0.8 1.2 • 0.6 Total Length of Stay 2.7 • 0.8 1.3 • 0.6 Days of Unemployment 31.0 • 18.3 11.9 • 9.2 Neither operative time or cost of surgery were

significantly different between groups. Of importance was the 50% reduction in length of unemployment for the laparoscopic patients.

Operative cholangiograms were performed in 57% of the open and 13% of the laparoscopic cholecystectomies. To reduce the incidence of complications and missed common bile duct stones, the percentage of cholangiograms performed during laparoscopies should be increased.

Laparoscopic patients enjoy the benefits of minimal scarring, less pain, and decreased length of stay. They also return to work sooner.

COLONOSCOPY TEACHING IN UNIVERSITY AFFILIATED GENERAL SURGERY RESIDENCY PROGRAMS Timothv J. Pritchard. M.D. and Dido Franceschi, MD. Dept. of Surgery, Case Western Reserve University, Cleveland, Ohio

Specific requirements for resident training and competence in performing diagnostic and therapeutic colonoscopy are not defined. To determine patterns of colonoscopic instruction to general surgical residents, we mailed a

questionnaire to 145 program directors of university affiliated general surgery residency programs. One hundred and two of these were returned, and the tabulation of their data constitute the basis of this report. Correlations were performed by the Chi square test with Yate's correction.

Sixty-one percent of the residency programs offered a formal rotation for residents. Of these 95% were required while only 5% were elective. Only 3 training programs had one or more full-time surgical endoscopy fellows. Teaching programs utilized general surgeons (82%), colon and rectal surgeons (52%), and gastroenterologists (45%) for colonoscopic instruction to residents. Eighty-three percent of programs which had certified colon and rectal surgeons as faculty members used them to teach colonoscopy to residents. Resident participation in faculty performed colonoscopy occurred in less than half of the available cases in 46% of the surveyed programs. Video colonoscopy was utilized exclusively or variably in 93% of the teaching programs, but was available in the operating room in only 42% of programs. Seventy-eight percent of program directors perceived that the use of video colonoscopy did not increase the number of cases for residents in their training programs, while 90% thought that the use of video colonoscopy improved their ability to teach colonoscopy to residents. The following trends were noted in programs which offered a formal colonoscopy rotation: a) more total colonoscopies were performed by residents (p = 0.18), and b) the percentage of colonoscopies performed with resident participation was greater (p = 0.30). Furthermore, programs who incorporated senior level residents (PGY 3 or above) into their colonoscopy rotation tended to have a higher percentage of resident pa~icipa- tion in colonoscopies performed by faculty members.

We conclude that colonoscopy instruction to general surgery residents in university affiliated programs is highly variable. A formal endoscopy rotation for residents is desirable, particularly for higher level residents. The use of video endoscopy improves the quality of colonoscopy instruction. Formal guidelines need to be implemented to assure adequate and consistent colonoscopy training to general surgery residents.

LAPAROSCOPIC MARCY TYPE REPAIR OF THE INDIRECT HERNIA

William O. Richards, M.D., Vanderbilt University, Nashville, Tn.

We have ut i l ized a variation of the Marcy repair laparoscopically to repair indirect hernias with excellent results. This type of repair avoids the crit icism that has been directed toward other types of laparoscopic hernia repairs - adhesion formation on intraperitoneal mesh or migration of prosthetic mesh stuffed into the hernia defect.

The repair is accomplished after establishing a pneumoperitoneum and identifying the presence of an indirect hernia. The peritoneum ( neck of hernia sack) is incised circumferentially at the level of the internal ring and the transversalis fascia is sutured together closing the internal ring. We have ut i l ized permanent suture for this closure (gortex or neurolon). The sutures have been tied extracorporeally and pushed into position using a endoloop pusher. This repair has been completed in 4 men with indirect hernias without complication. The patients had minimal pain postoperatively and were able to return to vigorous act ivi t ies within days of operation. One patient did a reverse bunji jump 2 weeks after hernia repair.

The laparoscopic Marcy repair has several advantages over other types of laparoscopic herniorrhaphy: I) There is no prosthetic mesh for adhesion formation; and 2) prosthetic mesh cannot migrate out of the inguinal canal because there is no prosthetic material inserted. The advantage over open repair is that the muscles of the inguinal canal are not divided and only the dilated internal ring is repaired. This reduces postoperative pain and allows the patient to return to vigorous act ivi t ies immediately after operation.

ACUTE CHOLECYSTITIS - A COMPARISON BETWEEN LAPAROSCOPIC AND OPEN TREATMENT

S.W. Unger, MD.; G. Rosenbaum, MD.; H.M. Unger, MD.; and D.S. Edelman, MD.

Dept of Surgery; Mr. Sinai Medical Center of Greater Miami, FI. and Baptist Hospital of Miami, FI.

To compare cholecystectomy via the laparoscopic (LC) and open (OC) approach in acute cholecystitis, a retro-

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spective review of i00 patients treated consecutively by both methods was analyzed. In a study period of comparable time, from 1989 through mid-1991, 2 groups of i00 patients each were treated by OC (72F:28M-average age 52.2 years) and LC (62F:38M-average age 54.8 years). Patients were comparable by mode of presentation and preoperative labs. Because of the nature of retrospective review, it was difficuls tb domphre'b6dy habi[us. Lefigth of surgery was shorter with OC (85 vs. 94 min.). Pathology showed an increased incidence of combined acute and chronic disease with OC and more pure acute cholecystitis with LC. Drains were placed more frequently in the 0C group (69 vs. 40). There was no mortality in either group. Morbidity was significantly higher with OC, complications totaling 46 (including ileus 12, fever 23), compared to 18 with LC (including fever 4, bleeding 3, pneumonia 4, urinary retention 3). Length of stay was significantly higher with OC, average 8 days(2-30), as compared to 2.4 days(.5-21) with LC. Comparison of costs shows a greater expense with the OC. These data support the cost effectiveness and safety of LC for acute cholecystitis.

similar for both groups. Four of the 6 T patients had acute cholecystitis, a significant increase % compared to NT (67% vs 13%,p<.0001). One T with gangrenous cholecystitis required conversion to open cholecystectomy (T=16.6% vs NT=8.6%,p=NS). This same patient developed a wound complication, the only direct LC-related complication in the T group (17% vs NT=3.3%, p=NS). Two T patients undergoing elective LC were discharged on postop days 1 and 2, while mean T postop stay (6.3• days) and hospitalization (18.5 • days) were significantly longer than NT (1.8• and 2.6• days, p<.0001). Two T patients expired 3 and 22 days postop from nonoperative and nonbiliary causes. We conclude that LC can be performed in transplant patients with reasonable efficacy but acute cholecystitis requiring LC in this patient population is associated with a high mortality rate from nonoperative causes.

LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERY. B.D. Schirmer, MD, J.Dix, PA-C, R.E. Schmieg, Jr., MD, M. Aguilar, M.D., Dept. of Surgery, University of Virginia Health Sciences Center, Charlottesville, VA.

We examined the impact of previous abdominal surgery on patients undergoing laparoscopic cholecystectomy (LC). Data base records for our first 400 cases of LC were analyzed and the 205 patients (51.25%) who had previous open abdominal operations (PS group) compared to patients who had no such previous surgery (NS group) using both ANOVA and Chi square analysis. The most common procedures in PS included C-section (n=75), appendectomy (n=61), and abdominal hysterectomy (n=56). Sixty five patients had two or more previous operations. The PS group had a higher percentage of females than NS (88.8% vs 65.56%;p<.001), as well as a lesser number of ASA class I patients (PS=34, NS=61, p<.02). There were no differences between groups for age, weight, duration of operation, length of hospital stay or postoperative stay, complication rate, or rate of conversion to open cholecystectomy. Among the PS group were

10 patients with previous incisions extending above the umbilicus. When compared to all other LC patients, this latter group had an increased risk of complications (p<.0001), but no significant differences were found for any of the other above-mentioned parameters. We conclude that previous lower abdominal surgery does not significantly impair the ability to safety perform LC, while upper abdominal incisions may be associated with a higher complication rate.

LAPAROSCOPIC CHOLECYSTECTOMY: A REVIEW OF 8,016 PATIENTS. TR Scott. M.D.. KA Zucker, M.D., and RW Bailey, M.D. Department of Surgery, University of Maryland School of Medicine, Baltimore, MD

Laparoscopic cholecystectomy is a viable altemative in the treatment of gallstone disease, however there is still concern about the incidence of major complications. The results from 16 studies reporting on laparoscopic cholecystectomy were reviewed, representing a collective experience with 8,016 patients. 97% of cases were performed on an elective basis with most patients presenting with evidence of cholelithiasis and biliary colic. 362/8,016 patients (5%) required conversion to standard cholecystectomy and of these, 171 patients (47%) were converted due to the presence of severe inflammation or adhesions. Laparoscopic cholangiography was attempted in 2,802/5,416 patients (52%) and was successful in 82%. The incidence of injury to the common bile duct, hepatic duct, cystic duct, and unspecified bile duct was 0.2%, 0.02%, 0.1%, and 0.1%, respectively. The overall incidence of major and minor bile duct injury therefore, was 0.5%. The incidence of bile leakage was 0.2%. The overall morbidity and mortality rates were 3% and 0.08%, respectively. 54-98% of patients were discharged within 24 hours of surgery and 77-98% of patients resumed full activities within 7 days of hospitalization. The morbidity and mortality figures compare favorably with previously published reports for open cholecystectomy.These collective data would indicate that laparoscopic cholecystectomy is a safe and efficacious procedure that offers a viable alternative to conventional cholecystectomy.

LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH PREVIOUS ORGAN TRANSPLANTATION. B.D. Schirmer, M.D., J. Dix, PA-C, M. Aguilar, M.D., Dept. of Surgery, University of Virginia Health Sciences Center, Charlottesville, VA.

Performance of laparoscopic cholecystectomy (LC) has not been described in patients with previous organ transplantation. We report our experience with LC in 3 heart, 2 kidney, and one heart-lung transplant patients (T). Patient records for T were compared to all other non- transplant (NT) patients undergoing LC (n=394). T and NT groups were of similar age and weight. There were more males in T (67% vs 22%,p<.01). Average ASA class was higher for T (3.17• vs 1.91Z.03,p<.0001). Duration of operation was

DUODENAL FEEDING TUBE PLACEMENT WITHOUT ENDOSCOPY OR FLUOROSCOPY

J.M. Bergstein MD, D. Seone MD, D.H. Wittmann MD, PhD, E.J. Quebbeman, MD, PhD,

C. Aprahamian, MD.

Section of Trauma and Emergency Surgery Medical College of Wisconsin, Milwaukee, WI

This study attempts to determine the feasibility of nasoduodenal intubation without fluoroscopy or endoscopy. Because gastric motility is often impaired in critically ill patients, nasoduodenal feeding tube placement is desirable. Yet for the same reason, feeding tubes may not pass the pylorus, thus requiring endoscopy or fluoroscopy with attendant risks

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and costs. We developed a technique of "blind" guidewire assisted duodenal intubation, and taught it to PGY-III Surgical ICU residents. They used the technique as the initial approach in Surgical ICU pas without gastroduodenal anastomoses~, ~ in whom enteral feeding was desired. In a series of 16 consecutive attempts, abdominal plain x-ray confirmed duodenal intubation in 9. There were no complications of the technique. 7 had subsequent nasogastric feeding or fluoroscopic nasoduodenal tube placement. We estimate savings of $192 in these 16 patients over fluoroscopic approach, $8382 over endoscopic approach. The "blind" guidewire technique appears safe and cost-effective. Success rate of 56% observed with novices, and consequent savings, would be expected to increase with experlence. This simple technique should be attempted before fluoroscopy or endoscopy for duodenal feeding tube placement.

LAPAROSCOPIC APPROACHES TO CHOLEDOCHOLITHIASIS Michael McGrath, M . D . , Stephen Shapiro, M . D . , Leo Gordon, M . D . , Kenneth Adashek, M . D . , and Leon Daykhovsky , M.D. Divis ion of General Su rge ry Cedars-Sinai Medical Center Los Angeles, Cal i forn ia

This paper descr ibes the laparoscopic approach to common duct stones. In 206 consecut ive laparoscopic cholecystectomies, 24 pat ients were noted to have common bi le duct stones.

21 of these pat ients underwen t laparoscopic common bi le duct e x p l o r a t i o n . The t rans -cys t i c duct approach was used in 20 cases. A d i rec t laparoscopic approach was used in I pat ient . CD stones were re t r i eved th rough the cyst ic duct using .035 in. "g l i dew i res , " S Fr shaft d i la t ing bal loons, 9 & I0 Fr f lex ib le choledochoscopes and a combinat ion of 3 Fr Segura baskets and 3-pronged graspers . For large stones which the d i la ted cyst ic duct could not accommodate, laser l i t ho t r i psy wi th a tunable pulse dye laser was used to f ragment the stones for ex t rac t ion . The d i rec t laparoscopic approach was used on a single pat ient whose cyst ic duct was unsui tab le for d i la ta t ion.

Sex: 14F 7M Age range: 20-88 years Average length of s tay : 2.8 days Average number o f stones: 4 Average length of s u r g e r y : 3.45 hours Abnormal LFT or cl inical suspicion of

CBD stones: 45% Unsuspected CBD stones: 55%

There were no s ign i f icant compl icat ions. These resul ts suppor t the use of the laparoscopic

approach to common bi le duct stones.

LAPAROSCOPIC CECOPEXY

Stephen A. Sheep, M.D. Dept. of Surgery University of Southern California Los Angeles, California

Jonathan Sackier, M.D. Cedars-Sinai Medical Center Los Angeles, California

The use of laparoscopic technique is a useful option in the treatment of cecal volvulus when coexistent disease makes resection undesirable. In this case report, laparoscopic cecopexy was successful in maintaining reduction of such a volvulus.

The patient, a 37 year-old male who is HIV positive, was hospitalized for treatment of a felon of the right

thumb. On the second hospital day, he developed acute abdominal pain and vomiting. A water soluble contrast enema demonstrated cecal volvulus, and the symptoms then resolved, indicating reduction of the volvulus.

Subsequently an elective exploratory laparoscopy was done. The cecum had returned to the right lower quadrant, but was highly mobile. Laparescopic cecopexy was completed using interrupted silk sutures and intracorporeal knots. An appendectomy was also done. The patient remains asymptomatic six months post-operatively.

Although right hemicolectomy remains the treatment of choice for cecal volvulus, laparoscopic cecopexy may, under appropriate conditions, offer a useful alternative procedure.

OPEN APPROACH TO CELIOSCOPY SAFER THAN BLIND NEEDLE INSUFFLATION AND TROCAR INSERTION H.H. Sigman, M . D . , G .M . Fried, M . D . , J. Garzon, M . D . , E.J. Hinchey, M . D . , M.J . Wexler, M . D . , J.L. Meaklns,M.D.

Aim: To show that an open technique can reduce risk of bowel or vascular injury from blind insufflation and trocar insertion.

Method: Surgeons at this insfitvtion used a blind celioscapy technique for laparoscopic cholecystectomyt except where per l - umbilical sears existed. After major Wocar injuries in two patients without previous surgery, several began to use only an open technique.

Results: 804 patients had laparoscopy for cholecystectomy. 694 patients had a blind trooar insertion. 110 had an open approach. Median duration of surgery for the blind group was 75 min compared to 70 min for the open (not significant - X2). The closed technique was associated with one needle injury to the small bowel which required no treatment; one unrecognized small bowel injury; one l i lac artery injury produced by a trocar with a protective plastic sheath. No injuries resulted from the open technique, nor were there any complications related to the incision. Gallbladder extraction was ~ubstantially easier in the open group.

Conclusion: While serious complication was not signif icantly increased by closed celiotomy stat ist ical ly, i t can be either avoidgd or easily recognized and corrected by an open approach, with no time sacrifice.

LAPAROSCOPIC APPENDECTOMY: THE SCOTT AND WHITE CLINIC EXPERIENCE. Samuel K. Snyder, M.D.; Richard E. Symmonds, M.D.; John W. Roberts, M.D.; John C. Hendricks, M.D.; Randall W. Smith, M.D.; Richard C. Frazee, M.D. General Surgery, Scott and White Clinic, Temple, Texas.

The advances in laparoscopic surgery f o r ga l l b l adde r disease have a natura l app l i ca t i on to appendiceal disease as we l l . To assess the i n i t i a l resu l t s of th i s approach a re t r ospec t i ve review of laparoscopic appendectomy in 72 pa t ien ts at the Scott and White C l i n i c from February 1990 through October 1991 was performed. 58 pa t ien ts had an appendectomy fo r suspected appendiceal in - f lammation and 14 i nc iden ta l appendectomies. 50 pa t ien ts were approached wi th the i n t e n t i o n to complete the appendectomy l a p a r o s c o p i c a l l y , 46 were success fu l l y done (92%) wi th an average operat ing t ime of 92 minutes and hosp i ta l s tay of 2.2 days. From these 46 pa t ien ts there were 11 pa t ien ts w i th a normal appendix (24%), 26 pa t ien ts wi th non-per fo ra ted append ic i t i s (15%), 2 pa t ien ts wi th chronic append ic i t i s (4%). The age of pa t ien ts ranged from 7-59 (average 27). There were i n fec t i ous com- p l i c a t i o n s in 6 pa t ien ts (13%) wi th 4 in t ra-abdomina l abscesses in the r i g h t lower quadrant (8.7%) and 4 wound in fec t i ons (8.7%) - 2 pa t ien ts had both in t ra-abdomina l abscess and wound i n f e c t i o n . The resu l t s compared favo rab ly to a review of appendectomies from 1988 except fo r a g rea te r than expected number o f in t ra-abdomina l abscesses. We conclude tha t the laparoscopic approach to pa t ien ts w i th suspected acute append ic i t i s can be successfu l ly and sa fe l y completed in the m a j o r i t y of pa t ien ts .

INTRACORPOREAL LAPAROSCOPIC BOWEL RESECTION AND ANASTOMOSIS. Nathaniel J. Soper, MD, L. Michael Brunt, MD, James Fleshman, MD, Thomas A. Meininger, Deanna L. Dunnegan, RN; Department of Surgery; Washington University School of Medicine; St. Louis, Missouri, U.S.A.

To date, laparoscopic methods to perform bowel resection and anastomosis have combined intracorporeal and extracorporeal techniques. Solely intracorporeal methods have not been utilized due to an inability to remove large pieces of tissue and because of difficulty performing laparoscopic-guided bowel anastomoses. After developing the technique in six animals, laparoscopic small bowel resection and anastomosis was performed in five female farm pigs weighing 20-50 kg. A CO 2 pneumoperitoneum was established after administering intravenous antibiotics and general anesthesia. Five trocars were then inserted (2-5 mm, 2-11 mm, 1-12 mm) for video laparoscopic access to the peritoneal cavity. A loop of proximal jejunum was elevated, its vascular supply isolated and ligated between clips, and a 5-10 cm segment excised using 2 firings of a 30 mm linear stapler (Endo- GIA| The anti-mesenteric corners of the staple lines were excised and the two limbs of bowel were anastomosed using 2 sequential firings of the stapler in a functional end-to-end fashion. The enterotomy was dosed with the same stapler and the staple line was inspected. In one instance, a small defect was dosed using a running 4-0 suture. The excised bowel segment was then placed in a nylon entrapment sack, morcellated and aspirated with an electrical tissue morcellator (Cook Urological, Inc . )and removed through one of the 11 mm incisions. The pigs recovered uneventfully from anesthesia. They were allowed oral feedings on the day following operation and gained weight (mean, 40 kg) in the postoperative period. All pigs have been sacrificed at 4 to 10 weeks postoperatively, revealing few intra-abdominal adhesions, no evidence of anastomotic leaks and the anastomoses to be widely patent. Clinical application of this technique will be facilitated by development of longer laparoscopic staplers and improved bowel grasping forceps, but should be a reality in the near future. (Support: U.S. Surgical Corporation; Karl Storz Endoscopy-America)

"OOLONOSCOPIC INDIRECT LYMPHANGIOGRAPHY IN A CANINE MODEL" Debra Sudan M.D., John Mellinger M.D. Sidney Miller M.D. ; Wright State University School of Medicine, Department of Surgery, Dayton, Ohio

Colorectal malignancies ~etastasize most frequently to mesenteric lymph nodes. The preoperative staging of mesenteric nodal status by current modalities is problematic. The present study was conducted to evaluate the feasibility of indirect mesenteric ly~phangiogra~hy as a colonoscopic technique in a canine mode. Ten mongrel dogs underwent flexible colonoscopy and endoscopic suhmucosal injection of Ethiodol contrast at various sites in the transverse, descending, and rectosigmoid areas. Serial abdcminal roentgenogramswere obtained up to two weeks following injection. In seven of the animals, demonstration of mesenteric nodal uptake corresponding to the area(s) of injection was radiograFhically docnanented. In the remaining animals (early in the series) inadequate nodal opacification was achieved, which appeared to be due to non-submucosal injection. No complications were noted. Colonscopic indirect lymphangiograFhy aFpears to be a safe and potentially useful modality in the evaluation of mesocolonic lymph nodes. Further studies to refine this techniqueand investigate its potential to preoperatively delineate abnormal nodal architecture are warranted.

CLINICAL SIGNIFICANCE OF GASTRIC PROLAPSE INTO THE ESO- PHAGUS. C. Sugawa, M.D., C. E. Lucas, M.D. Department of Surgery, Wayne State University, Detroit, Michigan.

Gastric prolapse (GP), caused by retching, is encountered during upper endoscopy in some patients (pts), but its significance is not clear.

We prospectively studied the incidence, endoscopic and clinical findings in 1035 pts undergoing 1364 procedures

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(proc.). Demographic characteristics were as follows: Total GP MW

Procedures 1364 79(5.8%) 106(7.8%) Age (mean) 49 36 43 Male:Female 2.2:1 5.1:1" 2.9:1

Endoscopic indications and associated diagnoses in pts with GP were as follows (number of pts with characteristic lesion bracketed): Indication

Diasnosis GI-Bleed Abd. Pain Other M-W tear 20 (5) 1 0 AGML 13 12 (4) 2 (i) Peptic ulcer 9 3 (i) 0 Others 7 (3) 7 5 Total (proc.) 49 23 7 Of the 76 pts (79 proc.) with GP, 52 (68%) were alco-

hol abusers, 60 (79%) had hiatal hernia*, 21 (27%) had a M~W*, and 14 (18%) had a characteristic round, well cir- cumscribed, reddened 2-8 cm. lesion. This lesion was seen on the fundic mucosa and caused bleeding in 3 pts. In contrast, longitudinal M-W tears were usually seen on the lesser curvature. GP was not a permanent finding, as it occurred in only 3/16 pts undergoing re-endoscopy. CONCLUSIONS: GP was seen in 5.8% of pts undergoing EGD. Symptoms in pts with GP appear to be caused by other lesions in the majority of pts. GP is an inconsistent finding and is caused by severe retching. Bleeding can occur spontaneously with GP, but is rare.

(* - p ~.01 by Chi square)

ORGANIZING TRAINING PROGRAMS IN LAPAROSCOPIC SUTURING, ANASTOMOSIS, AND INTRACORPOREAL KNOT TYING: SETUP, CURRICULA & STANDARDS FOR THE GENERAL SURGEON

Zoltan Szabo, Ph.D., George Berci, M.D., John G. Hunter, M.D.

The purpose of this presentation is to outline a training program that would alleviate the initial frustration presented by the laparoscopic approach, minimize iatrogenic injuries, develop advanced suturing skill and provide the surgeon with a realistic assessment of the potential and limitations of laparoscopic suturing techniques. Eye-hand coordination in the magnified surgical field, such as in microsurgery and in advanced laparoscopic surgical techniques, is a motor skill that can be self-taught through arduous trial and error, or learned in a formal training program. Those programs having a focused, progressive curriculum; a properly setup training facility; and dedicated, knowledgeable instructors are of particular benefit. A training approach is outlined based on the author's 20 years experience of teaching microsurgery and over a year of teaching laparoscopic suturing. Curricula and standards of skill are proposed.

LAPAROSCOPIC CHOLECYSTECTOMY IN THE ELDERLY

S.W. Unger i MD; H.M. Unger, MD; and D.S. Edelman, MD.

Dept. of Surgery; Mt. Sinai Medical Center of Greater Miami FI. and Baptist Hospital of Miami, FI.

A retrospective review was undertaken examining our first 500 pts. who underwent Laparoscopic Cholecystectomy (LC), in order to ascertain the safety of LC in the elderly. Patients were divided into 3 groups: I-less than 69 years old; II-70 to 79; and III-80 to i00. There were 416 pts. in group I (2:I,F:M), average age 48 (18-69); 61 pts. in group II (35F:26M), average age 73.8 (70-79); and 23 pts. in group III (12F:IOM), average age 85 (80-97). Length of surgery was relatively comparable in the 3 groups, being 97.5min. in group I (35-260), 95.6min in group II (45-205), and 104min in group III (60-175). Length of stay varied significantly at 1.8 days (1-21) in group I; 3 days (i-i0) in group II; and 4.6 days (2-14) in group III. Cholangio- graphy and perioperative ERCP were done in comparable percentages in all groups. Acute choleoystitis was present in 27: of group I, 58% of group II and 60% of group III,

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complications being predominantly self-limited and related to the anesthesia rather than the laparoscopic procedure. ]~% of group I, 3% of group II and 0% of group III were converted to open, suggesting a sligb/ly higher incidence of opening in the elderly, because of the higher incidence of acute cholecystitis. LC can be carried out with a good margin of safety in the elderly with the only difference being a slightly increased length of stay related to age. This latter conclusion may impact significantly on third party carriers suggesting outpatient management of these patients.

LAPAROSCOPIC PLACEMENT OF FEEDING TUBES Donald W. Weaver, M.D., David Bouwman, M.D., James Tyburski, M.D., Department of Surgery, Harper Hospital, Detroit, Michigan

Although percutaneous endoscopic placement of feeding tubes has become the preferred method for enteral alimentation, some patients, because of inability to pass an endoscope or because of prevlous gastric surgery, are not candidates for this method of tube placement. Presently these patients undergo open surgical placement of the feeding tube. Recently we have placed both

~ astrostomy and jejunostomy tubes using a aparoscoplc technlque. Routine

establishment of pneumoperitoneum and placement of a paraumbilical trocar allows Identification of the anterior gastric wall or jejunum into which the tube is to be placed. Brown/Mueller "T" fasteners (Versa Peg, Ross Laboratories) are then inserted through the abdominal wall and placed under direct vision into the lumen of the G.I. tract to be intubated. This is aided by stabilizing the stomach or jejunum with an atraumatic bowel grasper through a separately placed 5 mm port. A needle is placed into the intestinal tract and a guide wire passed through the needle into the lumen. A 16 french dilator with stripable introducer is then placed over the guide wire into the intestine. A 14 french Foley catheter is then placed through this strlpable introducer and the balloon inflated. The introducer is removed and traction applied to the T fasteners which brings the serosal surface of the intestinal tract to the abdominal wall.

Gentle traction is also placed on the catheter to allow the balloon to coapt the bowel to the peritoneal surface. We have performed this successfully in five patients. A video presentation will be made.

LAPAROSCOPlC CHOLECYSTECTOMY (LC) AND RESIDENT EDUCATION: WHO IS DOING THE CASES? T.A. Wierson, M.D., G.M. Larson, M.D. Dept. of Surgery, University of Louisvi l le, Lou., Ky.

In our residency program, i t appears that (LC) has influenced the selection of chief surgeon doing the :holecystectomies. The purpose of this study is to evaluate the impact of LC on resident training. We -~,mccd the cholecystectomies performed by our residents for two years: July 1, 1988 - July 1, 1989, (Pre LC) and July 1, 1990 - July 1, 1991 {Post LC), when LC had been established. The cases were performed at 3 hospitals in our program.

CHOLECYSTECTOMIES AS CHIEF SURGEON Post Graduate Year (PGY)

Year 1 2 3 4 5 Faculty ' 88 - '89 26 70 72 26 7 10 '90- '91 6 35 37 54 47 75

CASES AS FIRST ASSISTANT '88 - '89 61 18 13 6 1 '90- '91 126 20 26 16 2

The ch ie f res iden ts func t ioned as TAs on 54 cases in 1989 vs 22 in 1991. The number o f CBD exp lo ra t i ons performed in 1988 was 26 and in 1991 22. During 1990-91 65% of the cholecystectomies were performed l a p a r o s c o p i c a l l y .

These data i nd i ca te t h a t f o r the LC era in 1990-1991 compared to 1988-1989: 1) The PGY 1, 2, and 3 res iden ts performed fewer cholecystectomies whi le the ch ie f res iden ts performed more. 2) The PGYs 1, 2 and 3 ass is ted on many more cases in 1990-91. 3) A cons iderab le increase in the number o f cholecystectomies performed by f a c u l t y as ch ie f surgeon.

We c o n c l u d e t h a t LC has a f f ec ted res iden t educat ion and has s h i f t e d case assignments to more Senior Residents and Facul ty .

1992 Scientific Session of the Society of American Gastrointestinal Surgeons (SAGES) Washington,...

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Transcript of 1992 Scientific Session of the Society of American Gastrointestinal Surgeons (SAGES) Washington,...