Widespread Use Of Laparoscopy Research Articles

Do we need mesh fixation at the laparoscopic hernia repair?

ObjectiveWith the development of laparoscopic treatment, widespread use of laparoscopy has become inevitable for the treatment of inguinal hernias, which is one of the most common ailments in surgical practice. Fixing or not fixing the mesh during laparoscopic repair remains a debate. In our study, we aimed to compare patients with and without mesh fixation in terms of postoperative pain, recurrence, complications, hospitalization and return to social life. MethodThe surgical technique to be performed was randomly determined, 81 patients whose data were kept prospectively and evaluated retrospectively were included in the study. Total extraperitoneal repair (TEP) was performed in all patients. While the mesh was not fixed in 50 patients, it was fixed with 2 tackers in 31 patients. ResultsWhen the two groups of patients were compared, the group without mesh fixation was found to be superior in terms of postoperative pain, length of hospital stay and return to social life. There was no difference between the 2 groups in terms of complications and recurrence. ConclusionsIn the light of these findings, it is seen that TEP hernia repair can be performed safely without mesh fixation, although prospective randomized studies are needed.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil.

the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

How Can Laparoscopic Appendectomy Become the First-Line Treatment for Acute Appendicitis in Lower-Income Countries: A 15-Year Experience

Introduction: The barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource cost and availability. The present study evaluates the impact of actions took over 15 years in a single academic center aiming to implement the routine use of laparoscopy for acute appendicitis. Methods: Retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared with 4 major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: We identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p < 0.001). Since 2016 the standard of care in our institution is appendiceal stump closure with polymeric clips, even in complicated acute appendicitis. Conclusion: The development of a feasible, reproducible, and safe technical standardization is one of the cornerstones for a consistent and viable change in the current practice for appendectomies in lower-income countries.

Anatomic landmarks for laparoscopic gastric sleeve resection in obese patients with type 2 diabetes mellitus

Background. The widespread use of laparoscopy has greatly accelerated the development of bariatric/metabolic surgery. Mastering of the laparoscopic techniques in bariatric surgery is important considering the potential complications and their implications for the patient’s life. Laparoscopic sleeve gastrectomy is a common bariatric/metabolic procedure worldwide. This procedure seems relatively standard, but some steps of this procedure still depends on the choice of the surgeon. There are two main steps that are not standardized yet — the choice of the calibration bougie and the distance from the pylorus to the first staple. The objective of the study is to establish the anatomical landmarks of the beginning of staplerfiring, which are simple, constant, and which can be used to standardize laparoscopic gastric sleeve resection. Materials and methods. Thirty-six obese patients with type 2 diabetes mellitus undergo laparoscopic sleeve gastrectomy. Body measurements, such an age, gender, height, weight, body mass index, and carbohydrate metabolism parameters, such as glucose, glycated hemoglobin, insulin, C-peptide, HOMA index was analyzed. The distance from the gastric pylorus was measured intraoperatively using a silicone tape. Results and discussion. The study included 19 women and 17 men, with an average age of 50.3 ± 9.6 years (range 30—67 years). The average body mass index is 50.6 ± 10.9 kg/m2 (range 30.2—82.3 kg/m2). The average distance from the pylorus to the first branch of the gastroepiploic artery, which runs in the transverse direction to the axis of the antrum, was 41 ± 1.7 mm (range 38—44 mm). The average distance for women was 40.6 ± 1.6 mm, for men — 41.5 ± 1.6 mm. Conclusion. The first branch of the gastroepiploic artery which runs perpendicularly to the axis of the antrum can be used as constant anatomical landmark. It is located on average 41 mm proximal to the gastric pylorus. Using this landmark for the first stapler firing allows to offset the need of formally measurements of the distance from stomach pylorus.

Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population

PurposeThe widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter. MethodsAn online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics. ResultsA total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines. ConclusionsThe majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons. Type of studySurvey Level of evidenceVII (Expert Opinion)

Meta-analysis of perioperative outcomes of acute laparoscopic versus open repair of perforated gastroduodenal ulcers

Surgery is the treatment of choice for perforated peptic ulcer disease. The aim of the present review was to compare the perioperative outcomes of acute laparoscopic versus open repair for peptic ulcer disease. A systematic literature search was performed for randomized controlled trials (RCTs) published in PubMed, SCOPUS, and Web of Science. The search included eight RCTs: 615 patients comparing laparoscopic (307 patients) versus open peptic perforated ulcer repair (308 patients). Only few studies reported the Boey score, the Acute Physiologic Assessment and Chronic Health Evaluation score, and the Mannheim Peritonitis Index. In the RCTs, there is a significant heterogeneity about the gastric or duodenal location of peptic ulcer and perforation size. All trials were with high risk of bias. This meta-analysis reported a significant advantage of laparoscopic repair only for postoperative pain in first 24 hours (-2.08; 95% confidence interval, -2.79 to -1.37) and for postoperative wound infection (risk ratio, 0.39; 95% confidence interval, 0.23-0.66). An equivalence of the other clinical outcomes (postoperative mortality rate, overall reoperation rate, overall leaks of the suture repair, intra-abdominal abscess rate, operative time of postoperative hospital stay, nasogastric aspiration time, and time to return to oral diet) was reported. In this meta-analysis, there were no significant differences in most of the clinical outcomes between the two groups; there was less early postoperative pain and fewer wound infections after laparoscopic repair. The reported equivalence of clinical outcomes is an important finding. These results parallel the results of several other comparisons of open versus laparoscopic general surgery operations-equally efficacious with lower rates of wound infection and improvement in some measures of enhanced speed or comfort in recovery. Notably, the trials included have been published throughout a considerable time span during which several changes have occurred in most health care systems, not least a widespread use of laparoscopy and increase in the laparoscopic skills. Systematic review and meta-analysis, level III.

Short Term Results of the First Laparoscopic Urologic 25 Case [Laparoskopik Urolojik Ilk 25 Vaka'nin Erken Donem Sonuclari

The widespread use of laparoscopy in daily urology practice is increasing. The laparoscopic surgery has some advantages about bleeding, short hospitalization and smaller insicion when comparing open surgery. In this study, I aimed to evaluate the patients who were treated with laparoscopic surgery in Corum Training and Research Hospital. The patients who underwent laparoscopic surgery between May 2013 and January 2015 were evaluated retrospectively. The patients’ age, operation time, bleeding, peroperative and postoperatice complications were recorded. Monopolar and ultrasonic energy devices were used. All of the patients used antiembolic sock and low molecul weight heparine was performed on postoperative period. There were 25 patients in this study. 17 and 8 of these patients were male and female. The median age of the patients was 53±14.01 year and operation time was 101.4±79.3 minutes. Two patients needed blood transfusion on post operative period. Drain tube was used for 9 patients. Two of these patients had renal cyst. Bleeding and noromuscular pain were the complications of the operation on postoperative period. Laparoscopic surgery has more advantages about hospital stay, need of analgesia and smaller incisions when compared open surgery. After the basic urology education, laparoscopy can be performed by young urologists.

Pictorial review of normal postoperative cross-sectional imaging findings and infectious complications following laparoscopic appendectomy.

Laparoscopic appendectomy is increasingly accepted as the preferred surgical treatment for acute appendicitis and represents one of the most common emergency operations performed in both adult and paediatric populations. However, in patients with perforated appendicitis laparoscopy is associated with an increased incidence of postoperative intraabdominal infections compared to open appendectomy. Nowadays urgent imaging is commonly requested by surgeons when postoperative complications are suspected. Due to the widespread use of laparoscopy, in hospitals with active surgical practices clinicians and radiologists are increasingly faced with suspected postappendectomy complications. This pictorial essay illustrates the normal cross-sectional imaging findings observed shortly after laparoscopic appendectomy and the spectrum of appearances of iatrogenic intraabdominal infections observed in adults and adolescents, aiming to provide radiologists with an increased familiarity with early postoperative imaging. Emphasis is placed on the role of multidetector CT, which according to the most recent World Society of Emergency Surgery (WSES) guidelines is the preferred and most accurate modality to promptly investigate suspected intraabdominal infections and highly helpful for correct therapeutic choice, particularly to identify those occurrences that require in-hospital treatment, drainage or surgical reintervention. In teenagers and young adults MRI represents an attractive alternative modality to detect or exclude iatrogenic abscesses without ionising radiation. Teaching points • Laparoscopic appendectomy is the preferred surgical treatment for uncomplicated acute appendicitis • In perforated appendicitis laparoscopy results in increased incidence of intraabdominal infections • Multidetector CT promptly assesses suspected iatrogenic intraabdominal infections • Interpretation of early postoperative CT requires knowledge of normal postsurgical imaging findings • Postsurgical infections include right-sided peritonitis, intraabdominal, pelvic or liver abscesses

Unusual Trocar Site Metastasis in a Uterine Leiomyosarcoma after Laparoscopic Hysterectomy

With widespread use of laparoscopy in patients with gynecologic malignancy, occasionally port-site metastasis is an item of concern. Herein we report a case of leiomyosarcoma of the uterus that metastasized to an accessory port after laparoscopic-assisted vaginal hysterectomy. A 46-year-old woman with a preoperative diagnosis of leiomyoma underwent laparoscopic-assisted vaginal hysterectomy. Final histopathologic findings revealed leiomyosarcoma. A postoperative abdominopelvic computed tomography scan demonstrated no evidence of metastatic tumor. The patient received 6 courses of combined chemotherapy consisting of cisplatin and ifosfamide. Follow-up computed tomography was performed because of pelvic pain at 4 months after treatment and revealed a recurrent pelvic tumor and a metastatic mass at previous right trocar site. At debulking surgery, a pelvic mass measuring 10 cm was observed, and a subcutaneous nodule measuring 4 cm was noted at the site of the right accessory port, with intact underlying peritoneum. After complete removal of both tumors, concurrent chemoradiation consisting of external radiotherapy and cisplatin was administered. Six months after the second surgery, a pelvic mass measuring 15 cm was observed. A second debulking surgical procedure was performed. However, the patient died of the disease 6 months after the second recurrence.

What is the role of innovative minimally invasive surgery in today's medicine?

Medical advancements are often accompanied by surgical innovation. One such example is the introduction of laparoscopy into general and specialty surgery. Gynecologic surgery was at the forefront of this development with the widespread use of laparoscopy as a minimally invasive approach for adnexal surgery. In urogynecology laparoscopy was introduced as an alternative to open Burch colposuspension before it was superseded by the introduction of TVT sling. Aside from the obvious argument that a vaginal approach to female pelvic floor reconstructive surgery represents the least invasive surgical technique within our specialty, there continues to be widespread interest in the use of traditional “straight stick” and robotic-assisted laparoscopy. At the 37th Annual Scientific Meeting of the Society of Gynecologic Surgeons in San Antonio, TX, USA, Drs Catherine Matthews and Michael Heit debated the topic of Robotic or Straight Stick Laparoscopy for Minimally Invasive Pelvic Surgery. The debate centered on the technique of sacrocolpopexy for pelvic organ prolapse, which is widely considered to be one of the gold standards in our field. The two articles that follow capture the spirit of that debate. Drs Matthews and Heit clearly present the feasibility of performing each procedure. However, we all currently work in a world that places tremendous pressure on physicians to focus on quality, safety, and reducing costs per case. Both Drs Heit and Matthews acknowledge that escalating health care costs are unsustainable and undesirable. As stated by Dr. Heit, current evidence does not support the widespread adoption of the robotic approach for most surgical procedures, yet this has not slowed the enthusiasm for training, nor hospitals marketing of this new and yet unproven technique. There is no question that the current experience demonstrates that robotic technology is far more expensive with little offsetting value. With respect to sacral colpopexy, most published small series suggest far longer operative times, increased costs, as well as higher complication rates with both the robotic and laparoscopic approaches compared to the traditional open approach. Dr Matthew asserts that like other technologic breakthroughs, such as cellular telephones, the cost will naturally decrease and the procedures will become easier. However, cost reduction is typically dependent upon high volumes and having competing companies and technology. For now, there is only one player in the robotic field, Intuitive Surgical. In addition, there are concerns regarding patient safety and higher risks of complications with many endoscopic approaches compared to traditional open techniques, creating yet another barrier for new techniques within modern medicine. If cost effective robotic surgery is not likely, will the default be laparoscopic? As Dr. Matthews points out, the challenges faced by gynecologic surgeons in obtaining advanced laparoscopic skills is indeed formidable. It should not come as any surprise that we have lagged behind our general surgery colleagues in endoscopic Further contributions to this debate can be found at doi:10.1007/ s00192-011-1619-5 and doi:10.1007/s00192-011-1620-z.

Randomized clinical trial comparing the cost and effectiveness of bipolar vessel sealers versus clips and vascular staplers for laparoscopic colorectal resection

The widespread use of laparoscopy has resulted in a variety of instruments being used routinely for vascular control. This randomized controlled trial evaluated the cost-effectiveness of bipolar vessel sealer (BVS) compared with clips and vascular stapler (CVS) in straight laparoscopic colorectal resection. Patients scheduled for elective colorectal resection, including benign and malignant diseases, were randomized to either BVS or CVS for vascular control. Patients whose operation was converted to an open approach before pedicle ligation were excluded. The primary endpoints were duration of operation, including time taken to control vascular pedicles, and cost of disposable instruments for vascular control. Of 114 patients randomized to BVS (60 patients) or CVS (54), 14 did not receive the allocated vascular control device, leaving 55 and 45 respectively for analysis. The BVS reduced the time spent for vascular control by a mean of 6·9 min (P = 0·031) and reduced the cost of disposable instruments for vascular control by US $ 80·7 per patient (P = 0·043). For total colectomy, the BVS reduced the operating time by 103·6 min (P = 0·023) and the time taken for vascular control by 16·8 min (P = 0·022). For left colectomy, it decreased the time to vascular control by 9·3 min (P = 0·021). In multivariable analysis, the cost of disposable instruments for vascular control was independently reduced by randomization to BVS, type of procedure, female sex and estimated blood loss. The mean cost reduction was $ 88·2 for left colectomy (P = 0·037), $ 377·7 (P = 0·005) for total colectomy and $ 366·9 (P = 0·012) for proctectomy. Conversely, use of the BVS increased the cost of instruments used for vascular control in right colectomy by $ 92·6 (P = 0·012). BVS devices are expedient and cost-efficient in proctectomy, left and total colectomy procedures.

Intraoperative Management of Vascular Injuries During Laparoscopic Surgery

Introduction: Widespread use of laparoscopy for major urological procedures has brought a whole new gamut of complications with it. Vascular complications are the second commonest complication encountered during laparoscopic surgery. In this video we elude to the tips and tricks in managing vascular complications. Materials and Methods: In this video we allude to how these complications occurred and how we managed them. The majority of the complications were managed by laparoscopic approach. During a laparoscopic donor nephrectomy, the gonadal vein got avulsed from its junction with the inferior vena cava (IVC) the bleeding was controlled by securing the bleeder with Maryland forceps and clips. An external iliac vein injury was managed by incorporeal suturing using hemlock clips, which were attached at the tail of the suture; this trick helped in approximation of the vein edges. We had an instance of injury to the renal artery; in this case due to the concern of patient safety, the bleeding was controlled by open approach. In one of the patients while exposing the retropubic space in a radical cystectomy, the inferior epigastric artery bled; the video shows how we managed this complication. Results: We describe management of the following patients, one each of renal vein, gonadal vein, and inferior epigastric artery injury, and two patients, each with aortic and external iliac vein injury. Conclusions: With experience, the majority of vascular injuries can be managed with laparoscopy. The salient features for managing these injuries are the following: organize yourself, have a good team, be prepared for open conversion, and single hand suturing skills help to tide over the situation. All authors have declared no conflicts of interest. Runtime of video: 7 mins 1 sec

Benchmarking Best Practices in Weight Loss Surgery

Benchmarking Best Practices in Weight Loss Surgery

Robotics for Pelvic Floor Disorders: Rectopexy and Pelvic Organ Prolapse

Various surgical options exist for patients with pelvic organ prolapse. Conventionally, open procedures have been performed laparoscopically with similar results and fewer morbidity. However, widespread use of laparoscopy to treat rectal and vaginal vault prolapse has been limited by the technical challenges of performing these surgeries with a minimally invasive approach. Robotic surgery allows for improved visualization and ergonomics, enabling the surgeon to perform complicated procedures more easily. Robotically assisted laparoscopic rectopexies and sacrocolpopexies have been shown to have excellent results but they increase operative time and cost. Further investigation is needed to demonstrate clear advantages to using this approach over conventional laparoscopy.

Management of diaphragmatic injury during transperitoneal laparoscopic urological procedures

Carbon dioxide pneumothorax is a rare complication in laparoscopic urology, but with the widespread use of laparoscopy and the increasing surgical pathologies managed by this technique this infrequent complication has become a potential risk. A total of 786 laparoscopic transperitoneal urologic operations were reviewed at our institution. All procedures were performed by the same surgeon and included 213 adrenalectomies, 181 simple nephrectomies, 143 lymphadenectomies, 118 radical nephrectomies, 107 partial nephrectomies and 24 nephroureterectomies. Mean patient age was 53.2 years (range 24 to 70). Mean BMI was 28.15 Kg/m2 (range 20 to 48.9). A total of 6 cases (0.7%) of diaphragmatic injury were found. All reported patients had additional factors that may have contributed to diaphragmatic injury. Diaphragmatic repair was always carried out by intracorporeal suturing and only one case required chest tube placement. All patients evolved uneventfully. Repair of diaphragmatic injuries should always be attempted with intracorporeal suture since this is a feasible, reproducible and reliable technique.

Laparoscopic partial nephrectomy in infants and children. how difficult is it ?

Aim Despite the widespread use of laparoscopy for renal surgery in children, there are few large series of laparoscopic partial nephrectomies reported in the paediatric population. We report our experience with laparoscopic hemi-nephrectomy in duplex kidneys in children. Patients and methods Since 1993, 41 children underwent laparoscopic hemi-nephrectomy (39 retroperitoneoscopic, 2 transperitoneal) in our institution, including 30 upper-pole nephrectomies (UPN) and 11 lower-pole nephrectomies (LPN). Median age at surgery was 6.2 months (range 1.5-89), including 27 infants. The patient was placed in lateral position in 31 and prone in the last 10. Follow-up was based on clinical review and renal ultrasound. Results Median duration of surgery was 130 min (71-215). Ten procedures (25%) were converted into open surgery, mostly at the beginning of the experience (8 during the first 20 cases). Among 4 converted LPN, 3 were converted for difficulties during parenchymal section, all before acquisition of the Harmonic scalpel. Six UPN were converted for difficulties of visualization of vascular anatomy, including 3/6 with a dilated ureter (>15mm) and 2/6 with an accidental pneumoperitoneum. None of the 8 UPN performed in children older than 1 year were converted. Median follow-up was 14 months (4-125). We observed one case (case #4) of functional loss of the remaining lower moiety. There were no case of postoperative urine leak. Conclusions This study shows a high conversion rate during laparoscopic hemi-nephrectomy in children, that may decrease with experience and the use of modern instrumentation enabling easier parenchymal section. Retroperitoneoscopic UPN remains a challenging procedure, especially in small infants with very dilated collecting systems. The possibility of vascular damages to the remaining moiety warrants a very cautious dissection of the renal pedicle and should lead to conversion when clear visualization of vascular anatomy is not ascertained.

Minimally Invasive Treatment of Colon Cancer

The advantages of laparoscopy in the treatment of benign diseases have been well demonstrated. Compared with laparotomy, the laparoscopic approach is associated with a shorter hospitalization period, shorter duration of ileus, decreased postoperative pain, earlier return to work, and improved cosmesis. The role of laparoscopy for the treatment of gastrointestinal malignancy has had a slower evolution and been the subject of considerable debate over the past decade. Since 1991, several concerns have limited the widespread use of laparoscopy for attempted cure of colorectal carcinoma. This review aims to analyze the results of several studies published to date on short and long term outcome of laparoscopy for colorectal carcinoma, based on levels of evidence. From the least to the most convincing data, the hierarchy of study designs progresses through a spectrum ranging from retrospective reviews to prospective series, to case-controlled, cohort, and ultimately randomized controlled trials.

Incidence and characterization of diagnosed endometriosis in a geographically defined population

Objective We examined whether widespread use of laparoscopy was accompanied by increased diagnosis of asymptomatic endometriosis, inflated rates of diagnosis, or changes in the clinical spectrum of disease. Design Population-based cohort. Setting Olmsted County, Minnesota. Patient(s) All participants were women residents, aged ≥15 years. Intervention(s) None. Main outcome measure(s) We estimated the likelihood that women with a surgical procedure during which endometriosis could be visualized would receive a surgical diagnosis, as well as the proportions of all diagnoses, regardless of setting, that were [1] assigned without surgery, [2] refuted by surgery, [3] surgically confirmed, and [4] asymptomatic. The incidence of diagnosed endometriosis for 1987 to 1999 was compared with published rates for 1970 to 1979. Result(s) Of 8,229 women aged ≥15 years with ≥1 surgery during which endometriosis could be visualized, 11.5% received a surgical diagnosis of endometriosis. The incidence of diagnosed endometriosis, regardless of setting, was 1.9 per 1,000 person-years (10% were without relevant surgery, 6% had surgery but no surgical evidence, 85% had surgical evidence); 85% of surgically confirmed diagnoses had presenting symptoms. Using definitions comparable with those in the 1970 to 1979 study, the 1987 to 1999 incidence was 2.46 per 1,000 versus 2.49 per 1,000 for 1970 to 1979; 88% of symptomatic incident diagnoses were surgically confirmed versus 65% for 1970 to 1979. Conclusion(s) Widespread use of laparoscopy does not appear to have contributed to dramatically increased rates of endometriosis diagnoses but rather to a smaller proportion of diagnoses being assigned without surgical confirmation.

Utilization of laparoscopic antireflux surgery at a single Veterans Affairs facility compared with the Veterans Affairs national trend

Background The widespread use of laparoscopy in the early 1990s has led to an increase in the utilization of antireflux procedures for the treatment of gastroesophageal reflux disease (GERD). This trend has been observed in the private sector, but not within the Department of Veterans Affairs (VA) health care system. Published data suggest that among patients undergoing antireflux surgical procedures, those in the VA were less likely than those in the private sector to undergo laparoscopic surgery. The objective of this study was to determine the trend in the use of laparoscopic antireflux surgical procedures at our VA facility and compare it with the national VA trend. Methods All antireflux operations performed at our VA facility from 1991 to 2002 were recorded along with techniques used. National VA data on the utilization of antireflux procedures from 1991 to 1999 was extracted from a recent publication by Finlayson et al. Results In contrast to the trend observed nationally across VA hospitals, the rate of utilization of antireflux surgery at our VA facility has increased compared with baseline in 1991. Of 83 fundoplications performed from 1991 to 2002, 76 (92%) were attempted or completed laparoscopically. The conversion rate from laparoscopic to open approach was 6.6%. Conclusions We have observed an increase in the utilization of antireflux surgery since 1991 at our VA facility. In addition, most fundoplications were performed laparoscopically. These findings are in contrast to published national VA data. The presence of surgeons with interest in laparoscopy, institutional support, and a dedicated esophageal function laboratory may explain these findings.

Laparoscopic evaluation of testicular mobility as a guide to management of intra-abdominal testes.

The optimal management of intra-abdominal testes is the subject of an ongoing debate as the result of widespread use of laparoscopy since early 1990's. A simple laparoscopic technique uses cord mobility to act as a guide to cord length and therefore predict the success of a conventional orchidopexy in cases of true intra-abdominal testes. In the technique described, the testis is displaced by stretching the testes to overly the opposite internal inguinal ring. Over a 3-year period, a total of 36 boys with 38 intra-abdominal testes, confirmed laparoscopically, were prospectively assessed. The reported "stretching maneuver" was carried out in all cases. Successful conventional orchidopexy as predicted by a positive stretch maneuver was carried out in 20 testes. When the stretch maneuver failed, conventional 2-stage open operation was done in 3 patients and Fowler-Stephens orchidopexies for the remaining 13 children. A simple test determining testicular mobility assessed during laparoscopic evaluation of intra-abdominal testes provides information of significant importance upon which the correct surgical approach can be based.