The authors have performed 11 myotomies in 10 patients (age 12­p;77) with achalasia using minimally invasive techniques.
The initial 3 patients were treated via transthoracic approach; the subsequent 7 patients via transabdominal approach. The length of the myotomy was determined in conjunction with intraoperative endoscopy to facilitate dissection and demonstrate relaxation of the LES.
Only 1 patient required IV/IM narcotics greater than 24 hours postoperatively; 2 patients required no postoperative narcotics. The average hospital stay for those patients successfully treated endoscopically averaged 2.0±.5 days (range = 1.5 ­p; 3). One patient was converted to open thoracotomy secondary to perforation of the mucosa. One patient required repeat laparoscopic myotomy at three months due to recurrent dysphagia. Follow­p;up conducted at clinic visits showed all patients to have benefitted with relief of dysphagia; 80% (8) reported excellent results, 10% (1) reported good results, and 10% (1) fair results.
We converted from thoracic to laparoscopic myotomy because the abdominal approach simplified anesthetic and surgical management. We conclude that laparoscopic myotomy is a simple and effective treatment of achalasia.
Proponents of laparoscopic surgery point out the advantages of laparoscopic surgery are decreased hospitalization, paralytic ileus, postoperative pain, and wound complications including infection. This study compared open to laparoscopic appendectomy.
In order to compare the two techniques patients undergoing laparoscopic appendectomy at 4 hospitals were compared to patients undergoing open appendectomy over a 6 month period. Excluded were incidental appendectomies and patients with perforated appendicitis. An equal number of pediatric patients undergoing laparoscopic and open procedures were included in the analysis to avoid bias because most of the laparoscopic appendectomies were performed in the adult patient population (age>16).
A University Medical Center, a Veterans Administration and 2 community hospitals.
Patients undergoing laparoscopic appendectomy (N=54) had an average age of 25.7±1.5 (range 6-59). These patients were compared to 121 patients undergoing open appendectomy whose average age was 23.7±1.8 (range 3-83). The race, and sex distribution were similar in the 2 groups.
Traditional open appendectomy was compared to a group of patients undergoing laparoscopic appendectomy.
Variables evaluated were operating room time, number of patients who reported nausea, days until patient tolerated a regular diet, days of hospitalization, postoperative pain medication and wound infection rate.
Results are expressed as the mean±SEM. ANOVA was used to compute continuous variables and Fisher's exact test was used for discrete variables. The laparoscopic approach was attempted in 61 patients and completed in 54 patients. Open appendectomy was performed in 121 patients. Nineteen patients (18 open, 1 laparoscopic) were excluded from further analysis because of perforated appendicitis. The open procedure took less time (p<0.05), however there were more wound infections than in the laparoscopic group (7/103 vs 0/53, p=0.09). Patients with acute appendicitis recuperated more quickly from the laparoscopic procedure as evidenced by the time until eating regular diet, days in the hospital, incidence of nausea, and pain medications on postoperative day 1 (p<0.05).
The absence of wound infections after laparoscopic appendectomy can be attributed to the practice of placing the appendix in a sterile bag or into the trocar sleeve prior to removal from the abdomen. Laparoscopic appendectomy reduces hospital stay, postoperative ileus, nausea, and postoperative pain in patients with acute appendicitis. Another advantage to the laparoscopic procedure is the ability to thoroughly explore the abdomen not possible through a small Rocky-Davis type incision. Laparoscopic appendectomy reduces postoperative recovery but at the expense of a longer procedure time that had to be converted to an open procedure in 11% of our patients.
This prospective study was done to identify the incidence of
asymptomatic hernias diagnosed during laparoscopic surgery.
Previously unidentified inguinal hernias were discovered in thirteen
of one hundred consecutive patients undergoing laparoscopic
procedures (13%). Nine of the patients were male, four were female.
The average age was 43.3 years. Four defects were direct and nine
were indirect (patent processus vaginalis). Eleven defects were small
(<3cm) but two were large (>3cm). All four direct defects
occurred in male patients. We conclude that asymptomatic defects are
surprisingly common in our surgical population (13%) and that
laparoscopic examination of the pelvis is a very sensitive technique
to identify these defects. To date, no patient with laparoscopically
diagnosed hernia has developed symptoms or complications related to
the hernia. We recommend that the surgeon should note the presence of
a defect in the medical record but not proceed with prophylactic
repair of asymptomatic defects.