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Background: Minimally invasive pancreaticoduodenectomy, either laparoscopic or robotic, is a high-risk procedure with demanding learning curve. The aim of this prospective cohort study was to evaluate short-term clinical and oncologic outcomes of 3D-laparoscopic pancreaticoduodenectomy (3dLPD) with stented pancreaticogastrostomy (sPG) and Roux-en-Y gastroenterostomy (ryGES)., Methods: Between March 2016 and July 2021, 347 consecutive patients underwent 3dLPD for confirmed or suspected pancreatic or periampullary tumors. Pancreatic duct diameter measured 3 mm or less in 221 (64%) and pancreatic texture was soft in 191 (55%) patients. Simultaneous resection of the superior mesenteric or portal vein was performed in 52 (15%) patients., Results: Postoperative complications were observed in 189 (54%) patients, with severe complications (Clavien-Dindo grade > 2) in 68 (20%) including 4 (1.2%) deaths. Clinically relevant pancreatic fistula (cPOPF) occurred in 88 (25%), hemorrhage in 25 (7%), and bile leakage in 10 (3%) patients. Clinical pancreatic fistula was strongly associated with soft pancreatic texture and small pancreatic duct diameter (p < 0.001) and managed by endoscopic trans-gastric drainage in 34 (38.6%) patients, reoperation in 12 (13.6%), and ICU admission in 11 (12.5%). The remaining 31 (35%) patients with cPOPF were managed without invasive intervention. Median length of hospital stay after surgery was 13 (range 5-112; IQR 8-18) days. In pancreatic adenocarcinoma (PDAC) the R0-resection rate was 66/186 (36%), R1-indirect 95/186 (51%), and R1-direct 25 (13%). Median number of locoregional lymph nodes retrieved in PDAC was 21 (IQR 15-28). R0-resection rate for malignancy other than PDAC was 78/86 (91%) with a median of 16 (IQR 12-22) locoregional lymph nodes retrieved., Conclusion: 3dLPD with sPG and ryGES is associated with 1.2% mortality and 25% cPOPF. About two-third of patients with cPOPF were managed with some type of invasive intervention, whereas the intraoperatively placed drains sufficed in one-third of patients., Clinical Trial Registry: Clinicaltrials.gov NCT02671357., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis., Methods: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis., Results: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%., Conclusion: Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background and Aims: In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic GE (L-GE) are scarce. Our aim was to perform a propensity score-matched comparison between EUS-GE and L-GE., Methods: An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging., Results: Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE-treated patients (94.6%) versus 100% in the L-GE group (P = .493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P = .358). Median time to oral intake (1 [interquartile range {IQR}, .3-1.0] vs 3 [IQR, 1.0-5.0] days, P < .001) and median hospital stay (4 [IQR, 2-8] vs 8 [IQR, 5.5-20] days, P < .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P = .007) and severe (.0% vs 16.2%, P = .025) adverse events were identified more frequently in the L-GE group., Conclusions: For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Minimally invasive pancreaticoduodenectomy with synchronous vein resection for pancreatic cancer is controversial. The aim of this study was to evaluate outcomes and describe the surgical technique of 3d-laparoscopic pylorus-resecting pancreaticoduodenectomy (3dLPD) with venous resection for pancreatic cancer., Methods: A retrospective cohort analysis was performed with 26 patients [male/female 11/15; median age 68 (range 45-83) years] who underwent 3dLPD with stented pancreaticogastrostomy and superior mesenteric or portal vein resection for pancreatic adenocarcinoma between November 2016 and June 2019. Median follow-up time after surgery was 12 months (range 3-32)., Results: Median operating time was 340 min (range 240-420) and intra-operative blood loss was 100 mL (range 0-1000). Type of venous resection and reconstruction was wedge-resection with primary closure (n = 22), wedge-resection with reconstruction using a peritoneal patch (n = 3), and segmental resection with primary end-to-end reconstruction (n = 1). Laparoscopy was converted to open surgery in 4 (15%) patients. Postoperative complications occurred in 10 (38%) patients including severe complications (Clavien-Dindo grade > 2) in 4 (15%). Postoperative mortality was zero. R0 resection was achieved in 21 (81%) patients. Median number of lymph nodes retrieved was 25 (range 10-45). Venous patency was observed in 23 (88%) patients with a median patency duration of 11 months (range 0-31)., Conclusions: 3dLPD with simultaneous venous resection for pancreatic cancer results in acceptable reconstruction patency and adequacy of surgical oncology without compromising clinical outcomes.

Objective: The aim of the study was to assess feasibility and outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LPD)., Background: Whereas expert centers have reported promising outcomes of LPD, nationwide analyses have raised concerns on its safety, especially during the learning curve. Multicenter, structured LPD training programs reporting outcomes including the first procedures are lacking. No LPD had been performed in the Netherlands before this study., Methods: During 2014-2016, 8 surgeons from 4 high-volume centers completed the Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery (LAELAPS-2) training program in LPD, including detailed technique description, video training, and proctoring. In all centers, LPD was performed by 2 surgeons with extensive experience in pancreatic and laparoscopic surgery. Outcomes of all LPDs were prospectively collected., Results: In total, 114 patients underwent LPD. Median pancreatic duct diameter was 3 mm [interquartile range (IQR = 2-4)] and pancreatic texture was soft in 74% of patients. The conversion rate was 11% (n = 12), median blood loss 350 mL (IQR = 200-700), and operative time 375 minutes (IQR = 320-431). Grade B/C postoperative pancreatic fistula occurred in 34% of patients, requiring catheter drainage in 22% and re-operation in 2%. A Clavien-Dindo grade ≥ III complication occurred in 43% of patients. Median length of hospital stay was 15 days (IQR = 9-25). Overall, 30-day and 90-day mortality were both 3.5%. Outcomes were similar for the first and second part of procedures., Conclusions: This LPD training program was feasible and ensured acceptable outcomes during the learning curve in all centers. Future studies should determine whether such a training program is applicable in other settings and assess the added value of LPD.

Background: The role of laparoscopy for major hepatectomies remains a matter of development to be further assessed. The purpose of this study is to compare the short- and long-term outcomes between laparoscopic and open major hepatectomies meta-analyzing individual patient data from published comparative studies., Methods: All retrospective studies comparing between laparoscopic and open major hepatectomies published until March 2017 were identified independently by 2 reviewers by searching in PubMed and Cochrane Central Register of Controlled Trials. Individual patient data were sought from all selected studies. Postoperative outcomes, including intraoperative blood loss, operative time, hospital stay, postoperative complications, mortality rates, and long-term survival were analyzed., Results: A total of 917 patients were divided into the laparoscopic (427) and open (490) groups from 8 selected studies. The hospital stay was significantly shorter, and the total morbidity was lower in the laparoscopic group. When classified by severity, the incidence of postoperative minor complications was lower; however, that of major complications was not significantly different. The operative time was longer in the laparoscopic group; however, intraoperative blood loss, perioperative mortality, and blood transfusions were comparable between the 2 groups. The overall survival in the patients with colorectal liver metastases and hepatocellular carcinoma was not significantly different between the 2 groups., Conclusion: Laparoscopic major hepatectomies offer some perioperative advantages, including fewer complications and shorter hospital stay, without increasing the blood loss volume and mortality. Whether these results can anticipate the outcomes in future randomized controlled trials has not been determined., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Minimally invasive liver resection (MILR) for colorectal liver metastases (CRLM) is gaining widespread acceptance. However, data are still lacking on the feasibility, long- and short-term outcomes of laparoscopic major hepatectomy (i.e., three or more liver segments)., Methods: Between October 2002 and December 2008, prospectively collected data of 117 patients who underwent major liver resection [97 open (OMLR) and 20 laparoscopic (LMLR) procedures] for CRLM were analyzed. Twenty patients in the LMLR group were matched with 20 patients of the OMLR based on 13 parameters. We compared the long- and short-term outcomes between these two groups., Results: Median duration of surgery was 257.5 (range 75-360) min in LMLR versus 232.5 (range 120-400) min in OMLR (P = 0.228). Median blood loss during surgery was 550 ml in each group (range 100-4,000 vs. 100-2,500 ml, P = 0.884). There was no statistically significant difference in the rate of postoperative complications (both severity and location). Median magnitude of tumor-free resection margin was 7.5 versus 5.5 mm in the laparoscopy versus open group, respectively (P = 0.651). Median disease-free survival (DFS) of the entire study population was 18.4 months [95% confidence interval (CI) 11.9-50.0 months]. Median overall survival (OS) was 50.7 months (95% CI 36.2 months to undetermined). The estimated DFS and OS rates at 1, 2, and 5 years were comparable in the two groups (P = 0.637 and 0.872, respectively)., Conclusion: Laparoscopic MLR for selected CRLM is feasible and might result in comparable oncologic outcomes as in open liver resection.

Background: Few reports exist on long-term survival after minimally invasive liver surgery (MILS) for colorectal liver metastases (CRLM). No data are available assessing prognostic factors in the era of current modern treatment strategies., Methods: Between October 2002 and December 2008, 274 consecutive patients were analyzed on an intention-to-treat basis. Open liver surgery (OLS) was performed in 193 patients for a total of 437 metastases, and MILS was performed in 81 patients for 176 metastases. Systemic chemotherapy was administered preoperatively in 173 and postoperatively in 174 patients. The impact of 23 potential prognostic factors on disease-free (DFS) and overall survival (OS) was evaluated using univariable and multivariable Cox regression models., Results: Postoperative complications were observed in 54 patients after OLS and in 11 after MILS (p = 0.016). The median postoperative length of hospital stay was 9 days after OLS and 5 days after MILS (p < 0.0001). For the entire patient population, the 5 year DFS and OS rates were 29.9 and 59.5%, respectively. No differences in survival between patients treated with MILS and OLS were observed (p = 0.63). In univariable analyses, the number of liver metastases and the overall Fong's clinical risk score (CRS) were the only two variables that predicted DFS (p ≤ 0.0035) and OS (p ≤ 0.0005). In multivariable analyses, the total CRS was the only independent predictor of both DFS (p = 0.0002) and OS (p = 0.002)., Conclusion: The long-term oncologic outcome of surgically treated patients with CRLM is determined by the Fong's CRS. Although MILS does not influence long-term survival, it has a beneficial impact on the immediate postoperative clinical outcome.

Background: Concerns have been raised regarding outcome after laparoscopic resection of hepatic neoplasms. This prospective study compared morbidity and adequacy of surgical margins in laparoscopic (LLR) versus open liver resection (OLR)., Methods: Outcome in 359 consecutive patients [male/female ratio 187/172; median age 60 years (range 18-84 years)] who underwent partial hepatectomy was analysed. Cirrhosis was present in 32 patients and preoperative chemotherapy was administered in 141 patients. Comparative analyses were performed using propensity scores for all and for matched patients (n=76 per group)., Results: Complications occurred in 68/250 (27.2%) patients after OLR and in 6/109 (5.5%) after LLR [odds ratio (OR) 0.16; 95% confidence interval (CI) 0.07-0.37; p<0.0001]. Median intraoperative blood loss was 500 ml (range 10-7,000 ml) in OLR and 100 ml (range 5-4,000 ml) in LLR (p<0.0001). Postoperative hospital stay was 8 days (range 0-155 days) after OLR and 6 days (range 0-41 days) after LLR (p<0.0001). In patients treated for liver malignancy, the surgical resection margin was positive on histopathological examination in 5/237 after OLR and in 1/77 after LLR. The magnitude of the resection margin was 7.5 mm (range 0-45 mm) in OLR and 10.0 mm (range 0-30 mm) in LLR (p=0.087)., Conclusions: LLR for hepatic neoplasms seems to be noninferior to OLR regarding adequacy of surgical margins, and superior to OLR regarding short-term postoperative outcome.

Splenic abscess as a presentation of a Salmonella infection is described in children and adults. A combination of antibiotics and splenectomy is the standard treatment. We report a 12-year-old girl admitted to the hospital with fever, abdominal pain, and anorexia. White blood cell count was 17,900/microL and C-reactive protein level was 230 mg/L; abdominal ultrasound and abdominal computed tomographic (CT) scan showed a splenic abscess of 11.3 x 12.9 x 13.8 cm in the upper part of the spleen. She was treated with percutaneous drainage and antibiotics for 8 days. A week later, she represented with a recurrent abscess and identical symptoms. She was treated with percutaneous drainage and intravenous (i.v.) antibiotics for 21 days followed by oral therapy for another 2 weeks. Abscess culture grew Salmonella type B. Because of a persistent abscess on CT scan, she underwent a partial laparoscopic splenectomy with radiofrequency ablation to preserve functional splenic tissue. The operative and postoperative course was uneventful. Pathologic finding showed an inflammatory cystic reaction without epithelial cell lining. Splenic abscess in children is a rare condition. Long-term antibiotic therapy is needed. Percutaneous drainage can be a temporary solution, but (partial) splenectomy is the final treatment in most cases.

Background: The role of laparoscopic total gastrectomy (LTG) in the treatment of gastric cancer is controversial. The present study analyzed the morbidity and adequacy of resection in LTG versus open total gastrectomy (OTG) for gastric adenocarcinoma., Methods: Between 2003 and 2006, clinical data of 38 consecutive patients who underwent LTG for gastric adenocarcinoma were collected prospectively. The same data-entry form was used for retrospective data collection from 22 consecutive patients who underwent OTG within the same time period. Logistic regression models were used in univariate and multivariate analyses to identify the optimally combined factors related to the occurrence of postoperative complications and to the number of harvested lymph nodes., Results: Postoperative complications occurred in 24 patients with subsequent mortality in two. Median (range) length of hospital stay was 11 (6-73) days and comparable after LTG versus OTG (p = 0.847). The occurrence of postoperative complications was related (p = 0.004) to the first year of surgery and patients' medical condition before surgery [American Society of Anaesthesiologists (ASA) physical status III]. Microscopic tumor-free margins were obtained in all but two patients. The number of harvested lymph nodes was 17 (0-90), and determined by tumor wall penetration (p = 0.001)., Conclusions: The occurrence of complications after total gastrectomy is determined by the patients' medical condition before surgery and the surgical expertise, but not by the approach. LTG and OTG can result in adequate tumor-free resection margins and lymph node yield, which is related to the tumor wall penetration. The role of LTG in gastric cancer needs further evaluation in randomized controlled trials with large patient series.

Background: Laparoscopic common bile duct exploration (LCBDE) is as safe and efficient as endoscopic retrograde cholangiopancreatography (ERCP) in achieving bile duct clearance from stones. No clear guidelines are available on LCBDE with respect to indications for trans-cystic approach versus choledochotomy, or regarding when to use either flexible choledochoscopy (FCD) or intraoperative cholangiography (IOC) guidance., Methods: From January 2001 until November 2006, 113 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in a prospective non-randomized study to undergo laparoscopic cholecystectomy with LCBDE on an intention-to-treat basis. Twenty-three patients were aged 80 years or older with severe comorbidity. Preoperative ERCP with attempted stone clearance was performed in 24 patients. Laparoscopic common bile duct exploration was attempted for CBDS in the presence of acute cholecystitis in 24 patients. Laparoscopic common bile duct exploration was performed via the trans-cystic approach in 83 patients and via choledochotomy in 30 patients. Flexible choledochoscopy was used in 79 patients and IOC guidance in 34 patients., Results: No mortality occurred. Postoperative complications were encountered in nine patients. Laparoscopic stone clearance of the bile duct was successful in 91.8% of the patients. Median length of hospital stay (LOS) was two days (range, 0 to 24 days) after trans-cystic LCBDE and six days (range, 2 to 34 days) after stone clearance via choledochotomy (p < 0.0001). Choledochotomy was performed for CBDS measuring an average of 11.5 mm (range, 5 to 30 mm) in diameter while trans-cystic LCBDE was successful for stones measuring an average of 5 mm (range, 2 to 14 mm) (p < 0.0001). Mean duration of surgery was 75 minutes (range, 30 to 180 minutes) when FCD was used, and 107 minutes (range, 45 to 240 minutes) in patients undergoing LCBDE under IOC guidance (p < 0.0001)., Conclusion: Laparoscopic cholecystectomy and LCBDE with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. The use of flexible choledochoscopy is preferable to IOC guidance.

Background: Hemorrhage from portal and hepatic veins is a major concern with laparoscopic right hepatectomy (LRH). The standard hilar approach is dissection of the portal pedicle outside the liver parenchyma with separate transection of the right hepatic artery, portal vein, and bile duct. Variations in anatomy can hamper vascular and biliary control. The intrahepatic Glissonian access avoids these risks by en masse ligation of the portal structures without dissection for each separately. This technique was performed laparoscopically for the last 2 among 10 LRHs, and the results are presented., Methods: Total LRH was performed under ultrasound assistance for two patients with malignancy. After lymph node sampling at the hepatoduodenal ligament, dissection was started with the incision of liver parenchyma posterior and anterior to the hilum, then continued outside the portal pedicle bifurcation toward the right and left sheaths. An endoscopic vascular stapling device was placed to transect the right portal pedicle en masse under direct laparoscopic vision and cholangiography guidance. Parenchymal transection and vascular control of the right hepatic vein was accomplished with harmonic scalpel, cavitron ultrasonic aspirator, bipolar diathermy, clips, and endoscopic stapling device, as appropriate. No Pringle's maneuver was used. The specimen was extracted through a suprapubic incision using an endobag., Results: The operative times for the two patients were, respectively, 180 and 240 min. No blood loss occurred during the intrahepatic Glissonian dissection. Intraoperative blood loss (from the right hepatic vein) of 700 and 800 ml, respectively, was controlled laparoscopically. The postoperative periods were uneventful, with discharge, respectively, on days 6 and 7. The surgical resection margins were free of tumor., Conclusions: The laparoscopic intrahepatic Glissonian approach used for right hepatectomy is safe, simple, and reproducible. It facilitates the hepatic hilar dissection with minimal operative risk. Further implementation of this technique is encouraged to improve the outcome for patients undergoing laparoscopic liver resection.

Aims: Surgical radiofrequency ablation (RFA) of hepatic malignancies is associated with superior oncological outcome as compared to percutaneous RFA. The aim of this prospective non-randomized cohort study was to compare morbidity and mortality of laparoscopic (LRFA) vs. open (ORFA) radiofrequency ablation of liver cancer., Methods: Between October 1999 and November 2006, RFA was performed in 154 consecutive patients (percutaneous 12, LRFA 93, ORFA 49) for a total of 291 hepatic tumours (HCC 81, colorectal metastases 157, other 53). Seventy-four patients simultaneously underwent additional surgery. Laparoscopic RFA was performed in 45/54 patients with HCC, and in 44/54 patients with cirrhosis. Laparotomy was performed in 14/22 patients who underwent simultaneous colorectal resection, and in 12/22 patients with hepatic resection., Results: Postoperative complications occurred in 25 patients with subsequent mortality in 2. As compared with LRFA, ORFA was associated with significantly (p<0.01) higher intra-operative blood loss (median 20 (range 0-1700) vs. 10 (0-900) ml), longer duration of surgery (180 (25-440) vs. 75 (30-390) min), more postoperative complications (17 vs. 8), and longer postoperative hospital stay (8 (1-127) vs. 4 (1-51) d). According to the therapy-oriented severity grading system (TOSGS) classification, postoperative complications in the ORFA-group were more severe than those in the LRFA-group (p<0.01). These findings were consistent in patients without simultaneous colorectal and/or hepatic resection and in patients with liver tumours measuring 3cm or less. In univariate analysis the following factors were significantly (p<0.01) related to the presence of postoperative complications: simultaneous colorectal resection, laparotomy, duration of surgery, tumour location in right liver, liver segment 7 (p=0.01), absence of cirrhosis (p=0.02), liver segment 8 (p=0.03), and metastatic liver cancer (p=0.04)., Conclusion: LRFA for hepatic malignancies seems preferable above ORFA, provided good patient selection, surgical expertise, and long-term oncological control.

Background: The optimal treatment for patients with nonparasitic splenic cysts is controversial. This study aimed to evaluate the clinical outcome of patients treated for a symptomatic splenic cyst, and to define a surgical strategy., Methods: Spleen-preserving surgery (9 laparotomies and 6 laparoscopies) was performed for a primary cyst in six patients and a secondary cyst in nine patients. The median follow-up time was 37.5 months. Partial splenic resection was performed for eight patients and cyst decapsulation for seven patients., Results: Cyst recurrence was observed in four patients after decapsulation of a primary splenic cyst, as compared with none after resection. Postoperative complications were encountered only after laparotomy (5/9). The median hospital stay was 3.5 days (range, 2-5 days) after laparoscopy, as compared with 9 days (range, 5-14 days) after laparotomy., Conclusions: Symptomatic splenic cysts should be treated laparoscopically. For patients with recurrent or suspected primary splenic cysts, laparoscopic partial splenectomy is preferable. For other cases, a laparoscopic decapsulation is advocated.

Background: The use of radiofrequency (RF) energy has been described to perform open liver resection safely and with minimal blood loss. Yet no data are available on the potential contribution of RF energy to the limitation of intraoperative blood loss during laparoscopic liver resection (LLR). The aim of this prospective, nonrandomized study was to investigate the potential contribution of RF energy to the limitation of intraoperative blood loss in patients undergoing LLR., Methods: Forty-five patients [male/female ratio 22/23, age 57 years (26-80)] underwent LLR. Eleven benign and 47 malignant lesions (mostly colorectal metastases) were resected. Median number [1 (1-3)] and maximum diameter [40 mm (8-170)] of tumors as well as median tumor free margins [10 mm (1-30)] were comparable in patients undergoing LLR with (20 patients) or without (25 patients) RF-assistance. Thirty-eight minor (< or = 2 segments) and 9 major (> 3 segments) resections were performed. Eighteen patients simultaneously underwent additional surgery., Results: No mortality occurred. Median intraoperative blood loss was 200 (5-4000) ml and was similar in patients undergoing LLR with or without RF-assistance. The type of surgical procedure was a determinant for the amount of intraoperative blood loss (p = 0.0002). Significant bleeding occurred from large hepatic vessels at major resections. Median operation time was 115 (45-360) minutes. RF-assistance didn't seem to reduce perioperative morbidity., Conclusions: LLR can be performed with minimal intraoperative blood loss, which is determined by the type of hepatectomy. Significant intraoperative bleeding occurs from large hepatic vessels during major resections. RF-assisted parenchymal transection in LLR doesn't seem to reduce blood loss, operation time, or perioperative morbidity.

Radiofrequency ablation (RFA) is a safe and effective treatment in patients with unresectable liver malignancies. Since there is little information on its optimal approach, the feasibility, clinical outcome, and efficacy of laparoscopic RFA need further investigation. Twenty-three consecutive patients with unresectable hepatic malignancies were treated with RFA. RFA was performed percutaneously in 5 patients (5 tumors; median maximum diameter of 25 mm [range, 20-73]), via laparotomy in 9 (28 tumors; median maximum diameter of 38 mm [5-90]), and via laparoscopy in 9 (16 tumors; median maximum diameter of 35 mm [8-58]). Mortality and intraoperative complication rates were 0. In the laparoscopy and laparotomy groups, mean blood loss was 13 mL versus 421 mL and mean hospital stay was 5.7 versus 11.2 days, respectively (P = 0.0008 and P = 0.04). Postoperative complications occurred in one patient after laparoscopic RFA and in three after RFA via laparotomy. After a median follow-up of 12.2 months, local recurrence occurred in 2 patients (laparoscopic RFA, 1; percutaneous RFA, 1), and new hepatic tumors developed in 7 (laparoscopic RFA, 2/9; RFA via laparotomy, 5/9). Laparoscopic RFA is a safe and feasible treatment modality to achieve tumor destruction in selected patients with unresectable hepatic malignancies.

Objective: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting., Background: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors., Methods: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome., Results: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD., Conclusions: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Background: Considering the high recurrence rate after conventional inguinal hernia repair, the totally preperitoneal endoscopic inguinal hernia repair has been used., Methods: The present experience of the authors embraces 1085 patients with a total of 1717 inguinal hernias, including 200 recurrences. The operative technique is described with emphasis on pitfalls and tricks., Results: Analysis of the data concerning the first 403 patients with 1 year complete follow-up reveals a mean (SEM) operating time of 42 (1.2) min for unilateral and 58 (1.0) min for bilateral hernia repair. Mean (SEM) postoperative hospital stay was 2 (0.04) days. Complication rates during and after operation were 0.3% and 3.3% respectively. The morbidity rate at 1 month after operation was 3.5%. The recurrence rate was 0.3% at 1-year follow-up., Conclusion: Totally preperitoneal endoscopic inguinal hernia repair is safe and reproducible for any type of primary or recurrent inguinal hernia, even in patients with previous subumbilical surgery or severe systemic disease. Careful follow-up is mandatory to assess the late recurrence rate.

Background: Outpatient laparoscopic cholecystectomy (OLC) may decrease the use of hospital resources and save costs. In the current study, the effect of implementing a clinical pathway has been assessed in terms of outcome for patients scheduled to undergo laparoscopic cholecystectomy, hospital costs, and available bed capacity.Methods: Clinical outcome and hospital stay were analyzed for consecutive patients scheduled to undergo laparoscopic cholecystectomy 1 year before (n = 338) and after (n = 336) implementation of a clinical pathway. Patients with acute cholecystitis or bile duct lithiasis were excluded from the study. A cost accounting model was developed using the concept of the bill of activities.Results: Before implementation of the clinical pathway, 34 (94%) of 36 patients scheduled for OLC were discharged successfully on the day of surgery, as compared with 110 (94%) of 117 patients after pathway implementation. Among patients scheduled for OLC, the complication (0% vs 1.7%), unplanned admission (5.5% vs 6%), and readmission (0% vs 4.3%) rates were comparable before and after clinical pathway implementation. After pathway implementation, the increased number of OLCs resulted in a significant cost saving (40.5%) and benefit in bed capacity (1.41 beds per day per year) for the hospital.Conclusion: The implementation of a clinical pathway preserves the clinical outcome for patients undergoing OLC. It creates a significant increase in the number of patients treated in an outpatient setting and confers a significant benefit in terms of hospital costs and available bed capacity. [ABSTRACT FROM AUTHOR]