Abstract:

Therapeutic laparoscopy has developed rapidly since the first report of laparoscopic cholecystectomy in 1986. Several other reports followed before the end of that decade. Recent developments have resulted from a combination of the many technical improvements in laparoscopic equipment, together with the innovation and increasing experience of those performing laparoscopic surgery. Cholecystectomy, appendectomy, gastric fundoplication, and preperitoneal hernia repair are all now widely practiced and often laparoscopy is the favored approach.

Authors:

Gregory J. Fulton, F.R.C.S.I.; Thomas F. Gorey, F.R.C.S.I. - Mater Hospital, Dublin, Ireland

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Abstract:

Image guided surgery can be defined as the intraoperative use of a radiologicai technique to give the surgeon information not available from direct inspection or palpation of the surgical field. This information may then be used to change the course of an operative procedure. Magnetic resonance (MR) imaging has the potential to be the most useful radiologicai technique in the developing field of image guided surgery.

Authors:

Naomi Vaughan, F.R.C.S.; Stuart Gould, B.Sc., F.R.C.S.; Ara Darzi, M.D., F.R.C.S., F.R.C.S.I.; K. Birnie, M.Sc., D.C.R., C.T.C.; Wladyslaw Gedroyc, M.R.C.P., F.R.C.P. - St. Mary's Hospital, London, England, UK

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Abstract:

Totally extraperitoneal herniorrhaphy (TEP) is a highly technical procedure with a long learning curve for surgeons. It demands extra skills and may be frustrating, even to the experienced laparoscopic surgeon. The main eriticisms have been the higher costs, the need for general anesthesia, and the prolonged operating room time. When properly performed, TEP provides satisfaction to all involved, namely the patient, the surgeon and the third party payer. The initial concerns of safety, efficacy and efficiency are no longer valid issues as TEP has proved to be safe in numerous randomized trials. We find that there is increasing patient demand for this procedure.

Authors:

Peter Fan, M.D.; Hans J. Schmidt, M.D. - Hackensack University Medical Center, Hackensack/New Jersey Medical School, Newark, NJ

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Abstract:

Intraoperative ultrasonography (IOUS) of the intra- and extrabepatic biliary system is being used with increased frequency in many medical centers. The value of IOUS in facilitating surgery in patients with complicated diseases of the gallbladder or with stones in the bile ducts is well recognized. However, a variety of less common diseases affect the intrahepatic ducts, many of which require sophisticated surgical techniques when resection is being undertaken. In many situations, these operations can be facilitated by the use of IOUS, both for depicting segmental and ductal anatomy, and in guiding resections and anastomoses. This report summarizes the techniques currently used for performing IOUS of the biliary system, and illustrates the spectrum of clinical applications that may require IOUS guidance.

Authors:

Jonathan B. Kruskal, M.D., Ph.D.; Simon P. Blake, F.R.C.P.; Robert A. Kane, M.D. - Harvard Medical School, Boston, MA

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Abstract:

Laparoscopic hepatic cryotherapy, using intraoperative ultrasound monitoring, was introduced in the 1980s by Onik who combined the freezing process with intraoperative ultrasound for monitoring the extent of freezing. The results of open cryotherapy of the liver have been reported for more than 900 patients, the majority having received cryotherapy for liver metastases from colorectal carcinoma and primary hepatocellular carcinoma. While data on the long-term outcome of patients treated with cryotherapy are limited, some authors have documented survival comparable to that for hepatic resecrion. This is remarkable, considering these patients are often deemed unresectable and most do not even survive 1 year.

Authors:

Gregg H. Jossart, M.D.; Kazuhiko Shibuya, M.D.; Michel Gagner, M.D. - Mount Sinai Medical Center, New York, NY

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Abstract:

The minimally invasive direct access surgical technology (MIDAST) has grown out of previous experience applied in otolaryngology and endoscopic microsurgery. From the time of Ambroise Pare and for centuries surgeons have made large incisions to gain adequate access for manipulation with large, straight, bulky instruments and achieved adequate illumination by the sun and later by artificial lighting.

Authors:

Geza J. Jako, M.D., Boston University School of Medicine, Boston, M.A.; Ronald A. von Jako, M.D. Atlantis Surgical Inc., Greenwich, CT

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Abstract:

The advent of volumetric helical computed tomography (CT), coupled with the almost universal use of oral and intravenous contrast agents, has resulted in CT becoming the diagnostic and therapeutic cornerstone for alimentary tract disease. Recent technical advances, further enhanced by innovative software developments, now permit multiplanar and endoluminal projections of the entire abdomen, and have resulted in the development of novel diagnostic applications in the abdomen.

Authors:

Martina Morrin, M.D.; Jonathan B. Kruskal, M.D., Ph.D.; Karen Weisinger, M.D.; Kevin Reynolds, R.T.R.; Vassilios Raptopoulos, M.D. - Harvard Medical School, Boston, MA

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Abstract:

The impact of adequate nutrition on wound healing, immunity and patient morbidity has been ap preciated since the early work of Stanley Dudrik in the late 60s and early 70s. Although total parenteral nutrition improved the outcome in nutritionally debilitated patients, it often led to overwhelming infections in these immunologically sensitive patients. In the 90s, the importance of gut as an endocrine and immune organ has been well established, as weU as the superiority of enteral feeding over parenteral nutrition, in most cases. Here we discuss the available techniques for accessing the gastrointestinal tract as well as the guidelines for selection of patients.

Authors:

Heena Rajdeo, M.D., F.A.C.S.; Atiq Rehman, M.D.; Kalyani Bhuta, M.D., F.A.C.S. - New York Medical College, Valhalla, NY

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Abstract:

The process of unraveling small bowel pathology by endoscopic means may be the last frontier for gastroenterologists. When the source of blood loss remains obscure after upper and lower gastrointestinal endoscopy, small intestinal pathology becomes a considerarion. Traditionally, the 3 m of small bowel have been examined with contrast and nuclear radiology with discouraging results. Barium, smallbowel follow through x-rays have low yield. Enteroclysis is a radiographic technique using contrast and careful examination with a 10 to 25% diagnostic yield in obscure gastrointestinal bleeding. Nuclear bleeding scans and angiography have reported varying degrees of success.

Authors:

Jack A. DiPalma, M.D. - University of South Alabama College of Medicine, Mobile, AL

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Abstract:

Repair of incisional herniae by direct approximation of the edges is associated with high incidence of recurrence. Tension free repair with prosthetic material was an advance in decreasing the incidence of recurrence. Repair with prosthetic material, to be successful, re qui res extensive dissection and its associated complications. Advances in laparoscopy along with the improvements in prosthetic materials has opened up opportunity for further decreasing the incidence of recurrence with minimal dissection.

Authors:

Venkatachala I. Sreenivas, M.D., F.R.C.S. - Yale University School of Medicine; Vishwanadham Pothula, M.D. - Yale New Haven Hospital; Aziz Benbrahim, M.D. - Hospital St. Raphael; Raghu Savalgi, M.D., Ph.D.(Surg), F.R.C.S. - Yale University School of Medicine, New Haven, CT

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