Laparoscopic Gastrointestinal Surgery:
Current State of the Art
IRVIN M. MODLIN MD PhD, DENNIS G. BEGOS MD,
GARTH H. BALLANTYNE MD
GARTH H. BALLANTYNE, M.D.
BOARD CERTIFIED IN:
GENERAL SURGERY & COLON AND RECTAL SURGERY
OFFICE: 50 EAST 69th STREET, NEW YORK, NEW YORK 10021
DIRECTOR, CENTER FOR ADVANCED LAPAROSCOPIC SURGERY
CHIEF, DIVISION OF LAPAROSCOPIC SURGERY
ST. LUKE'S - ROOSEVELT HOSPITAL CENTER
NEW YORK, NEW YORK
PRACTICE LIMITED TO LAPAROSCOPIC SURGERY
CONTACT US AT:
1-800-LAP-SURG or firstname.lastname@example.org
Elective surgery for the gastrointestinal tract was initiated by intrepid
individuals whose talents reflected courage, manual dexterity, and digital
celerity. The advent of general anesthesia, muscle relaxants, and antibiotics
facilitated the introduction of more complex procedures and allowed a
safe outcome for the patient. In almost a century of gastrointestinal
surgery, few advances can compare to the revolution engendered by the
advent of minimally invasive surgery. The interface of creative surgeons
and the science of biotechnology has given rise to a novel consideration
of hoary techniques and dogma. With the introduction of laparoscopic surgery
has come the recognition of both advantages and difficulties. The benefits
conferred on patients by less invasive procedures, decreased pain, and
shorter recovery have to be weighed against overenthusiasm of application
and the problems created by a lack of familiarity with new techniques
and instruments. Nevertheless, the introduction of novel technology in
a field almost synonymous with tradition has provided a unique opportunity
to reevaluate current therapeutic strategies and options.
The introduction and acceptance of laparoscopic surgery for gastrointestinal
disease will undergo a number of phases. In the first, the introduction
and application of new technology to perform old procedures will be evaluated.
The learning curve of surgeons and the selection of patients are the primary
considerations in this phase. Thereafter, consideration will be given
to the application of alternative technologies not previously considered
in surgery but thought of more as part of the industrial and technological
complex. In this context, robotic surgical components, self-propelling
devices, memory metals, and implanted miniature visual instruments are
examples. The final phase will be the evolution of a generation of surgeons
capable of developing therapeutic strategies radically different from
those implemented by the first wave of laparoscopic surgeons, who used
relatively simple and crude instrumentation. In the last phase, the ultimate
goal will be the interface of the problem-solving powers of a medical
mind with the manometer precision of a robotic instrument. Thus, there
already are prototype operating devices with which long-range telemetric
control of surgical robotic instrumentation is possible. Although this
may seem exotic, technology of this sort has already been tested, patented,
and employed in the aerospace and military programs. The resources and
technology currently used to explore outer spacemight be better utilized
resolving the problems of inner space as exemplified by the peritoneal
This chapter provides an overview of the current status of laparoscopic
surgery as it is applied to the management of conditions of the gastrointestinal
tract that are considered to require surgical intervention. In brief,
it documents the techniques and balances the applications against potential
advantages and disadvantages. In essence, this overview proposes to shine
a light on a surgical technique which has languished too long in the dark.
Attempts at minimally invasive therapy for afflictions of the gastrointestinal
tract date back to the time of Hippocrates, who described noninvasive
remedies for conditions such as intestinal obstruction, rectal prolapse,
and hemorrhoids 1. Hippocrates also detailed the use Of d speculum, or
primitive anoscope, for examining hemorrhoids. Early endoscopists were
hampered by the lack of a satisfactory light source. Thus, until the nineteenth
century, physicians relied on sunlight reflected by mirrors or focused
through flasks of water 2. In the early 1800s, physicians began using
candles or paraffin lamps for illumination; however, the idea of "a
magic lantern into the human body" was for the most part scorned
and ridiculed 3.
The first experimental laparoscopy was performed in Berlin in 1901 by
the German surgeon Georg Kelling, who used a cystoscope to peer into the
abdomen of a dog after first insuffiating it with air 4. Kelling was an
early advocate of the ability of minimally invasive surgery to avoid unnecessary
laparotomy and decrease hospital stays. The first human laparoscopy was
performed in Sweden by jacobeus in 1910 to investigate ascites. Diagnostic
laparoscopy enjoyed some popularity in the early twentieth century, but
early laparoscopists were limited by a lack of technology 5 (Fig. 1).
The first laparoscopes had a light source at the distal end, and pneumoperitoneum
was achieved by means of air insulation through the scope. Initially,
intraabdominal thermal injury, along with bowel and vascular injuries,
posed the most significant problems. In 1929, Kalk advocated a second
puncture site for the establishment of pneumoperitoneum, described several
diagnostic and therapeutic laparoscopic procedures, and devised a sophisticated
lens system. He has been called by some the "father of modern laparoscopic
surgery" 2. Fiberoptic technology and closed-circuit videolaparoscopy
evolved in the 1950s. This development enabled surgeons to deliver more
intense light with less heat, and allowed the participation of an assistant
in the procedure. As a result, more sophisticated procedures could be
undertaken, and the modality was embraced primarily by gynecologic surgeons.
Kurt Semm in particular became a powerful advocate of laparoscopy and
was responsible for the development of numerous laparoscopic instruments,
including an automatic air insufflation device, an electrocoagulator,
and an aspiration/irrigation system .5 In addition, he described techniques
for laparoscopic tubal thermocoagulation, oophorectomy, and adhesolysis
and is credited with performing the first laparoscopic appendectomy in
While the majority of general surgeons remained skeptical of laparoscopy,
a few groups recognized its potential. Initially, however, only diagnostic
procedures were considered .7 8 By 1982, the first laparoscopic liver
biopsy had been reported.' Meanwhile, surgeons in Chicago and Dundee were
developing the technique of laparoscopic cholecystectomy in animal models
10. The first human laparoscopic cholecystectomy was performed by Mouret
in France in 1987,11 and groups in the United States 12 13 and the United
Kingdom 14 followed in 1988 and 1989, respectively. Soon afterward, the
lay press applauded the "new" surgery, and popularity in the
public domain culminated in patients demanding this Band-Aid
surgery instead of traditional techniques.
Thus began the modern laparoscopic era. As this document attests, it
has in a short time earned a unique niche in general and gastrointestinal
surgery. Virtually no abdominal organ is exempt from laparoscopic techniques.
The application of more sophisticated technology will no doubt yield more
refinements and applications.
SURGICAL TECHNIQUE OF LAPAROSCOPY
The operative technique involves a number of stages. The establishment
of pneumoperitoneum is the first step. Afterward, insertion of trocars
for the introduction of the camera and surgical instruments is undertaken.
A Veress needle (spring-loaded with a blunt tip) (Fig. 2) is inserted
through a small paraumbilical incision to initiate the pneumoperitoneum.
The patient is placed in Trendelenburg's position to displace the small
bowel from the pelvis. The Veress needle is inserted pointing inferiorly,
and insufflation Of C02 is begun until an intraperitoneal pressure of
12 to 18 mmHg is attained. The needle is then removed and replaced with
a 10-mm trocar (Fig. 3) through which the videolaparoscope is inserted.
The peritoneal cavity is inspected to identify any injury caused by the
initial insertions. Then the remaining trocars are placed under direct
laparoscopic observation, minimizing the possibility of visceral injury.
The different instruments needed to undertake the procedure may then be
inserted through the trocars. The sites, sizes, and number of trocars
placed may vary with the procedure.
Operative indications for laparoscopic surgical procedures are the same
as those for their open counterparts. The goal of laparoscopic surgery
is to perform procedures in a manner not significantly different from
standard techniques but without opening the peritoneal cavity. The minimally
invasive technique allows less morbidity, shorter hospitalization, and
improved cosmetic results. While the only absolute contraindication is
an inability to tolerate general anesthesia, patient and technique selection
should be guided by the experience of the surgeon with a particular procedure.
Thus, a surgeon should choose patients on the basis of the likelihood
of being able to undertake the laparoscopic procedure successfully (Table
1). Patients who require conversion from laparoscopic to open procedures
have "the worst of both worlds," i.e., increased operating room
time and the costs associated with laparoscopic techniques without the
benefits. Nonetheless, it is appropriate to convert to open surgery if
undue difficulty is experienced by the operator. While it is impossible
to predict with certainty which patients will require conversion, guidelines
exist. Obese patients and those with prior abdominal operations generally
prove more difficult. In cases which require pelvic dissection, previous
gynecologic procedures may obscure dissection planes or be associated
with dense adhesions. Adhesions to a right upper quadrant incision may
make mobilization of the right side of the colon particularly difficult.
However, patients with prior appendectomies may have adhesions which actually
improve exposure of the cecum by providing anterior traction. While these
situations make dissection, either laparoscopic or open, more tedious,
with experience, surgeons have gained skill in lysing adhesions and identifying
tissue planes through the laparoscope. Other relative contraindications
include severe portal hypertension, coagulopathy, and diffuse carcinomatosis
of the abdomen (Table 1).
Table 1 Patient Selection
Same as for open procedure
Low likelihood of conversion
innability to anesthetize
Training of surgeon
Fitness for pneumoperitoneum
Patients should be evaluated medically as they would be for any open
procedure, with particular attention paid to their cardiac and pulmonary
status. Any laparoscopic procedure may need to be converted to an open
one, and so patients deemed unfit for laparotomy should not undergo an
elective laparoscopic procedure.
A difficult decision is engendered by pregnancy. Several considerations
are essential in this circumstance, including initial trocar placement
to avoid injuring the gravid uterus, the physiologic effects Of C02 pneumoperitoneum
on the fetus, and an alteration in technique resulting from the presence
of an enlarged uterus." While the scope of this chapter precludes
a detailed discussion of these issues, they will be briefly considered.
The most common indications for laparoscopic surgery during pregnancy
are appendicitis, cholelithiasis, and ectopic pregnancy. During the first
trimester of pregnancy, the uterus remains in the pelvis. Thus, Veress
needle insertion through the umbilicus is generally safe. After-, ward,
the enlarged uterus usually precludes adequate visualization of the gallbladder
or appendix, and these procedures may have to be performed by open surgery.
Close attention to the acid-base status and hemodynamic parameters of
the mother is essential. The patient should be rolled approximately 30
degrees to the left to avoid inferior vena cava compression, and low intraperitoneal
insufflation pressures should be used. The fetal heart rate should be
monitored during anesthesia induction and periodically during the procedure.
Pathophysiology of Pneumoperitoneum
Before the introduction of laparoscopic cholecystectomy, laparoscopy
was used predominately for short procedures in relatively young, healthy
patients. In the laparoscopic gynecologic procedures performed 20 to 30
years ago, intraabdominal pressures (IAPS) as high as 40 mmHg were used.
Initial physiologic studies focused on such patients and found no significant
pulmonary or cardiovascular compromise. 16,17 While many of these data
are valuable and applicable to general surgical patients, individuals
with significant cardiovascular or pulmonary disease present unique and
The physiologic changes associated with pneumoperitoneum depend on the
IAP, the amount Of C02 absorbed, the circulatory volume of the patient,
the ventilatory technique used, the underlying pathologic conditions,
and the type of anesthesia used.18
Carbon dioxide pneumoperitoneum has two main effects on pulmonary function:
the mechanical changes associated with increased IAP and the biochemical
alterations resulting from absorbed C02 (Table 2). Thus, the elevated
IAP creates a ventilation-perfusion mismatch that is manifested by an
in-creased shunt and physiologic dead space. The increase in dead space
is due to atelectasis and decreased functional residual capacity and may
be minimized by maintaining low insufflation pressures or using positive
end expiratory pressure (PEEP) ventilation. These changes are more pronounced
in patients with cardiac or pulmonary disease. 19 Careful monitoring of
arterial blood gases is necessary in high-risk patients to prevent acidosis.
Hypercarbia and associated acidosis may be controlled by increasing minute
Table 2 Physiology of Pneumoperitoneum
* Ventilation-perftision mismatch
Increased physiologic dead space Atelectasis
Decreased functional residual capacity
* Need for increased minute ventilation
* Increased airway pressure
* Cardiac output
Varies with intraabdominal pressure:
<20 mmHg, no change to increased
>20 mmHg, decreased
* Increased central venous pressure
* Increased lower extremity venous pressure
Changes in hemodynamics resulting from increased IAP are variable and
unpredictable. A consistent finding in all human studies is an increase
in central venous pressure and arterial pressure in patients during 15-
to 20-mmHg pneumo-peritoneum. The critical pressure is approximately 25
mmHg."," At this point, patients manifest increased central
venous pressure (CVP), peripheral venous pressure, and airway pressure
and experience tachycardia and hypertension (Table 2).
The head-down position and acidosis tend to increase cardiac output.
Acidosis can also lead to vasoconstriction and an increase in total peripheral
resistance. 11,21 Venous return from the legs is hindered by the increased
IAP, decreasing cardiac output and predisposing the patient to deep venous
thrombosis. Thus, pneumatic compression boots are used during most laparoscopic
The complications of laparoscopic surgery can be divided into two categories:
those which are specific to the procedure itself or result from anesthesia
and are common to all operations and those which are unique to laparoscopy,
such as injury from trocar insertion (Table 3). It is a matter of debate
whether laparoscopic procedures are inherently more risky than their open
counterparts. Several factors must be considered in attempting to answer
this question. First, a laparoscopic surgeon has only a two-dimensional
view, with a restricted field of vision. Second, tactile feedback is limited,
and thus visual cues become more critical in identifying anatomy. Additionally,
the increasing reliance of the surgeon on technology adds an intangible
layer of separation between the doctor and patient. Although these limitations
are real, the learning curve appears to be steep, with rapid acquisition
of skill. While the field of vision may be restricted, objects are magnified,
and resolution is of exceptional quality with current digital cameras.
Areas which are difficult to inspect in an open procedure are now usually
extremely well visualized. Technological alternatives such as 30-degree
and 45-degree laparoscopes or flexible devices have further amplified
visibility. Newer modalities such as laparoscopic ultrasound have helped
replace the sense of touch, enabling visualization of liver metastases,
blood vessels, and bile duct stones. Finally, it seems that surgeons are
able to adapt to these limitations. Thus, after a relatively brief period
of adaptation, complication rates (e.g., for cholecystecomy) are not significantly
different when undertaken by the open or the closed technique22. With
more complex procedures, the equilibra tion of skills may take longer
Table 3 Complications
Needle and Trocar Insertion
Complications from Needle and Trocar Insertion
Veress needle insertion and trocar insertion may cause injury to the
intestines, stomach, bladder, or major vascular structures (Fig. 4). The
rate is higher for insertion of the needle and primary trocar, as this
is done blindly. The overall incidence of visceral injury in several large
series ranges from 0.05 to 0.2 percent 23.
Vascular Injury. The most life-threatening laparoscopic complications
are those to the large retroperitoneal blood vessels. A survey of 77,604
laparoscopic cholecystectomies identified 36 (0.05 percent) injuries to
the aorta, inferior vena cava, or iliac vessels.24 The mortality in these
patients was 8.8 percent. In a collected series of 16 major vascular injuries,mortality
was 13 percent 25.
To avoid serious complications from these injuries, early recognition
and prompt treatment are critical. Thus, the Veress needle should be aspirated
after insertion to identify bright red (arterial) blood. In this circumstance,
the needle should be left in place and immediate laparotomy should be
undertaken 26. Some authors have advocated proceeding with laparoscopy
if aspiration reveals blood 23 and exploring the patient only if there
is evidence of hemodynamic instability. However, given the high mortality
associated with this complication and the risk of gas embolism if insufflation
is attempted, this seems to be an unwise management strategy.
Gastrointestinal Injury. Clinically significant stomach or intestinal
injury from needle or trocar insertion has been reported in approximately
0.01 to 0.4 percent of patients. 23,26 A larger number of these injuries
may, however, go unrecognized because of the ability of the stomach and
intestines to heal small injuries. Undetected bowel injury is a major
contributor to postoperative mortality. Such patients present with sepsis
or peritonitis. Intraabdominal abscess or fistulas may occur at a later
date. In a survey of over 75,000 laparoscopic cholecystectomies, 4.6 percent
of patients with gastrointestinal injuries died 24.
A significant proportion of bowel injuries may result from initially
unrecognized thermal burns from electrocautery devices. However, when
an injury presents late, it is often difficult to determine the exact
cause. Management of an intestinal injury depends on the etiology and
severity. Thermal injuries from laser or electrocautery devices are generally
more severe than they appear, and surrounding areas of intestine may necrose
after several days as a result of intramural spread of energy at the time
of the injury. For this reason, resection of the involved area should
be undertaken 26. Mechanical injury from a needle, trocar, or other instrument
can be managed by simple observation, primary repair, or resection. Repair
or resection can be performed either laparoscopically or by laparotomy,
depending on the level of experience of the surgeon.
Genitourinary Injury. There are few data on the incidence and
etiology of genitourinary injury during laparoscopy. Bladder injuries
generally occur during trocar insertion, and an indwelling bladder catheter
helps minimize this complication. Management of bladder injury is similar
to that of bowel injury. Veress needle punctures may be managed conservatively
with bladder decompression. Larger injuries induced by trocars or dissection
should be primarily repaired.
Ureteral injury is usually a consequence of a thermal burn, ligation,
or laceration caused by inadequate exposure or poor dissection. This injury
can be avoided by preoperative placement of ureteral stents, which facilitate
identification of the ureters. All ureteral injuries should be explored
promptly at open surgery 26.
Complications from Pneumoperitoneum
Cardiovascular Changes. Absorbed carbon dioxide leads to hypercarbia
and acidosis. This may cause myocardial irritability, as manifested by
an increased rate of cardiac dysrhythmias, most notably ventricular ectopy."
These effects are not seen with nitrous oxide pneumoperitoneum, but as
a result of its ability to support combustion, this is used mainly for
diagnostic procedures. The mechanical effects of increased IAP cause variable
changes in the cardiac output (see "Pathophysiology of Pneumoperitoneum").
Extraperitoneal Insufflation. This commonly occurs because of
improper positioning of the Veress needle, resulting in preperitoneal
insufflation and subcutaneous emphysema. Subcutaneous emphysema rarely
results in serious sequelae. Intraabdominal structures such as the omentum
and mesentery may also be inadvertently insufflated, increasing their
chance of being injured and obscuring visualization.
Pneumothorax. This may occur during upper abdominal procedures
when injury occurs to the diaphragm,,resulting in a sudden collapse of
the lung on the affected side. Occasionally, however, pneumothorax may
develop without diaphragmatic injury, possibly as a result of retroperitoneal
dissection of C02 . This may have a more subtle onset manifested by increased
ventilatory pressures and arterial desaturation. Treatment in either instance
is by insertion of a thoracostomy tube.
Gas Embolism. Reports of gas embolism are unusual and have ranged
from 0.002 to 0.0016 percent. The etiology is presumably venous injury
combined with high insufflation pressures. 26 Signs of gas embolus include
circulatory collapse, an abrupt increase in end-tidal C02, a so-called
mill-wheel cardiac murmur, and flash pulmonary edema. Cardiac arrhythmias
may occur, and electrocardiographic alterationsincluding a widened QRS
complex may be evident 27. Treat ment consists of placing the patient
in Trendelenburg's position with the left side down (the Durant position)
to prevent the gas from entering the pulmonary outflow tract, aspiration
of the gas with a central venous catheter, and external cardiac massage
to fragment large bubbles 20, 26.
Hernia. This has been reported to occur in 0.1 to 0.3 percent
of patients 23. The larger the diameter of the cannula used, the more
likely the possibility of herniation. Wound infection is a predisposing
factor. It is generally recommended that fascial defects from cannulas
10 mm or larger be sutured.
Wound Infection. This is an unusual occurrence and depends on
the operation performed. Procedures such as diagnostic laparoscopy have
extremely low rates of approximately 0.1 percent 23. Wound infection rates
after laparo scopic cholecystectomy may be as high as 1 percent, generally
at the site of gallbladder removal 22, 23. This is comparable with the
rate seen with open procedures. The use of a bag or another device to
remove the specimen may decrease the incidence of infection 28-31. This
difference has been most notable in appendectomies in which bag retrieval
is used, with several series reporting zero incidence of wound infection.
Other prospective studies have confirmed a lower infection rate in laparoscopic
appendectomy versus the open procedures 29. 32.
Tumor Recurrence. Abdominal wall recurrence after resection of
colorectal and gallbladder cancers or diagnostic evaluation of ovarian
and gastric cancers has been noted. 33-43 Current reports reflect a seemingly
higher frequency of this situation, although this may not be the case,
given the increased number of laparoscopic procedures performed. Nevertheless,
it is an area of considerable concern for surgeons who are contemplating
the laparoscopic resection of malignant neoplasms. To some extent these
recurrences appear to be analogous to wound infections and occur at the
site where the specimen is removed.
Extreme care must be exercised in removing malignancies through laparoscopic
incisions, with a low threshold for enlarging incisions or retrieval of
specimens in a protective bag.
Laparoscopy was utilized as a diagnostic modality for many years. Its
potential in the establishment of a definitive diagnosis is well recognized.
The use of diagnostic laparoscopy became less popular with the advent
of improved radiologic modalities such as computed tomography and ultrasound,"
but the limitations of these diagnostic tests are well recognized, and
diagnostic laparoscopy has thus undergone a renaissance (Fig. 5). This
reflects the increased use of other laparoscopic procedures and the advent
of improved technology which has facilitated the acquisition of information.
The development of laparoscopic ultrasound (Fig. 6) has added a new modality
in the evaluation of solid organs, and current research in radioimmune-guided
surgery (RIGS) may prove valuable in detecting microscopic foci of malignancy
that are not evident with current imaging devices.
The goals in staging laparotomy for cancer are to safely establish a
definitive tissue diagnosis and to assess resectability, with the objective
of avoiding unnecessary surgery (Fig. 7).
Several groups have reported that stage IV Hodgkin's disease can be diagnosed
without laparotomy 45, 46. Using local anesthesia, percutaneous liver
and occasionally splenic biopsies were undertaken with laparoscopic guidance.
While the staging of Hodgkin's disease is now generally accomplished without
the need for laparoscopy or laparotomy because of improved imaging modalities,
this represented an important initial step in the development of diagnostic
Survival from esophageal cancer often reflects its stage at diagnosis,
with curative surgery possible in only a minority of patients. Assessment
of resectability may be difficult with conventional radiologic and endoscopic
techniques, although endoscopic ultrasound has shown promise. 17 Laparoscopy
is superior to computed tomography and ultrasound in detecting abdominal
tumor spread, especially small (<l cm) he48,49 patic, peritoneal, and
omental metastases. Patients with unresectable disease are thus spared
the morbidity and longer hospital stay of laparotomy, which are not insignificant
in such debilitated individuals. With increased emphasis on multimodality
therapy (preoperative chemoradiation), accurate pretreatment staging is
possible with combined laparoscopy and thoracoscopy.'o
Gastric cancer has a relatively low resectability rate, which may not
be definitively ascertained by radiologic or endoscopic techniques. A
difference between gastric and esophageal cancer, however, lies in the
greater need for palliative surgery to obviate bleeding or obstruction
in gastric cancer. Although laparoscopic gastrojejunostomy and gastric
resection are feasible, few surgeons have been trained in these techniques.
For this reason, diagnostic laparoscopy for gastric cancer should be limited
to asymptomatic lesions and to definitively establishing staging in patients
who are at high risk for palliative surgery.
In a stud Y52 of 40 patients considered to have resectable gastric tumors
after evaluation with ultrasound and computed tomography, laparoscopy
identified unresectable disease in 40 percent (5 with metastases and 11
with advanced local disease). In the remainder who underwent laparotomy,
the resectability rate was 87 percent.
Pancreatic cancer ranks second as a cause of death from gastrointestinal
malignancies. Detection at an early stage is difficult, with 60 percent
of individuals exhibiting distant metastases and 14 percent showing local
or regional lymph nodeinvolvement at presentation 53. While the majority
of these patients have unresectable disease, there is a small subset of
patients with favorable characteristics, i.e., tumors less than 2 cm and
no lymph node metastases. 54
Laparoscopy has been utilized in conjunction with computed tomography
and angiography to study 55 consecutive 55 patients with carcinoma of
the head of the pancreas. Laparoscopy was useful in identifying small
peritoneal metastases. If all studies were negative, the resectability
rate was reported as 78 percent. Whether this will confer any benefit
in terms of the long-term outcome remains to be proved. The addition of
laparoscopic ultrasound may further amplify delineation of pancreatic
lesions 56. With improved endoscopic stenting devices as well as laparoscopic
techniques for biliary bypass 57, even patients with symptomatic lesions
may benefit from laparoscopic evaluation.
While percutaneous biopsy of a liver mass is now generally performed
under CT or ultrasound guidance, laparoscopy may detect additional smaller
lesions. For lesions that are identifiable with these imaging modalities
and that can be percutaneously biopsied, laparoscopy holds little advantage
58. In patients with uncorrectable coagulation abnormali ties and a critical
need for tissue diagnosis, biopsy under direct laparoscopic vision provides
an opportunity to contr bleeding at the biopsy site. In diseases such
as hepatic cirrh sis, chronic hepatitis, and fatty infiltration, direct
visualiz tion is extremely useful in assessing the pattern and severi
of disease 59. A review of blind percutaneous biopsy vers laparoscopically
directed biopsy for the diagnosis of cirrhos in over 6000 patients revealed
a false-negative rate of 24 pe cent for blind biopsy, compared with only
9 percent for laproscopy 60.
A novel technique for assessing fibrosis in chronic hepat tis is observation
of the lobular pattern of the liver surfac after intravenous injection
of indocyanine green 61. With thi technique, the presence or absence of
bridging fibrosis was assessed with a sensitivity of 89 percent and a
specificity 80 percent 61.
Definitive diagnosis of enterhopathies such as celiac sprue Crohn's disease,
and general malabsorptive or diarrheal dis orders is often possible only
with a small bowel biopsy While duodenal or occasionally jejunal biopsy
is possibl endoscopically, the diagnosis may require a more specifi site.
Laparoscopy offers the potential for full-thickness, spe cifically directed
biopsy." It also affords the option of visual ization of the serosal
surface of the bowel, which may aid i confirming diagnoses, especially
in cases of suspecte Crohn's disease.
Appendicitis. The diagnosis of appendicitis in wome of childbearing
age is a problem which continues to plague physicians. There is no reliable
noninvasive test that conclusively rules it out, and negative appendectomy
rates of 5 to 15 percent are currently considered acceptable (Fig. 8).
It is this group of patients in whom diagnostic laparoscopy may have substantial
benefit. In 1980, Leape and Ramenofsk y8 successfully reduced the negative
appendectomy rate from 10 percent to 1 percent by employing selective
laparoscopy in patients with an equivocal diagnosis. Although similar
results have been reported," not all series reflect this level of
success. 64 The main problem is often difficulty in adequately visualizing
the appendix, particularly if it lies in the retrocecal position.
Ciltically Ill Patients. The evaluation of an acute abdomen in
individuals in intensive care units is often challenging. In many instances,
the mental status of the patient obviates an accurate diagnosis, and other
confounding variables may cloud the situation. It is possible to perform
diagnostic laparoscopy at the bedside with local anesthesia and sedation.
In a study of 25 intensive care unit patients with a suspected abdominal
pathologic condition, the accuracy of laparoscopy was 96 percent in determining
the need for laparotomy.
Other. Certain groups of patients, such as those on corticosteroid
therapy, diabetic patients, and patients with neurologic deficits, pose
difficult diagnostic problems. Moreover, comorbid diseases may make a
negative laparotomy a risky procedure, while the delay in diagnosing an
abdominal pathologic condition such as ischemic bowel or covert perforation
is often fatal.
While no organized studies are available to support its use, it seems
probable that diagnostic laparoscopy would maximize diagnostic accuracy
while reducing the need for unnecessary laparotomy or potentially harmful
Evaluation of Trauma
Diagnostic laparoscopy is useful in the evaluation of both blunt and
penetrating abdominal trauma. Peritoneal lavage is a widely used and generally
accurate technique for assessing the need for laparotomy. It is sensitive,
rarely missing a significant intraabdominal injury," but may lead
to laparotomy for relatively minor injuries which could be managed expectantly.
A prospectively randomized study evaluated peritoneal lavage versus laparoscopy
performed with local anesthesia and intravenous sedation after blunt trauma.rr'
The negative laparotomy rate was lower in the laparoscopy group (8 percent
versus 2 7 percent for peritoneal lavage). The difference did not, however,
attain statistical significance. The retroperitoneum is an area in which
both laparoscopy and lavage provide only limited information. Diagnostic
laparoscopy may be of some use in evaluating tangential gunshot wounds"
and stab wounds. If the peritoneum is not violated by the bullet or knife,
early discharge of the patient is possible and laparotomy can be avoided.
The success of cholecystectomy initiated the laparoscopic surgical revolution
of the late 1980s (Figs. 10 and 11). It continues to rank among the most
commonly performed laparoscopic procedures in North America." While
the scope of this article precludes a detailed consideration of all the
data relevant to this procedure, several important aspects will be discussed.
Incidence. Laparoscopic cholecystectomy has gained popularity
among both surgeons and the lay public. This is reflected in reports that
the cholecystectomy rate has increased because of alterations in the public
perception and evidence of decreased morbidity.69-" Thus, surgeons
may be more likely to recommend this procedure to individuals with marginal
symptoms, and patients are more likely to accept a less invasive procedure
widely popularized by the media than to live with these symptoms.
Complications. Because of this increased prevalence and public
demand for the procedure, it is unlikely that a large randomized trial
will be undertaken. This has led to concern that rates of complications,
most notably common bile duct injuries, may be higher than they are with
open procedures. Two modestly sized prospectively randomized studies have
been reported, with 70 (72) and 74 (73) patients, respectively. The overall
complication rate between open and laparoscopic surgery was not significantly
Several retrospective analyses of over 1000 patients undergoing laparoscopic
cholecystectomy have been reported 22, 24, 69, 74, 75. The overall rates
of common bile duct injury ranged from 0.25 to 0.6 percent. There is evidence
of a relatively steep learning curve. Thus, the possibility of bile duct
injury decreases significantly after a surgeon has performed 13 operations
(22) or when procedures are undertaken at institutions where more than
100 laparoscopic procedures have been performed 24. At present, these
figures are slightly higher than those reported for open cholecystectomy
(O to 0.4 percent) 23. It is probable that improved training and increase
awareness of the critical areas of the operation will result in a further
decrease of this complication.
Mortality after laparoscopic cholecystectomy ranges from 0 to 0.1 percent
in large series 22,24,69,74,75. The deaths were largely attributable either
to comorbid diseases or to the complications of iatrogenic injuries sustained
during surgery. These figures are somewhat lower than those reported after
open cholecystectomy (O to 0.5 percent)23 and may reflect patient selection.
Conversion to open cholecystectomy is not regarded as a complication
of laparoscopic cholecystectomy but instead reflects the exercise of appropriate
judgment in successfully and safely accomplishing the procedure. Reported
conve sion rates range from 3.6 to 6.9 percent. 22,24,69,74,75 The indic
tions include unclear anatomy, bleeding, and common bil duct injury and
are more common in the elderly, in thos with acute cholecystitis, and
in patients with gallstone pan creatitis.'g As experience with laparoscopy
and patient selec tion grows, conversion rates below 2 percent can be
Recovery. Two prospectively randomized studie showed a statistically
significant improvement (decrease) i hospital stay, return to full activity,
and requirement (de crease) for opiate analgesia 72,73. The average hospital
stay ranged from 1.2 to 3 (22,72,73,75) days, lower than the typical 4
to 7 days after open cholecystectomy.
While data regarding postoperative length of stay an overall convalescence
are important, one has only to observ patients after traditional and laparoscopic
cholecystectomy t be convinced that the latter represents a quantum leap
for ward in patient satisfaction.
Common Bile Duct Evaluation
A number of techniques are available at the time of surger for evaluation
and stone clearance of the common bile duct Cholangiography can be performed
via the gallbladder o through the cystic duct. There is a debate about
whether rou tine cholangiography should be undertaken, Proponents cit
increased awareness of anatomy and identification of com mon bile duct
stones. Preoperative endoscopic retrograd cholangiography (ERCP) is a
potential option for common bil duct anatomic definition and identification
of common bil duct stones. Initial low yield rates have lessened enthusias
for this approach. Preemptive removal of a common duc stone facilitates
laparoscopic cholecystectomy and obviate the need for open exploration
of the common bile duct.
The available techniques for exploring the common duct a the time of
laparoscopic cholecystectomy include, in order o increasing invasiveness,
balloon catheter manipulation (use to push stones into the duodenum, dredge
the common duc for stones, or dilate the arnpulla), fluoroscopically guided
bas ket extraction, and choledochoscopy (either transcystic or through
a choledochotomy) (Fig. 12). The utility of such techniques is operator-dependent,
but success rates of 96 to 98 percent have been reported 76,77.
Upper Gastrointestinal Tract/Small Bowel
Antireflux Procedures. Gastroesophageal reflux reflects the consequences
of malfunction of the valvular mechanism of the cardioesophageal junction.
Open surgical ftindoplication techniques have been utilized successfully
for over 40 years to restore this function 78, 79. These techniques are
effective, but substantial morbidity is associated with a large upper
abdominal incision, and poor access may culminate in splenic damage. The
introduction of H2-receptor blockers and, more recently, proton pump inhibitors
has led to a reassessment of the utility of medical treatment. Potent
acid inhibition offers symptomatic improvement for the majority of patients
but does nothing to correct the fundamental problem of a defective lower
esophageal sphincter. In addition, the consequences of long-term potent
acid inhibitory therapy have not been fully determined. A recent prospective
randomized study of patients with complicated reflux reported that the
results of surgery are superior to those of medical therapy for both symptomatic
relief and the improvement of the ondoscopic appearance of the esophageal
Fundoplication is a technique ideally suited for the laparoscopic approach.
Visualization of the esophagogastric junction (Fig. 13) is generally better
than in open operations, since the laparoscope can access areas deep under
the diaphragm that are not easily visualized at open operation. In addition,
the assistant may be able to facilitate the procedure instead of blindly
retracting, as is often the case in the open procedure. Since no anastomosis
is performed and manipulation of the lower gastrointestinal tract is minimal,
postoperative ileus is not a problem and patients can be discharged earlier.
The two procedures which are most commonly performed laparoscopically
for reflux are the Nissen (360-degree wrap) and the Toupet (270-degree
wrap) procedures 78,81. Early data from patients undergoing laparoscopic
Nissen procedures have been good, with symptomatic relief in over 90 percent
of patients. In addition, a shortened hospital stay, decreased convalescence,
and low rates of dysphagia and gas-bloat syndrome have been noted 82-84.
Cardiomyotomy. Achalasia is a relatively rare disease, affecting
only about 1 in 100,000 persons 85. Although blind, repetitive balloon
dilatation has been widely utilized for treatment, the only prospectively
randomized study undertaken demonstrated a clear advantage for surgical
esophagomyotomy or cardiomyotomy 86. The laparoscopic approach to this
procedure (Fig 14) (85,87) has the same theoretical advantages as it does
for antireflux procedures. Thoracoscopic esophagomyotomy has also been
described 88. Only a limited number of patients have undergone the procedure;
thus, it is unclear if the advantages will be fully realized. The early
results are promising.
Procedures for Peptic Ulcer Disease. Surgical therapy for peptic
ulcer disease has dramatically devolved since the advent of H2-receptor
blockers. Elective surgery for ulcer disease is unusual, but in emergency
surgery for complications, the ulcer-related mortality rate is unchanged
89. For complications such as perforation and gastric outlet obstruction,
laparoscopic procedures are appropriate 90. These procedures include primary
repair with omental patch for perforation and gastrojejunostomy in cases
of obstruction. Management of bleeding by laparoscopic techniques has
not been reported, but gastrectomy has been undertaken and is potentially
feasible in a stable patient. Considerable technical experience is necessary
for procedures of this magnitude. Nevertheless, the same thing could have
been said about the first report of gastrectomy by the open technique
Indications for elective surgical treatment include patients refractory
to medical therapy and young patients who may face a lifetime of acid
inhibitory therapy. Issues of compliance, cost-effectiveness, and long-term
results may be important factors, but detailed information is not available.
Treatment options include truncal vagotomy accompanied by a drainage procedure
(pyloroplasty or pyloric balloon dilatation), highly selective vagotomy,
gastric seromyotomy (which is functionally similar to highly selective
vagotomy), and a combination of seromyotomy and vagotomy (Figs. 15 and
16). Early results of two series have been reported, 91,92 with rates
of ulcer healing over 95 percent in both. This is clearly an area of evolution
in laparoscopic surgery, but further studies are necessary before its
true role can be defined. At best, the results should presumably be comparable
to those obtained by open surgery, with the added advantage of a minimally
Antrectomy. A number of antrectomies and gastrotomies have been
described for benign gastric lesions 93 or peptic ulcer disease 51. Although
technically feasible, total gastrectomy has not been described. Experience
with these techniques is relatively recent, and few cases have been reported.
Procedures for Gastric Obstruction. Gastrojejunostomy is the standard
open procedure performed for advanced, unresectable gastric cancer either
as a prophylactic measure or for actual obstruction. With the increased
popularity of laparoscopic gastric cancer staging, laparoscopic gastrojejunostomy
may be performed more frequently 51.
Resection. Indications for laparoscopic resection of the small
bowel are the same as those for open procedures and include benign and
malignant neoplasms, strictures or inflamed areas from radiation or inflammatory
bowel disease, Meckel's diverticulum, and bleeding arteriovenous malformations.
Operations can be performed by constructing the anastomosis inside the
peritoneal cavity (intracorporeal anastomosis) 94 or by bringing the loops
to the outside through a 9small incision (extracorporeal anastomosis)
(Fig. 17) 95. The technique used depends on the nature and location of
the lesion. A problem arises, however, when one is attempting to remove
large specimens through small port incisions. If an abdominal incision
has to be extended to facilitate specimen removal, extracorporeal anastomosis
can be undertaken expeditiously. Occasionally the specimen may be small
enough to be removed through a 12-mm port or is suitable for morcellation
and bag retrieval. In such instances, intracorporeal anastomosis is an
option, provided that the surgeon is technically capable of undertaking
intracorporeal bowel anastomosis, which requires considerable skill.
Lysis of Adhesions. This procedure is commonly used to resolve
small bowel obstruction and occasionally to relieve abdominal pain syndromes
96. The etiology of adhesions is usually related to prior abdominal surgery,
although congenital bands and adhesions from intraabdominal or pelvic
inflammatory processes may be responsible. While prior surgery represents
a challenge in trocar placement, it is no longer a contraindication to
laparoscopic surgery. Nevertheless, a history of previous surgery demands
the utmost caution in regard to laparoscopic surgery. The initial trocar
may be placed using an "open" technique or, alternatively, at
a site distant from the previous abdominal incision. The remaining trocars
are then placed under direct vision by the laparoscope. At operation,
the small bowel is grasped with atraumatic laparoscopic clamps and "run"
until the point of obstruction is encountered. The causative adhesions
are then divided (Fig. 18). It may be useful to divide any other obvious
bands. The results with this technique have been favorable both for resolution
of obstructive symptoms and in providing symptomatic relief in patients
with chronic abdominal pain syndromes 96.
Laparoscopic Colorectal Surgery
Application of videolaparoscopic techniques to colorectal operations
was initially limited by the lack of appropriate instruments. Consequently,
the first laparoscopic colon resections were "laparoscopically assisted"
colectomies; i.e., minilaparotomies were utilized for ligation of mesenteric
vasculature, extracorporeal anastomoses, and specimen removal. The first
laparoscopic colonic resection using this technique was a right hemicolectomy
performed in 1990.97
The introduction of a laparoscopic intestinal stapler, the Endo-GIA 30
(United States Surgical Corporation, Norwalk, CT), allowed transaction
of the bowel to be accomplished inside the abdomen (Fig. 19). Using this
instrument for ligation of the mesentery and transaction of the colon,
Fowler performed a sigmoid resection in October 1990.98 The anastomosis
was constructed with a circular stapling device. In rapid succession thereafter,
virtually all types of colorectal procedures were accomplished using minimally
invasive techniques. These laparoscopic techniques replicate exactly the
operation undertaken through large abdominal incisions. Unfortunately,
laparoscopic colorectal surgery is extremely difficult, and few surgeons
have developed the skills needed for such procedures. Indeed, few surgeons
perform these operations. Nonetheless, laparoscopic colorectal operations
offer many of the same advantages to patients as do other laparoscopic
operations. Patients tend to experience less pain, fewer wound complications,
a shorter length of hospital stay, and a quicker return to normal activity.
An increased rate of Richter's hernias and tumor implants in wounds after
laparoscopic procedures is apparent.
Laparoscopic techniques have been applied to virtually all types of colorectal
procedures. The diseases most commonly treated with laparoscopic operations
include complications of diverticular disease,99 Crohn's disease 100,101,
chronic ulcerative colitis102, rectal prolapse 103-106, constipation 107
Sigmoid volvulus 108, endometriosis 109-111 and benign colorectal neoplasms112-114.
Closure of colostomies after a Hartmann's procedure or the creation of
a colostomy can be easily accomplished laparoscopically 115-116. Treatment
of colorectal malignancies with laparoscopic resections is controversial
117-119. Most surgeons would agree that patients with metastatic disease
are appropriate candidates. Disagreement exists, however, about the use
of laparoscopic techniques in patients with surgically curable malignancies.
This issue reflects the concern about whether adequate en bloc resection
can be undertaken using the laparoscopic technique and the apparently
high rate of tumor recurrence in trocar sites. Long-term follow-up is
not available after laparoscopic resections for colorectal cancers.
Virtually all patients who require colorectal operations are candidates
for laparoscopic procedures. A rare patient with severe restrictive pulmonary
disease may not tolerate the carbon dioxide pneumoperitoneum. A major
obstacle to laparoscopic colorectal surgery is obesity. Consequently,
these procedures are easier in thin patients than in overweight patients.
The pattern of fat deposition in women appears to facilitate laparoscopic
procedures. Women deposit much of their fat within the abdominal wall
and very little within the omentum, intestinal mesentery, and retroperitoneum.
In contrast, overweight men often have thin abdominal walls but large
amounts of fat within the omentum, epiploic tags, mesentery, and retroperitoneum.
This results in poor visibility of important anatomic landmarks. Thus,
laparoscopic colorectal operations are most easily performed in thin women
who have not undergone previous operations.
Several large series of laparoscopic colorectal operations have been
published.9' 120-125 These series compiled the early experience of several
institutions with a wide variety of procedures. Additionally, these surgeons
often used quite different techniques. As a result, the information provided
in different papers is often difficult to compare. Furthermore, none of
these studies is randomized. Nonetheless, a general pattern (see below)
has emerged from these publications. Laparoscopic colorectal operations
are more difficult to perform than are other laparoscopic procedures.
Even in selected patients operated on by surgeons with considerable laparoscopic
colorectal experience, rates of successful completion of the operation
laparoscopically range from about 65 to 90 percent. These operations require
more time to complete than do open operations, although these figures
may reflect the level of experience of the surgeons. Quantitative measures
of the size of the specimen, the length of the mesentery, and the number
of lymph nodes present suggest that the quality of the operation for colorectal
malignancies is maintained when it is performed laparoscopically (only
long-term follow-up and comparative studies can confirm this). Blood loss
is diminished during laparoscopic colorectal resections, and the requirement
for blood transfusion is unusual. The amount of pain and the requirement
for pain medication are decreased in patients after laparoscopic operations.
The median length of stay after laparoscopic colorectal resections is
about 4 to 5 days in most reports. A few studies, however, have reported
median stays of 5 to 7 days or longer. 123,124 Performance scores after
operation indicate that patients return to normal activity sooner after
laparoscopic colorectal operations than after traditional open operations
The currently published series of laparoscopic operations are not randomized
series and often reflect a bias in patient selection. Consequently, direct
comparison of rates of complications in laparoscopic versus open operations
is not possible. The published studies suggest, however, that the rate
of intraabdominal complications such as anastomotic leaks and intraabdominal
abscesses is not different from that observed with open operations. This
is not surprising, since the extent of dissection and the magnitude of
resection are the same for both techniques. Moreover, identical techniques
are used for the construction of anastomoses. Insufficient laparoscopic
operations have been reported to assess accurately either rare complications
such as pulmonary embolism or rates of mortality, though both seem comparable
for laparoscopic procedures and open operations at specialty centers.
Wound implantation is, however, a worrisome new complication that has
been noted and may occur more frequently after laparoscopic colectomies
than after open operations 33,36,37,119. These implantations have occurred
both at the extraction site of the specimen and at distant trocar sites.
The mechanism of this complication is unclear.
Cost issues have been compared for laparoscopic versus open colorectal
operations in several studies. 122,126,127 In general, operating room
costs are increased significantly with laparoscopic colorectal operations
compared with open operations. Total hospital costs, however, are decreased
or about the same for laparoscopic procedures. The cost reduction is achieved
through a shortened length of stay.
Initial randomized trials uniformly support the use of laparoscopic appendectomy
rather than traditional approaches. The length of operation is about the
same for both groups. The length of hospital stay, the requirements for
pain medicine, and the period of disability are all shortened in the laparoSCOPIC
groups 32,128. Moreover, in one randomized trial the number of complications,
particularly wound infections, was 29 greater in the open group of patients
29. In a retrospective audit, the total hospital cost for a laparoscopic
appendectomy was not significantly different from that for an open appendectomy
The surgical technique of laparoscopic appendectomy is well established.
The clear advantages of laparoscopy over exploration through a right lower
quadrant incision for women with lower abdominal pain have been well documented
over decades. Randomized trials have confirmed that after laparoscopic
appendectomies patients sustain fewer complications, suffer less pain,
are discharged earlier, and return to work sooner. The cost for both procedures
is similar. All available information indicates that laparoscopic appendectomy
has superior results and will become the standard of care.
Use of the laparoscope engenders a loss of tactile sense. As a result,
difficulty exists in performing certain procedures. This has led to a
novel opportunity for surgeons and gastroenterologists to be jointly involved
in the development of combined techniques of both a diagnostic and a therapeutic
Large, sessile colonic polyps provide a challenge to colonoscopists.
While it is desirable to spare patients unnecessary surgery, the risk
of perforation or bleeding from colonoscopic polypectomy, particularly
in the right colon, leads to many open procedures. In such cases, an alternative
approach may be to undertake polypectomy through the colonoscope with
laparoscopic observation of the integrity of the serosal surface (Fig.
For some colonic and gastric lesions identified by endoscopy, laparoscopic
identification is impossible. Such neoplasms must be identified either
preoperatively or intraoperatively by endoscopy. Preoperative identification
may be accomplished with India ink injection, or alternatively combined
laparoscopy and intraoperative endoscopy can greatly facilitate this process.
Treatment options for choledocholithiasis in the laparoscopic era are
numerous 130. A skilled therapeutic endoscopist who can reliably clear
a common bile duct by ERC may greatly facilitate laparoscopic cholecystectomy
and avoid conversion to an open operation. In patients with preoperative
identification of common bile duct stones, preemptive papillotomy and
stone extraction may obviate the need for open surgery and allow safe
laparoscopic cholecystectomy. 16,111 In appropriately equipped operating
rooms, intraoperative endoscopic papillotomy with laparoscopic cholecystectomy
may be considered.
Hernia repair is one of the most common surgical procedures performed in
the United States (Fig. 21). Standard repairs attempt to reconstruct the
weakened floor of the inguinal canal either by reapproximating the endogenous
tissue or by interposing a piece of mesh. Laparoscopic repair emphasizes
placing a piece of mesh over the floor of the canal either from inside the
peritoneal cavity or through a preperitoneal approach. An earlier technique
of using a mesh "plug" was abandoned because of unacceptable recurrence
rates. 132 A multicenter report of 736 laparoscopic hernia repairs using
the prosthetic patch technique found a recurrence rate of 2.2 percent at
a mean follow-up of 6 months. 113 Recurrence after open repair varies widely,
depending on the surgeon, the center where the repair is done, and the length
of follow-up. Recurrence for first time hernia repairs assessed over a broad
population base ranges from 5 to 10 percent. 90
Critics of laparoscopic herniorrhaphy argue that standard hernia repair
is an outpatient procedure done under local anesthesia with no violation
of the peritoneal cavity. Despite this, the convalescent period may be
as long as 4 to 6 weeks.'30 Laparoscopic repair is associated with less
postoperative pain and an earlier return to full activity. 132,133 Long-term
recurrence data have not yet accrued, nor is there a prospective randomized
study available for comparison of open versus laparoscopic repair efficacy.
Diaphragmatic Hernia Repair
The use of mesh to seal defects in the diaphragm requires the use of
the same techniques employed for inguinal hernia repair. Access provided
by the laparoscope is often superior to that available at open surgery.
Little experience is currently available.
Placement of gastrostomy or feeding jejunostomy tubes is ideally suited
to the laparoscopic approach because of the often debilitated nature of
the patients who require these interventions. Several techniques have
been described.","' Percutaneous endoscopic gastrostomy is superior
in most instances. Considering the myriad complications associated with
total parenteral nutrition, laparoscopic feeding jejunostomy may be a
viable alternative for patients with an intact gut.
Splenectomy may be necessary in the management of a variety of hematologic,
neoplastic, metabolic, and infectious conditions. 131 In addition, splenic
salvage is increasingly popular for traumatized spleens, especially in
young patients. Laparoscopic techniques have been applied successfully
to splenic surgery, with benefits similar to those noted in other laparoscopic
Laparoscopic surgery reflects the evolution of an exciting collaboration
between surgeons and the science of biotechnology. Innovative thought
and creative technology have been fused to redefine the management of
old problems. Apart from the technical advances, this scenario presages
a fundamental alteration in the fashion in which surgeons will practice
in the future. It is apparent that "quantum leaps" in medical
and surgical thought are necessary if therapy is to evolve beyond a purely
technical skill and escape from the dogma which often surrounds manual
resolution of complex problems.
While the unbridled enthusiasm of the early days of laparoscopic surgery
has been tempered, it is evident that this is not a temporary phenomenon
or a gimmick. Although much thoughtful work has been undertaken to assess
its impact both on individuals and on society in general, much remains
to be done to evaluate procedures and assess long-term results. It is
probable that certain techniques will fall into demise once data on long-term
results have been evaluated over time or newer technologies have been
Advances in technology are continuing at a rapid rate, and the future
types of surgical procedures may be vastly different from those contemplated
today. New developments such as virtual reality may make training for
surgical procedures more standardized and revolutionize surgical capabilities.
1313 Robotics has reached the point where operations performed with the
surgeon at a site remote from the patient (telepresence surgery) are becoming
a possibility. The use of special instrumentation may enable tactile feedback
It is clear that laparoscopy has gained acceptance and with time will
earn its rightful niche in the field of gastrointestinal surgery. As patient
satisfaction grows and clinical results improve, the light of laparoscopic
surgery will continue to illuminate the resolution of gastrointestinal
1. Adams F (trans.): The Genuine Works of Hippocrates. London, Sydenham
Society, 1849, pp 820-821.
2. Gunning JE, Rosenzweig BA: Evolution of endoscopic surgery, in White
RA, Klein SR (eds): Endoscopic Surgery. Boston, Mosby Year Book, 1991,
3. Berci G: History of endoscopy, in Berci G (ed): Endoscopy. New York,
Appleton-Century-Crofts, 1976, pp xix-xxiii.
4.Kelling G: Zur Colioskopie. Archi Klin Chir 126:226-228, 1923.
5. Philipi Cj, Fitzgibbons Rj, Salerno GM: Historical review: Diagnostic
laparoscopy to laparoscopic cholecystectomy and beyond, in Zucker KA (ed):
Surgical Laparoscopy. St. Louis, Quality Medical Publishing, 1991, pp
6. Semm K: Endoscopic appendectomy. Endoscopy 15:59-64, 1983.
7. Robinson HB, Smith GB: Applications for laparoscopy in general surgery.
Surg Gynecol Obstet 143:829-833, 1976.
8. Leape LL, Ramenofsky ML: Laparoscopy for questionable appendicitis:
Can it reduce the negative appendectomy rate? Ann Surg 191:410-413, 1980.
9. Lightdale Cj: Laparoscopy and biopsy in malignant liver disease. Cancer
10. Macintyre IMC, Wilson RG: Laparoscopic cholecystectomy. Br I Surg
11. Mouret G: From the first laparoscopic cholecystectomy to the frontiers
of laparoscopic surgery: The future perspectives. Dig Surg 8:124-125,
12. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy: A comparison
with nonlaparoscopic cholecystectomy. Surg Endosc 3:131-133, 1989.
13. McKernan JB: Laparoscopic cholecystectomy. Am Surg 57:311-312, 1991.
14. Nathanson LK, Shimi S, Cuschieri A: Laparoscopic cholecystectomy:
The Dundee technique. Br I Surg 78:155-159, 1991.
15. Bordelon BM, Hunter JG: Laparoscopy in the pregnant patient, in Ballantyne
GH, Leahy PF, Modlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 69-77.
16. Smith 1, Benzie Rj, Gordon NL, Kelman GR, Swapp GH: Cardiovascular
effects of peritoneal insulation of carbon dioxide for laparoscopy. Br
Med 1 22:69-70, 1971.
17. Marshall RL, jebson PJR, Davie IT, Scott DB: Circulatory effects
of carbon dioxide insulation of the peritoneal cavity for laparoscopy.
Br I Anaesth 44:680-684, 1972.
18. Cunningham AJ: Anesthesia, in Ballantyne GH, Leahy PF, Modlin IM
(eds): Laparoscopic Surgery. Philadelphia, Saunders, 1994, pp 42-61.
19. Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel Lj, Dahms TE,
Kaminski DL: Analysis of the hemodynamic and ventilatory effects of laparoscopic
cholecystectomy. Arch Surg 126:997-1001, 1991.
20. Svenberg T: Pathophysiology of pneumoperitoneum, in Ballantyne GH,
Leahy PF, Modlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 61-68.
21. Westerband A, Van De Water JM, Amzallag M, et al: Cardiovascular
changes during laparoscopic cholecystectomy. Surg Gynecol Obstet 175:535-538,
22. Meyers WC: A prospective analysis of 1518 laparoscopic cholecystectomies
(the Southern Surgeons Club). N Engl I Med 324:1073-1078, 1991.
23. Crist DW, Gadacz TR: Complications of laparoscopic surgery. Surg
Clin North Am 73:265-289, 1993.
24. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC: Complications
of laparoscopic cholecystectomy: A national survey of 4@292 hospitals
and an analysis of 77,604 cases. Am j Surg 165:9-14, 1993.
25. Baadsgaard SE, Bille S, Egeblad K: Major vascular injury during gynecologic
laparoscopy: Report of a case and review of published cases. Acta Obstet
Gynecol Scand 68:283-285, 1989.
26. Flowers JL, Zucker KA, Bailey RW: Complications, in Ballantyne GH,
Leahy PF, Medlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 77-94.
27. Ostman PL, Pantle-Fisher FH, Faure EA, et al: Circulatory collapse
during laparoscopy. I Clin Anesth 2:129-132, 1990.
28. Richards W, Watson D, Lynch G, et al: A review of the results of
laparoscopic versus open appendectomy. Surg Gynecol Obstet 177:473-480,
29. Attwood SEA, Hill ADK, Murphy PG, Thornton J, Stephens RB: A prospective
randomized trial of laparoscopic versus open appendectomy. Surgery 112:497-501,
30. Valla JS, Limonne B, Valla V, et al: Laparoscopic appendectomy in
children: Report of 465 cases. Surg Laparosc Endosc 1:166-172, 1991.
31. Schreiber JH: Early experience with laparoscopic appendectomy in
women. Surg Endosc 1:211-216, 1987.
32. McAnena Oj, Austin 0, O'Connell PR, Hederman WP, Gorey TF, Fitzpatrick
J: Laparoscopic versus open appendicectomy: A prospective evaluation.
Br I Surg 79:818-820, 1992.
33. Walsh DCA, Wattchow DA, Wilson TG: Subcutaneous metastases after
laparoscopic resection of malignancy. A ust NZj Surg 63:563-565, 1993.
34. Drouard F, Delamarre J, Capron J: Cutaneous seeding of gallbladder
cancer after laparoscopic cholecystectomy. N Engl I Med 325:1316, 1991.
35. Pezet D, Fondrinier E, Rotman N, et al: Parietal seeding of carcinoma
of the gallbladder after laparoscopic cholecystectomy. Br J Surg 79:230,
36. Fusco MA, Paluzzi MW: Abdominal wall recurrence after laparoscopic-assisted
colectomy for adenocarcinoma of the colon. Dis Colon Rectum 36:858-861,
37. Alexander RJT, Jaques BC, Mitchell KG: Laparoscopically assisted
colectomy and wound recurrence. Lancet 341:249-250, 1993.
38. O'Rourke N, Price PM, Kelly S, Sikora K: Tumour inoculation during
laparoscopy. Lancet 342:368, 1993.
39. Fligelstone L, Rhodes M, Flook D, Puntis M, Crosby D: Tumor inoculation
during laparoscopy. Lancet 342:368-369, 1993.
40. Landen SM. Laparoscopic surgery and tumor seeding. Surgery 114:131-132,
41. Dobronte Z, Wittmann T, Karacsony G: Rapid development of malignant
metastases in the abdominal wall after laparoscopy. Endoscopy 10:127-130,
42. Stockdale A, Pocock T: Abdominal wall metastases following
laparoscopy: A case report. Eur J Surg Oncol 11:373-375, 1985.
43. Cava A, Roman J, Gonzalez-Quintela A, Martin F, Arambuxo P: Subcutaneous
metastasis following laparoscopy in gastric adenocarcinoma. Eur I Surg
Oncol 16:63-67, 1990.
44. Boyce HW, Henning H: Diagnostic laparoscopy 1992: Time for a new
look. Endoscopy 24:671-673, 1992.
45. Bagley CM, Thomas LB, Johnson RE, et al: Diagnosis of liver involvement
by lymphoma: Results in 96 consecutive peritoneoscopies. Cancer 31:840-847,
46. Spinelli P, Beretta G, Bajetta E, et al: Laparoscopy and laparotomy
combined with bone marrow biopsy in staging Hodgkin's disease. Br Med
1 4:554-556, 1975.
47. Caletti GC, Ferrari A, Fiorino S, Bocus P, Barbara L: Staging of
esophageal carcinoma by endoscopy. Endoscopy 25:2-9,1993.
48. Dagnini G, Caldironi MW, Marin G: Laparoscopy in abdominal staging
of esophageal carcinoma. Gastrointest Endosc 32:400402, 1986.
49. Watt I, Stewart 1, Anderson D, et al: Laparoscopy, ultrasound, and
computed tomography in cancer of the esophagus and gastric cardia. Br
I Surg 76:1036-1039, 1989.
50. LoCicero j III: Laparoscopy/thoracoscopy for staging: II. Pretherapy
nodal evaluation in carcinoma of the esophagus. Semin Surg Oncol 9:56-58,
51. Uddo JF Jr: Antrectomy with Billroth 11 Anastomosis, in Ballantyne
GH, Leahy PF, Medlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 444-448.
52. Kriplani AK, Kapur BML: Laparoscopy for pre-operative staging and
assessment of operability in gastric carcinoma. Gastrointest Endosc 37:441-443,
53. Baylor SM, Berg JW: Cross-classification and survival classification
of 5000 cases of cancer of the pancreas. J Surg Oncol 5:335-358, 1973.
54. Leach SD, Medlin IM: Approaches to pancreatic disease, in Ballantyne
GH, Leahy PF, Medlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 165-173.
55. Warshaw AL, Gun ZY, Wittenburg J, Waltman C: Preoperative staging
and assessment of resectability of pancreatic cancer. Arch Surg 125:230-233,
56. Murugiah M, Paterson-Brown S, Windsor JA, Miles WF, Garden Oj: Early
experience of laparoscopic ultrasonography in the management of pancreatic
carcinoma. Surg Endosc 7:177181, 1993.
57. Shimi S, Banting S, Cuschieri A: Laparoscopy in the management of
pancreatic cancer: Endoscopic cholecystojejunostomy for advanced disease.
Br j Surg 79:317-319, 1992.
58. Leuschner M, Leuschner U: Diagnostic laparoscopy in focal parenchymal
disease of the liver. Endoscopy 24:689-692, 1992.
59. Boyce HW: Diagnostic laparoscopy in liver and biliary disease. Endoscopy
60. Nord Hj: Biopsy diagnosis of cirrhosis: Blind percutaneous versus
guided direct vision techniques-a review. Gastrointest Endosc 28:102-104,
61. Abei M, Tanaka N, Matsumoto H, et al: Laparoscopic observation of
liver colored with indocyanine green in chronic hepatitis: 1. Improved
sensitivity for diagnosis of fibrosis. Gastrointest Endosc 39:406-409,
62. Eltringham WK, Roe Am, Galloway SW, Mountford RA, Espiner Hj: A laparoscopic
technique for full thickness intestinal biopsy and feeding jejunostomy.
Gut 34:122-124, 1993.
63. Paterson-Brown S, Thompson JN, Eckersley JRT, et al: Which patient
with suspected appendicitis should undergo laparoscopy? Br Med j 296:1363-1364,
64. Harrison LE, Mosenthal AC, Caushaj PF: Diagnostic laparoscopy, in
Ballantyne GH, Leahy PF, Medlin IM (eds): Laparoscopic Surgery. Philadelphia,
Saunders, 1994, pp 319-326.
65. Brandt CP, Priebe PP, Eckhauser ML: Diagnostic laparoscopy in the
intensive care patient: Avoiding the nontherapeutic laparotomy. Surg Endosc
66. Cuschieri A, Hennessy TPJ, Stephens RB, Berci G: Diagnosis of significant
abdominal trauma after road traffic accidents: Preliminary results of
a multicentre clinical trial comparing minilaparoscopy with peritoneal
lavage. Ann R Coll Surg Engi 70:153-155, 1988.
67. Sosa JL, Sims D, Martin L, Zeppa R: Laparoscopic evaluation of tangential
abdominal gunshot wounds. Arch Surg 127:109110, 1992.
68. Gollan JL, Kalser SC, Pitt HA, Strasberg SS: National Institutes
of Health Consensus Development Conference Statement on Gallstones and
Laparoscopic Cholecystectomy. Am j Surg 165:390-396, 1993.
69. Orlando R III, Russell JC, Lynch J, Mattie A, and the Connecticut
Laparoscopic Cholecystectomy Registry: Laparoscopic cholecystectomy: A
statewide experience. Arch Surg 128:494499, 1993.
70. Legoretta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL: Increased
cholecystectomy rate after the introduction of laparoscopic cholecystectomy.
JAMA 270:1429-1432, 1993.
71. Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP: Surgical
rates and operative mortality for open and laparoscopic cholecystectomy
in Maryland. N Engl J Med 330:403-408, 1994.
72. Barkun JS, Barkun AN, Sampalis JS, et al: Randomised controlled trial
of laparoscopic versus mini cholecystectomy. Lancet 340:1116-1119, 1992.
73. Trondsen E, Reiertsen 0, Andersen OK, Kjaersgaard P: Laparoscopic
and open cholecystectomy: A prospective, randomized study. Eur I Surg
74. Larson GM, Vitale GC, Casey J, et al: Multipractice analysis of laparoscopic
cholecystectomy in 1,983 patients. Am J Surg 163:221-226, 1992.
75. Cuschieri A, Dubois F, Mouiel J, et al: The European experience with
laparoscopic cholecystectomy. Am J Surg 161:385387, 1991.
76. Petelin JB: Laparoscopic approach to common duct pathology. Am I
SuFg 165:487-491, 1993.
77. Carroll Bj, Phillips EH, Daykhovsky L, et al: Laparoscopic choledochoscopy:
An effective approach to the common duct. J Laparoendosc Surg 2:15-21,
78. Nissen R: Eine einfache operation zur beeinflussung der refluxoesophagitis.
Schweiz Med Wochensch 86:590-592, 1956.
79. Belsey R: Surgical treatment of hiatus hernia and reflux esophagitis.
World J Surg 1:421-423, 1977.
80. Spechler Sj and the Department of Veterans Affairs Gastroesophageal
Reflux Disease Study Group: Comparison of medical and surgical therapy
for complicated gastroesophageal reflux disease in veterans. N Eng] j
Med 326:786-792, 1992
81. Toupet A: Technique d'oesophago-gastroplastie avec phrenogastropexie
appliques dans la cure radicale des hernies hiatales et comme complement
de l'operation de Heller dans les cardiospasmes. Mem Acad Chir 89:394-397,
82. Dallemagne B, Weerts JM, jehaes C, Markiewicz S, Lombard R: Laparoscopic
Nissen fundoplication: Preliminary report. Surg Laparosc Endosc 1:138-143,
83. Hinder RA, Filipi Cj: The technique of laparoscopic Nissen fundoplication.
Surg Laparosc Endosc 2:265-272, 1992.
84. Cuschieri A, Shimi S, Nathanson LK: Laparoscopic reduction, crural
repair, and fundoplication of large hiatal hernia. Am J Surg 163:425-430,
85. Spencer J: Cardiomyotomy, in Ballantyne GH, Leahy PF, Modlin IM (eds):
Laparoscopic Surgery. Philadelphia, Saunders, 1994, pp 400-404.
86. Csendes A, Braghetto I, Henriquez A, Cortes C: Late results of a
prospective randomized study comparing forceful dilatation and oesophagomyotomy
in patients with achalasia. Gut 30:299-304, 1989.
87. Shimi S, Nathanson LK, Cuschieri A: Laparoscopic cardiomyotomy for
achalasia. j R Coll Surg Edin 36:152-154, 1991.
88. Pellegrini C, Wetter LA, Patti M, et al: Thoracoscopic esophagomyotomy:
Initial experience with a new approach for the treatment of achalasia.
Ann Surg 216:291-296, 1992.
89. Oddsdottir M, Soybel DI: Peptic ulcer disease, in Ballantyne GH,
Leahy PF, Modlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders,
1994, pp 137-153.
90. Soper NJ, Brunt LM, Kerbl K: Medical progress: Laparoscopic general
surgery. N Eng] j Med 3 30:409-419, 1994.
91. Bailey RW, Zucker KA: Laparoscopic management of peptic ulcer disease,
in Zucker KA (ed): Surgical Laparoscopy Update. St. Louis, Quality Medical,
1993, pp 241-286.
92. Katkhouda N, Mouiel J: Laparoscopic treatment of peptic ulcer disease,
in Hunter JG, Sackier JM (eds): Minimally Invasive Surgery. New York,
McGraw-Hill, 1993, pp 123-130.
93. Fowler DL: Gastric resection, in Ballantyne GH, Leahy PF, Modlin
IM (ads): Laparoscopic Surgery. Philadelphia, Saunders, 1994, pp. 441-443.
94. Soper NJ, Brunt LM, Fleshman J, Meininger TA, Dunnegan DL: Laparoscopic
small bowel resection and anastomosis. Surg Laparosc Endosc 3:6-12, 1993.
95. Attwood SE, Kelly I, O'Connell PR, Corrigan T: Laparoscopic mobilization
and exteriorization for minimally invasive small bowel resection. Br J
Surg 80:225, 1993.
96. Mouret P, Gelez C: Lysis of adhesions, in Ballantyne GH, Leahy PF,
Modlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders, 1994, pp
97. Jacobs M, Verdeja JC, Goldstein HS: Minimally invasive colon resection
(laparoscopic colectomy). Surg Laparosc Endosc 1:144-150, 1991.
98. Fowler DL, White SA: Laparoscopy-assisted sigmoid resection. Surg
Laparosc Endosc 1:183-188, 1991.
99. Phillips EH, Franklin M, Carroll Bj, Fallas Mj, Ramos R, Rosenthal
D: Laparoscopic colectomy. Ann Surg 216:703-707, 1992.
100. Milsom JW, Lavery IC, Bohm B, Fazio VW: Laparoscopically assisted
ileocolectomy in Crohn's disease. Surg Laparosc Endosc 3:77-80, 1993.
101. Romero CA, James KM, Cooperstone LM, Mishrick AS, Ger R: Laparoscopic
sigmoid colostomy for perianal Crohn's disease. Surg Laparosc Endosc 2:148-151,
102. Wexner SD, Johansen OB, Nogueras Jj, Jagelman DG: Laparoscopic total
abdominal colectomy: A prospective trial. Dis Colon Rectum 35:651-655,
103. Berman IR: Sutureless laparoscopic rectopexy for procidentia: Techniques
and implications. Dis Colon Rectum 35:689-693, 1992.
104.Cuesta MA, Borgstein Pj, de Jong D, Meijer S: Laparoscopic rectopexy.
Surg Laparosc Endosc 3:456-458, 1993.
105. Senagore Aj, Luchtefeld MA, MacKeigan JM: Rectopexy. J Laparoendosc
Surg 3:339-342, 1993.
106. Ballantyne GH: Laparoscopically assisted anterior resection for
rectal prolapse. Surg Laparosc Endosc 2:230-236, 1992.
107. Lointier pH, Lautard M, Massoni C, Ferrier C, Dapoigny M: Laparoscopically
assisted subtotal colectomy. J Laparoendosc Surg 3:439-453, 1993.
108. Leach SD, Ballantyne GH: Laparoscopic management of sigmoid volvulus:
Modern management of an ancient disease. Semin Colon Rect Surg 4:249-256,
109. Redwine DB, Sharpe DR: Laparoscopic segmental resection of the sigmoid
colon for endometriosis. I Laparoendosc Surg 1:217-220, 1991.
110. Sharpe DR, Redwine DB: Laparoscopic segmental resection of the sigmoid
colon for endometriosis. Surg Laparosc Endosc 2:120-124, 1992.
111. Nezhat F, Nezhat C, Pennington E, Ambroze W Jr: Laparoscopic segmental
resection for infiltrating endometriosis of the rectosigmoid colon: A
preliminary report. Surg Laparosc Endosc 2:212-216, 1992.
112. Saclarides Tj, Ko ST, Airan M, Dillon C, Franklin J: Laparoscopic
removal of a large colonic lipoma. Dis Colon Rectum 34:1027-1029, 1991.
113. Cooperman AM, Katz V, Zimmon D, Botero G: Laparoscopic colon resection:
A case report. flaparoendosc Surg 1:221-224, 1991.
114. Leach SD, Modlin IM, Goldstein L, Ballantyne GH: Laparoscopic local
excision of a proximal rectal carcinoid. I Laparoendosc Surg 4:65-70,
115. Lange V, Meyer G, Schardley HM, Schildberg FW: Laparoscopic creation
of a loop colostomy. I Laparoendosc Surg 1:307-312, 1991.
116. Hashizume M, Haraguchi Y, Ikeda Y, Kajiyama K, Fujie T, Sugimachi
K: Laparoscopy-assisted colostomy. Surg Laparosc Endosc 4:70-72, 1994.
117. Pappas TN: Laparoscopic colectomy-the innovation continues. Ann
Surg 216:701-702, 1992.
118. O'Rourke NA, Heald Rj: Laparoscopic surgery for colorectal cancer.
Br I Surg 80:1229-1230, 1993.
119. Billingham RP: What's new in colon and rectal surgery. Bull Am Coll
Surg 79:16-21, 1994.
120. Monson JRT, Darzi A, Carey PD, Guillou Pj: Prospective evaluation
of laparoscopic-assisted colectomy in an unselected group of patients.
Lancet 340:831-833, 1992.
121.Peters WR, Bartels TL: Minimally invasive colectomy: Are the potential
benefits realized? Dis Colon Rectum 36:751-756, 1993.
122. Falk PM, Beart RW Jr, Wexner SD, et al: Laparoscopic colectomy:
A critical appraisal. Dis Colon Rectum 36:28-34, 1993.
123. Tate JJT, Dawson JW, Lau WY, Li AKC: Prospective comparison of laparoscopic
and conventional anterior resection. Br I Surg 80:1396-1398, 1993.
124. Wexner SD, Cohen SM, Johansen OB, Nogueras Jj, Jagelman DG: Laparoscopic
colorectal surgery: A prospective assessment and current perspective.
Br I Surg 80:1602-1605, 1993.
125. Puente I, Sosa JL, Sleeman D, Desai U, Tranakas N, Hartmann R: Laparoscopic
assisted colorectal surgery. Laparoendosc Surg 4:1-7, 1994.
126. Senagore Aj, Luchtefeld MA, MacKeigan JM, Mazier WP: Open colectomy
versus laparoscopic colectomy: Are there differences? Am Surg 59:549-554,
127. Musser DJ, Boorse RC, Madera F, Reeds JF: Laparoscopic colectomy:
At what cost? Surg Laparosc Endosc 4:1-5, 1994.
128. Buanes T, Raeder MG: Introduction of laparoscopic techniques in
gastrointestinal surgery: Experience at a Norwegian university hospital
as revealed by prospective comparative studies. Surg Laparosc Endosc 3:21-28,
129. Cohen MM, Dangleis K: The cost-effectiveness of laparoscopic appendectomy.
J Laparoendosc Surg 3:93-97, 1993.
130. Graham SM, Scott TR: Laparoendoscopic management of common bile
duct stones, in Ballantyne GH, Leahy PF, Modlin IM(eds):Laparoscopic Surgery.
Philadelphia, Saunders, 1994, pp 198-212.
131. Aliperti G, Edmundowicz SA, Soper NJ, Ashley SW: Combined endoscopic
sphincterotomy and laparoscopic cholecystectomy in patients with choledocholithiasis
and cholecystolithiasis. Ann Intem Med 115:783-785, 1991.
132. Schultz L, Grabor J, Pietrafitta J, Hickok J: Laser laparoscopicherniorrhaphy:
A clinical trial: Preliminary results. Laparoendosc Surg 1:41-45, 1990.
133. Fitzgibbons R, Annibali R, Litke B, Filipi C, Salerno G, Comet D:
A multicentered clinical trial on laparoscopic inguinal hernia repair:
Preliminary results (abstract). Surg Endosc 7:115, 1993.
134. Stellato TA: Endoscopic intervention for enteral access. World I
Surg 16:1042-1047, 1992.
135. Ferzoco Sj, Modlin IM: Splenic surgery, in Ballantyne GH, Leahy
PF, Modlin IM (eds): Laparoscopic Surgery. Philadelphia, Saunders, 1994,
136. Satava RM: Surgery 2001: A technological framework for the future.
Surg Endosc 7:111-113, 1993.