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448
14.3 Minimally Invasive Surgery by Video-Endoscopic Techniques
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14.3 Minimally Invasive Surgery by Video-Endoscopic Techniques: New Technology Rejuvenat es Prov en Concept
F. M. Steichen, J.M. Loubeau, B. Herz, E. B. Sottile
“Primum Non Nocere” has been a leading concept of the healing
arts and sciences since Hippocrates. Throughout history this
aphorism has stimulated surgeons to develop operative techniques that restore injured and diseased tissues and organs to
an optimal level of form and function while protecting the
patient’s anatomical, physiological and psychological integrity
from progression of disease or injury and from treatment
plethora. These goals are always accomplished in the self-imposed context of high ethics and with a view to a just mobilization and equitable distribution of necessary health care re-
sources.
Over the course of surgical history many means have been employed to fulfill these lofty goals. The most recent one is the reduced access to a body cavity or hollow organ made possible by
video-endoscopic techniques. This approach to a given operative site enables the surgeon to perform a traditional intracavitary or intraluminal procedure at a distance, visually guided or
assisted by images obtained endoscopically and projected onto
a television monitor, for the entire operating team to observe
and respond to with a cooperative, goal oriented diagnostic or
therapeutic activity.
However the concept of minimal invasion or minimal harm extends far beyond the importance of a limited or reduced surgical approach. It includes the entire surgical activity and its impact on the patient’s anatomy, physiology, psychology and financial resources, as well as on the accepted code of ethics. Only
those video-endoscopic operations that respect the patient’s integrity and represent a real improvement in his or her health
status, can be part of the concept of Minimally Invasive Surgery—
a concept that guides treatment techniques and dominates the
technology used to implement these techniques.
“L’habit ne fait pas le moine”
Just as “the cloth does not an Abbot make,” so does the use of
the video-endoscopic armamentarium not confer the minimally invasive label. Video-endoscopy, a technique, is not synonymous with minimally invasive—a surgical concept or prin-
ciple. Technology should serve and not dominate or determine
the surgeon’s actions on behalf of his or her patients. By using
this reasoning, it is easy to decide the optimal access to a given
operative site.
Operations that need to be planned and accomplished in a
traditional fashion should not convey the aura of hopeless obsolescence, if the surgeon chooses to not initiate, or worse, to not
stubbornly pursue an operative course that is based on the
availability of video-endoscopic instrumentation and self indulging dexterity, rather than on the use of good judgement in
the primary selection of an operative approach.
The ability to reasonably decide which is the least invasive approach, without blindly following a novelty appealing bias
favoring the routine initial use of laparoscopy or thoracoscopy
and courting double-technical and financial-jeopardy by a predictable need for conversion, is illustrated by the following examples:
− Open subxyphoid versus thoracoscopic pericardial drainage,
− Needle aspiration/biopsy versus laparoscopy or thoracoscopy intended for diagnosis only,
− Mediastinoscopy/lateral mediastinotomy versus thoracoscopy for lymph node staging only,
− Minilaparotomy versus laparoscopy for pyloromyotomy in
newborns,
− Open versus preperitoneal laparoscopic inguinal hernia repair in children and women,
− “Buttonhole” RLQ incision versus laparoscopy for clinically
certain appendicitis,
− Open versus laparoscopically assisted colectomy for diverticulitis and carcinoma—unless done within the framework
of a planned comparison with a concurrent “traditional” experience or as a prospective, randomized clinical trial,
− Open or laparoscopically assisted versus laparoscopically
guided staging for lymphoma.
Value Assessment of Laparoscopic Procedures
449
The rule to prefer surgical entry into the space that harbors the
pathologic condition, rather than to use the more invasive approach through a contiguous area, is well illustrated by subxyphoid versus transhoracic drainage of the pericardium and by
mediastinoscopy or lateral mediastinotomy versus thoracos-
copy in the staging of mediastinal and hilar lymph nodes. At
other times there is great virtue in keeping simple things
simple, e. g., needle aspiration or biopsy for diagnosis only, open
pyloromyotomy for pyloric hypertrophy in newborns, tradi-
tional herniorrhaphy in children and (under local anesthesia) in
women, as well as “buttonhole” McBurney incisions for clini-
cally certain appendicitis. Finally, exploration by laparoscopy
only, although very desirable in some situations, may not satisfy
all the diagnostic or therapeutic requirements such as in staging
for lymphoma or operating for cancer of the large bowel. Laparotomy or a laparoscopically assisted procedure is preferable
as a primary approach under such circumstances.
Goals of Minimally Invasive Surgery
by Video-Endoscopy
The goal of a surgical procedure, regardless of the type and size
of the incision(s), is to achieve one of four results:
− Diagnosis only,
− Excision of organ or remedial operation,
− Excision and reconstruction or repair,
− Repair only.
The term “advanced laparoscopy” has been used for operative
procedures that fall into the third and fourth groups of these
goals. This is a very unfortunate formulation because it lacks
definition and does not correspond to any existing level or stage
of teaching and learning in a surgical training curriculum, which
is based on progressive responsibility with increasing ability to
perform all operative procedures, small and large. At b est the
term inflates the image of the, often self-anointed, “advanced
laparoscopist” at worst will give added ammunition to litigious
lawyers.
For comparable clinical presentations of disease or injury,
video-endoscopic and open techniques may be chosen inter-
changeably, within an overall framework of dual expertise, instrument availability and factual preoperative decision making
as to the preferred primary approach: closed or open. If a primary laparoscopic approach appeared reasonable under this
rule, and intraoperative findings mandated conversion to an
open operation, this change should not be construed as a complication or a failure to perform adequately, but simply as a demonstration of sound judgement. Conversely, if a primary open
approach has been chosen and the operative course demonstrates that a laparoscopy would have been equally useful, effi-
cient and economical, the ethical conclusion would be that a
valuable lesson has been learned for a future comparable opera-
tive situation and that no harm has been done, because open
operation is still the standard to which all other approaches
have to be compared at present.
In the area of diagnosis examples of the potential benefits of a
minimal or reduced access with video-endoscopy are:
− Exploration for “acute” and injured abdomen,
− Early diagnosis of suspected, silent malignancy,
− Tissue diagnosis of pleuro-pulmonary and intra- or retroperitoneal disease,
− Staging of primary and metastatic epithelial tumors.
For organ excision only or remedial operations advantages to the
patient and the health care system may occur with vidoeendoscopically guided:
− Cholecystectomy, appendectomy, diverticulectomy,
− Oophorectomy, hysterectomy, cure of benign GYN lesions,
− Intestinal adhesiolysis, drainage of collections,
− Cure of pneumothorax.
Partial or total organ excision with immediate or delayed recon-
struction may benefit from vidoendoscopically guided or as-
sisted procedures in operations on:
− The vagus nerves and gastric drainage procedures,
− Units or segments of the hollow G.I. tract,
− Intra- and extraperitoneal solid organs,
− Broncho-pulmonary units,
− Vascular tree segments,
− Intervertebral disk herniation and spinal repair.
Repair only of anatomical and/or functional anomalies may
derive particular benefit from videoendoscopically guided procedures in:
− Inguinal herniorrhaphy,
− Cardiamyotomy, G.E. anti-reflux procedures,
− Correction of bladder neck incontinence,
− Spinal fusion.
Value Assessment of Laparoscopic
Procedures
To further explore the value of laparoscopy in the various goal
oriented groups, our clinical experience with a representative
example in each category will be reviewed. The criteria for this
value assessment are:
− Usefulness—as compared to the traditional equivalent
operation,
− Efficiency—short and long term of treatment.
− Economy—to hospitals, health care and social systems,
− Ethics—of new techniques and advanced technology.
The value of diagnostic V−E procedures is by now well established through the test of time, since the first description of laparoscopy by Jacobaeus in 1910:
− Usefulness ***
− Efficiency ***
− Economy ***
− Ethics ***
The accuracy of diagnostic V−E procedures and hence their value
can be enhanced by non-invasive, transabdominal ultrasonography preceding and in fact often delineating the indications
and extent of the V−E procedure, especially in emergency situations where CT scans and MRI examinations are time consuming. Additionally, minimally invasive laparoscopic ultrasonography is invaluable if during a therapeutic V−E guided or assisted
operation a suspicious or unexpected intraoperative finding requires additional diagnostic exploration.
The value of organ excision only will be examined by using
cholecystectomy as a model; for excisional and reconstructive
procedures the value parameters will be illustrated by reviewing
450
14.3 Minimally Invasive Surgery by Video-Endoscopic Techniques
the clinical experience with VE-assisted colo-rectal procedures,
as compared to a concurrent series of operations performed in
the “traditional” fashion; the category of VE-operations for re-
pair only will be assessed by looking at results obtained with
preperitoneal inguinal hernia repair.
Video-Endoscopically Guided
Organ Excision: Laparoscopic
Cholecystectomy
This value assessment model is based on a series of patients
treated from March 1990 to May 1992.
During this time period the authors treated all (110) patients
admitted with the diagnosis of acute or chronic cholecystitis by
laparoscopic cholecystectomy. There was no selection, no
patients were treated primarily by conventional operation.
There were 82 (75%) women, medium age 50, range 20−83 years
and 28 (25%) men, medium age 54, range 25−83 years.
Chronic inflammation: 78 (71%), women 63 (81%), men 15
(19%).
Acute inflammation: 32 (29%), women 19 (59%), men 13 (41%).
One patient died of causes unrelated to his operation.
Of interest is the high incidence of acute cholecystitis, more so
in men then in women. This was not a contraindication to la-
paroscopic removal, even though all these patients were seen in
the initial phase of our experience. There was no common duct
injury or any other biliary tract mishaps. Seven patients were
found to have unexpected acute cholecystitis, one patient presented with severe scarring due to repeated episodes of inflam-
mation and one patient’s intraoperative cholangiogram, done
because of elevated liver function tests, showed a filling defect.
He was treated by open common bile duct exploration.
Conversion to open procedure became necessary in 15 patients:
Five times for chronic and ten times for acute inflammation.
Since there was a total of 32 patients with acute cholecystitis,
22 of these were treated by laparoscopic removal: Data analysis
shows that these patients had stayed in the hospital preopera-
tively for diagnosis and preparation on an average of 1.9 days,
whereas patients having to undergo laparotomy (10) had re-
mained under non-operative management for an average of five
days.
The vast majority of all patients was sent home on the day fol-
lowing operation, some even on the same day, in these early
stages of our experience. Rare, longer hospitalizations were due
to reasons not related to the operative procedure.
It therefore does not take accounting sophistication to find that
even though operating room expenses were higher than with
conventional cholecystectomy, the overall costs were much
lower for patients with laparoscopic cholecystectomy. Since the
operation is useful, efficient and does not lead to increased mor-
bidity—therefore it is ethically acceptable—its value is very high
and almost establishes videoendoscopy and minimally invasive
virtues as equals.
− Usefulness ***
− Efficiency ***
− Economy ***
− Ethics ***
A reasoning similar to this can be used for most other organ or
pathologic lesion excisions, provided that the operative team
recognizes indications that are relevant to the patient’s habitus
and disease, is prepared to accomplish each individual procedure and have at its disposal the necessary resources, for:
− VE-assisted abdomino-vaginal hysterectomy,
− Eradication of foci of endometriosis,
− Adrenalectomy and splenectomy.
Appendectomy at first sight seems like an ideal indication.
However, since the excision of an appendix through a “buttonhole” McBurney incision for a clinically obvious diagnosis of appendicitis, is a matter of surgical pride and craft, little is gained
by the mode of access. Furthermore, hospitalization for most of
these patients is short, so that the costs of instrumentation and
OR facilities make the equation lean in favor of conventional appendectomy. However, this equation changes in favor of laparoscopy if the preoperative diagnosis of an “acute abdomen”
is not clear cut, especially in women.
Videoendoscopically Assisted Organ
Excision and Reconstruction:
Segmental or Hemicolectomy and
Colo-Rectal Procedures
This value assessment model is based on a series of patients
treated from March 1993 to March 1997.
During this period of time 108 patients were treated by laparoscopically assisted colon resection (LACR), whereas 109 patients
underwent an open operation.
The average age was 70.7 years (range 35−91) for the LACR
group, and 71.2 years (range 35−95) for the OPEN group.
There were 56 men and 52 women in the LACR group, 46 men
and 63 women in the OPEN group.
While this does not represent a prospective, randomized, controlled study, the surgeons operating on both groups of patients
were the same. The patient population was homogeneous,
drawn from a community served by a single hospital. The criteria used for deciding between the two operative approaches
related to conditions that were independent of a given operative indication; such as preexisting cardiac, respiratory and
renal liabilities, where our bias, governed by tradition in the initial phases of this experience, favored open operation. Initially
also the laparoscopic approach in malignancies was confined to
patients with small, localized cancers; patients with known
metastatic disease in need of a palliative procedure and to
elderly patients in whom a large incision represented an excessive physiological burden. As the experience with all of these
patients progressed, and the continuous comparison between
the LACR and OPEN groups did not demonstrate a significant
difference in the short term results, the indications for LACR
were extended and the two groups of patients became alike for
each pathologic condition requiring operative treatment, regardless of preexisting co-morbidity factors.
Conversion from laparoscopy to open operation became necessary in seven patients (6.4%): Three times during right
colectomy, three times during a left or sigmoid colectomy and
once in a transverse colectomy. Besides the occasional technical
challenges, usually such conversions were occasioned by the
absolute rule of providing each patient with the best possible
chance for cure of his or her disease, benign or malignant.
Technical mishaps occurred three times in laparoscopy cases
(2.7%). Twice an accidental enterotomy required repair while la-
Videoendoscopically Guided Operations for Anatomical Repair: Preperitoneal Inguinal Herniorrhaphy
451
paroscopy was maintained and once a ureteral injury—recognized immediately—led to an open repair.
While morbidity and mortality were clearly greater in patients
with open operations, some—but not all—of these incidents
were related to preoperative co-morbidity factors that had
favored the decision to perform a traditional incision. However
wound infections and increased pulmonary complications were
clearly related to the larger incisions. Deaths were due in both
groups to co-morbidity factors. To date there have been no port
site or incisional tumor implantations in either group, by now a
seven to three year follow-up.
Based on the analysis of these results, the value assessment of
laparoscopically assisted colo-rectal procedures has to be
divided into separate conclusions: One for benign and another
for malignant disease. In both of these categories the economic
advantage, although real, is not as clear cut as it is in laparos-
copy for organ excision only. Furthermore, the need for a con-
tingency incision to facilitate the anastomosis and specimen removal, reduces the level of usefulness as compared to the more
invasive open operations. Finally and most importantly in laparoscopic operations for malignancy, the final judgement as to
efficiency and hence ethics has to wait until we can assess long
term, five and ten year survivals. While such outcome studies
are in the making, participation in a registry, or a prospective
randomized trial or a well planned, in house comparison with
concurrent traditionally performed operations will and should
protect us (and our patients) from going down harm’s way by
possibly ignoring danger signs that should clearly lead to reflec-
tion and a change in direction if necessary. The five to seven year
follow-up in patients done from 1993 to 1995 has so far not
shown a divergence of cancer recurrence or metastases be-
tween the LACR and open groups.
Videoendoscopically Guided Operations
for Anatomical Repair: Preperitoneal Inguinal Herniorrhaphy
This value assessment model is based on a series of patients
treated from November 1993 to December 1995.
The early attempts at inguinal hernia repair by a variety of laparoscopic techniques, such as: Sac ligation and internal ring
closure, plug and patch procedure, iliopubic tract suture and
transabdominal pre- or intra-peritoneal patch placement across
the inguinal floor, while ingenious, represent prime examples of
operative adaptations to available technology. The opposite,
namely the development of new instruments that are adjusted
to established principles of surgical operative techniques
should have prevailed. Therefore these various herniorrhaphy
techniques represent at best valuable steps in the creation of a
procedure respecting the basis of a successful hernia repair as
enunciated by Edoardo Bassini in 1889: High ligation or control
of the hernia sac and repair or reinforcement of the inguinal
floor.
The videoendoscopically guided, entirely preperitoneal inguinal and femoral hernia repair, made possible by new technology
developed in response to these well established anatomical re-
quirements, guarantees a classical hernia repair, performed
within the space afflicted by the abdominal wall defect, albeit
under general anesthesia.
The technique as it evolved in our experience, consists of six
steps: Access to the inguinal, preperitoneal space; identification
through careful dissection of area boundaries and component
Table 14.3.1 Indications for Operation.
LACR OPEN
Malignancy 71 72
Benign Polyps 18 8
Inflammatory Bowel Disease 4 2
Diverticulitis 12 21
Rectal Prolapse 1 1
Sigmoid & Cecal Volvulus 2
Totals 108 109
Table 14.3.2 Operative Procedures and Therapeutic Goals.
LACR OPEN
Right Colectomy 50 30
Transverse Colectomy 6 7
Left/Sigmoid Colectomy 45 44
Anterior Resection 3 17
APR, Amputation Rectum 3 7
Enterotomy & Excision 1 1
Subtotal Colectomy 0
Totals 108 109
Curative Intent in Malignant Disease 62 69
Palliation of Malignant Disease 9
Totals 71 72
Table 14.3.3 Postoperative Morbidity and Mortality.
LACR OPEN
Gastrointestinal (SBO, Ileus, UGI bleeding) 6 6
Urinary (UTI, Sepsis, Retention) 3 3
Cardio-Vascular(CHF, MI,Hypotension, DVT) 4 5
Infectious (Wound, Leak, C. Diff.) 2 6
Respiratory (Pneumonia) 0 2
Neurological (Seizures) 0 1
Multiple System-Organ Failure 1
Totals 16 (15%) 25 (24%)
Deaths (Not related to Malignancy) 2 (1.9%) 6 (5.5%)
Table 14.3.4 Tumor Location, Lymph node Yield and Metastases.
LACR OPEN LACR OPEN
Right Colon 36 19 11.1 (2−26) 12.4 (6−24)
Transverse Colon 3 9
Left/Sigmoid Colon 28 29 7.9 (0−23) 9.7 (0−32)
Rectum 4
Totals 71 72
Node Metastases 44% 34%
Incision Tumor Implantation 0 0
Table 14.3.5 Duration of Operation, of Postoperative Recovery and Related Costs.
Operative Time 137 min
Days to P.−O. Diet 2 (1−7) 3.8 (1−16)
Days in Hospital 6.0 (2−20) 11.2 (3−59)
OR & RR Costs $ 4088 $ 2983
OR, RR, Hospital Costs
(6.0 vs. 11.2 days at $ 510/day)
Table 14.3.6 Value of Laparoscopically Assisted Colo-Rectal Procedures.
Usefulness * * *
Efficiency * * * ? ?
Economy * *
Ethics * * ? ?
15
LACR OPEN
(60−285)
$ 7148 $ 8695
Benign Malignant
5
3
3
2
157 min
(45−360)
452
14.3 Minimally Invasive Surgery by Video-Endoscopic Techniques
anatomical structures; ligation or control of the hernia sac at
the peritoneal level (higher than in a conventional indirect herniorrhaphy); preparation of the mesh to reinforce the inguinal
floor; placement and anchoring of the mesh; closure of the
access sites.
Indications are: Recurrent and primary bilateral hernias, pantaloon direct and indirect hernia, coexisting indirect and
femoral hernia, primary unilateral hernia if early return to normal activities is important.
Contraindication: Irreducible inguino-scrotal incarceration.
We have also continued to favor traditional indirect inguinal
hernia repair under local anesthesia in women, as well as open
repair under general anesthesia in children. However in case of
a unilateral hernia in a boy, creation of a mild pneumoperitoneum through the opened hernia sac and inspection of the
opposite side with a 2 mm scope, have largely eliminated the
vexing problem of a clinically silent, but later apparent contralateral hernia.
During the 26 months period under consideration, 252 patients
(238 men, 14 women) have undergone 310 inguinal hernia repairs. In twenty patients a reducible inguino-scrotal hernia was
successfully treated with this technique; conversion to an open
procedure became necessary in eleven patients, mostly early
on, for technical reasons.
Postoperatively most patients complain of a scrotal ecchymosis
due to migration of minimal amounts of blood from the communicating inguinal area. This is usually resorbed within a
week, and patients should be warned preoperatively. There
were two seromas of the cord in this series that were treated by
single aspirations. There have been no vascular injuries to date.
There has been one lateral femoro-cutaneous nerve injury in a
patient with a repair for hernia recurrence, in spite of the fact
that in this patient as in all our patients the placement of tacks
below the iliopubic tract and lateral to the epigastric vessels is
never done. In this patient the course of the nerve may have
been altered at the original operation There were four recurrences early in this experience: Three were due to a direct defect by the medial lift of the patch. Repair was accomplished
under local anesthesia by placing a Lichtenstein plug into the
direct defect. The fourth recurrence occured in a patient with an
onlay patch rather than a patch placed around the cord which is
our usual technique. Overall satisfactory results as shown above
have continued since 1995 in a series of well over 1000 patients.
In spite of the need for general anesthesia, all patients are discharged on the day of operation, unless co-morbidity factors
mandate a longer hospital stay for observation or treatment of
preexisting diseases. The near total absence of pain and early return to the preoperative occupation of the patients—often
within days, always within a week—stand in obvious contrast to
comparable parameters in patients operated on by traditional
techniques. We have however not been able to quantitate these
differences, since the number of patients operated in a traditional fashion has been fading progressively.
In spite of the obvious postoperative advantages of less or no
analgesic requirements and much earlier return to normal activity and productivity, the economic equation is not as demon-
strably favorable to this operation as it is for cholecystectomy or
even colon resection. The reason for this lies in the much higher
operating room costs as compared to the traditional operation;
costs that are counterbalanced and marginally eclipsed by the
earlier return to work. However since the support for operation
and postoperative course is controlled by two different purse-
strings—often widely apart in their social intentions and desire
to preserve a financial edge—it is near impossible to obtain a
comparable accounting of expenses and savings for competitive
surgical approaches in today’s western health care systems.
With these limitations in mind, we have judged the Value of
Video-endoscopic Preperitoneal Inguinal Herniorrhaphy as follows:
− Usefulness ***
− Efficiency ***
− Economy *
− Ethics***
This value assessment can be extended to other laparoscopic
anatomical and functional repairs, although the financial equation is much more favorable in cardiamyotomy, G−E antireflux
procedures and bladder neck reconstruction because of reduced
hospital stays as compared to their respective “open” counterparts. In spinal operations the hospitalization is often determined by factors other then the surgical approach.
Conclusions
Surgery is the science and art or craft to heal wounds, repair anatomical defects and improve or cure deficiencies and disease by
mecanical therapeutic means. While treatment is in progress, it
should not harm intact tissues and organs, but should restore optimal form and function. These goals are depending on the therapeutic means e. g.: operative technique and scientific technology to the extent that by improving these two, surgeons improve treatment outcomes in favor of the patient.
Minimally Invasive Surgery by videoendoscopic means fits these
goals and satisfies the surgeons’ continuous quest for better outcomes, by improving the healing process, accelerating convalescence and limiting tissue trauma through reduced access sites to
intraluminal or intracavitary operations.
The waysand means used in traditional surgical actions to obtain
optimal outcomes, e. g., anesthesia and analgesia, asepsis and
antisepsis, hemostasis and homeostasis remain the same with
the use of videoendoscopic techniques, except that reduced
access sites lead to a lesser need for analgesia and limit the
danger of wound contamination. However the intracavitary
operation, always using the same strategy and technique as the
equivalent open procedure, after access has been gained, requires careful hemostatic techniques. If this cannot b e assured
because of a reduced access, then conversion to or a primary
decision in favor of open operation has to be accepted, and the
patient should always agree to this preoperatively. In the vast
majority of operations done through a limited, videoendoscopic
access, careful dissection and ever improving hemostatic techniques and means, will make conversion to open operation for
hemostasis unnecessary.
Therefore, except for minor adjustments as outlined, minimally
invasive endoscopic techniques can be accomplished by using
the same means and ways that surgeons are used to for traditional operative procedures. With the understanding that the
progress as shown in the four categories of minimally invasive
endoscopic activities is based on ever advancing technology, but
can and should never be dominated by the scientific-industrial
complex.
Bibliography
Arregui M, Fitzgibbons jr. RJ, Katkhouda N, McKernan JB, Reich H. Principles
of Laparoscopic Surgery. New York-Berlin: Springer-Verlag; 1995.
Arregui M, Sackier JM. Minimal Access Coloproctology. Oxford: Radcliffe
Medical Press; 1995.
Kremer K, Lierse W, Platzer W, Schreiber HW, Weller S. Minimal Invasive
Chirurgie. Stuttgart-New York: Thieme-Verlag; 1995.
Liem MS, Halsema JAM, van der Graaf Y. Schrijvers AJP, van Vroonhoven
TJMV. Cost-effectiveness of extraperitoneal laparoscopic inguinal hernia
repair: a randomized comparison with conventional herniorraphy.
Philadelphia: Lippincott-Raven, Annals Surgery 1997; 226:668−676.
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453
454
Index
A
Abdomen
acute, see acute abdomen
frozen 320
lower
exploration 60
inspection 65
lower right
transrectal incision, loop
ileostomy 329
middle
inspection 65
systematic 70
trauma
diagnostic laparoscopy 61 ff
upper
exploration 60
inspection 64
topography 86 f
Abdominal cavity
exploration 293
Abdominal pain
acute, after appendectomy 306
Abdominal perfusion
reduced, laparoscopy 439
Abdominal sepsis
pneumoperitoneum 446
Abdominal trauma
blunt 438
laparoscopy 438
Abdominal wall
anatomy 19
emphysema 412
after inguinal hernia repair 412
hematoma
prevention 440
infection 410
Abscess
after abdominoperineal rectum
excision 390
after appendectomy 304, 306
appendiceal 302
intraabdominal 304
nonoperative drainage 309
peristomal 341
postoperative
appendectomy 293
retroperitoneal 363
retrouterine pouch
after appendectomy 306
subcutaneous 306
subfascial 306
subhepatic subphrenic 94
subphrenic 306
after ligamentum teres repair
268
Access
videolaparoscopic surgery 9 ff
Acetylsalicylic acid 194
Achalasia 262 ff
cardiomyotomy and fundoplasty
262ff
complications 262
intraoperative 262
contraindications 262
indications 262
objectives 262
operative technique 265 f
patient information 262
patient positioning 262 f
position of operating team 262 f
preparation 262
risks 262
trocar placement 263
pneumatic dilatation 262
Acute abdomen
laparoscopy 68 ff
anesthesia 69
comments 74
complications 71
contraindications 68
indications 68
instrumentation 69
patient monitoring 69
patient positioning 69
patient preparation 68
peritoneum 69
position of monitors 69
therapeutic choices 70
trocar placement 69
types of patients 74
bowel obstruction 74
peritoneal signs and no free
air 74
rigid abdomen and free air 74
Adhesions
after appendectomy 304
avascular 321
lysis with bipolar electro-
cautery 321
lysis with internal ligature 321
lysis with Roeder loop and knot
321
embryonic 351
female pelvic organs 83
gallbladder
lysis 96
inflammatory to liver capsule 103
cholecystectomy 103
laparoscopic lysis 320 ff
aquadissection 321, 324
bipolar electrocautery 321, 326
blunt dissection 321
clip technique 321, 327
coagulation near abdominal
wall 326
complications 327 f
intraoperative 327
late 328
postoperative 327 f
contraindications 321
conversion to open procedure
321
hydrodissection 321, 324
indications 321
internal ligature 321
objectives 320
patient information 321
patient with multiple previous
operations 321f
pneumoperitoneum 321
position of operating team 321 f
preparations 321
Roeder loop and knot 321, 327
sharp dissection 325 f
special trocar 323
stapler technique 321, 326
techniques 321
trocar placement 321f
lysis
fenestration of splenic cysts 165
hernia repair 425
peritoneal
appendectomy 291
Adnexae 82
inflammatory processes 83
Adnexitis
purulent 71
Adverse events 437
Alfentanil 56
American Society of Anesthesiolo-
gists see ASA
Ampulla of fallopian tube 82
Analgesia 56
postoperative requirements 58
Anastomosis
absorbable anastomotic rings 311
breakdown
after Meckel’s diverticulotomy
315
after resection of sigmoid colon
356
after small bowel resection 320
end-to-end
small bowel resection 319
gastroduodenostomy 177ff
gastrojejunal 179f
bleeding from staple rows 228
insufficiency 57
jejunal side-to-side
gastrojejunostomy 231
Meckel’s diverticulotomy 315
palliative small bowel bypass 320
triangular
small bowel resection 319
Anastomotic rings
absorbable 315
Anemia
hemolytic 155
Anesthesia 54 ff
balanced 56
control 56
depth 56
induction 55
local
diagnostic laparoscopy 63
performance 55 ff
regional 56
risk assessment
preoperative 55
total intravenous 56
videolaparoscopic surgery 11,
55ff
Anesthetics
volatile 56
Angina
abdominal 439
Anterior linear strip gastrectomy
denervating 197ff
Anterior resection
laparoscopically assisted (perineal
approach) 379ff
complications 380
contraindications 380
indications 379
objectives 379
patient information 380
patient positioning 380
trocar placement 380
with recto-sigmoidostomy 379
laparoscopically assisted 379 ff
Antibiotic therapy
appendectomy 302
Antral space
posterior, inspection 66
Antrectomy 174, 193, 206
Antrum
muscular structure 240
Anus
injuries 334
Anvil
resection of sigmoid colon 355
Appendectomy 291ff
anatomy 292
antibiotic therapy 302
bleeding, source of 304
changing graspers 297
coagulation
base of appendix 304
mesoappendix 303
complications 298, 302 ff, 444
late 306
postoperative 304 ff
contraindications 293
conventional 308
conversion to open procedure
293, 302
corrective laparoscopy 304
cutting ligature at base of appen-
dix 297
disinfecting stump of appendix 298
double-loop technique 300
drainage 302
error prevention 444
exploration of peritoneal cavity 293
extractor error 298
grasping appendix tip 296
indications 291, 293
laparoscopic
advantages 307
avoidance of electrocautery 308
comments 307 ff
ligating base of appendix 299
milking contents from base of ap-
pendix 297
morbidity 293
postoperative 304
necrosis of cecum 304
open procedure to treat cecum
444
patient information 293
patient positioning 293 f, 309
peritoneal adhesions 291
placing Roeder loop 296
position of equipment 294
position of operating team 293 f
preparation 293
regional anatomy 291
retrograde technique 293, 299 ff
coagulation of mesoappendix
300
specimen retrieval 300
window of mesoappendix 299
reversed technique 297 f
source of bleeding 304
specimen retrieval 295
staple technique 299 ff
surgical site 301
trocar placement 300
transection of base of appendix
298
transection of mesoappendix 296
trocar placement 295
vessel management with clips 296
Index
455
Appendiceal stump
coagulation by electrocautery 293
complications 444
overly long 293
Appendicitis 74, 291
acute 438
staging 291
chronic 291
diagnostic laparoscopy 308
early 291
gangrenous 291
intramural abscess-forming 291
nongangrenous 308
phlegmonous 291
ruptured 291
ulcerous/phlegmonous 291
Appendicostomy 334
Appendix
avulsion 303
base
coagulation 304
transection 298
carcinoid tumor 291
carcinoma 291
mucoceles 291
retrocecal position 305
stump
avoidance of complications 302
complications 444
disinfection 298
management 444
Approach
least invasive 448
Aquadissection
adhesions 321
Arch
iliopectineal 418
Arcuate line 418
Arterial pressure, mean 445
Artery(ies)
appendiceal
bleeding 303 f
clip ligation 296
positional variations 292
cecal
anterior 292
appendiceal branch 292
posterior 292
colic
left 395
cystic 86, 90, 107
bleeding 94, 109
branching 90
ligation technique 99
stump
bleeding 94
transection 99
variations in origin 90
epigastric
inferior 415
femoral 418
gastric
left 86
posterior 249
right 86, 241
short 157f
gastroduodenal 86, 89 f
ileac branch 292
right 86
hepatic
common 86
early division 89
proper 87
right branch
course variations 89
trifurcation 89
ileocolic 292
iliac
common
injury by first trocar 441
puncture during appen-
dectomy 303
external 415
mesenteric
inferior 393
exposure 394
high ligation
rectum amputation 387
ischemia of supplied organs
439
ligation 352
transection 352, 394
pancreatoduodenal
superior anterior 91
superior posterior 91
rectal
middle
transection 398
superior 395
sigmoid 395
splenic 157 f, 249
division 159
testicular 422
course with lateral inguinal
hernia 421
ASA risk assessment
preoperative 55
Atrophy
Testicular
hernia repair 435
B
Babcock clamp 210
Babcock stomach grasper 211
Balloon catheter/stone basket 146
Barbiturates 55
Barrett’s esophagus 246, 255
Belsey Mark IV repair 241
thoracoscopic 252
Benzodiazepines 55
Bile duct(s)
common 86 f, 144
see also common bile duct
arterial supply 91
course 88
injury in cholecystectomy 94
terminal
arterial supply 91
drainage 87
extrahepatic
diagnosis 128ff
treatment 128ff
injuries 440, 442 f
during choledochoscopy 143
intraoperative 85
prevention 440, 442 ff
intraoperative radiography 443
stones
transpapillary endoscopic re-
moval 85
ultrasonography 128 ff
avoiding problems 129
complications 129
contraindications 128
equipment 128
indications 128
patient information 128
patient positioning 128
position of equipment 130
position of operating team 130
preparations 128
trocar placement 128, 131
Bile leakage/loss
after cholecystectomy 94
after fenestration of hepatic cysts
166
Biliary obstruction
malignant unresectable 148
Biliary operations
Laparoscopic
comments 153
Biliary stent
endoscopic implantation 148
Billroth I gastric resection 174
anastomotic ulcer 233
Billroth II gastric resection 174
anastomotic ulcer 233
Bleeding
intraluminal
gastrojejunostomy 228
laparoscopically-assisted right
hemicolectomy 342
intraoperative
abdominoperineal rectum exci-
sion 390
gastric banding 273
hernia repair 433
inguinal hernia repair 412
resection of sigmoid colon 349
small bowel resection 320
truncal vagotomy with pyloro-
plasty 218
mesentery
loop ileostomy 333
postoperative
abdominoperineal rectum exci-
sion 390
cholecystectomy 94
ligamentum teres repair 268
selective proximal vagotomy
207
Block
sympathetic 56
Blood gas analysis
venous 57
Blood vessels
sealing 32
see also vessels
Body mass index 283
Bowel
ischemic 74
large, see large bowel
obstruction 74
preoperative preparation 155,
249, 349, 364, 368
resection of sigmoid colon 349
splenectomy 155
small, see small bowel
Bowel
thermal damage during resection
of sigmoid colon 354
Bursa
omental, opening 158
Bypass
biliary-enteric, laparoscopic 148
C
Calot’s triangle 96 f
extensive inflammation 117
Canal
femoral 418
Capnometry 57
Carcinoid tumor
appendix 291
Carcinoma
appendix 291
esophagus
laparoscopic staging 75
pancreas
laparoscopic staging 75
rectal
inoperable 334
sigmoid 348
stomach
laparoscopic staging 75
Cardia
injury
during fundoplication 253
during Nissen fundoplication
238
Cardiac output 444
pneumoperitoneum 55
Cardiomyotomy 262 ff
Cardiomyotomy and fundoplasty
for achalasia 262f
complications 262
postoperative 262
contraindications 262
indications 262
objectives 262
operative technique 265 f
patient information 262
position of operating team 262 f
preparation 262
risks 262
trocar placement 263
Cardiopulmonary risk 51
Cardiovascular system
effect of pneumoperitoneum 444
direct systemic CO
pressure related phenomena
444
Carter-Thomason Needle-Point Su-
ture Passer
Catheter
central venous 56
Cecal distension syndrome 293, 306
Cecostomy 334
Cecum 291, 331
necrosis 304
open management 444
Cervix
uterine 82
Cholangiographic catheter 134
Cholangiography
endoscopic, retrograde (ERC)
intraoperative 133
intraoperative 107, 127, 133ff, 153
catheter placement 134
comments 136
complications 135
indications 133
intravenous 133
oral 133
transhepatic 133
Cholangitis 140
purulent 137
with gallstones 142
Cholecystectomy 1, 85 ff, 438, 440
analgesic requirements
postoperative 57
anatomy 86 f
anterograde 117ff
anesthesia 118
complications 118
contraindications 117
cystic artery
cystic duct
dissection of gallbladder from
indications 117f
methods 117
patient information 118
patient positioning 118
preparation 118
trocar placement 118
approaches 93
bleeding
intraoperative 94
location of source 442
blunt dissection of gallbladder
from liver bed 100
clip
faulty placement 109
improperly placed 94
technique 98
coagulation of blood vessels 100
common bile duct
dissection 107
injury 93
insufficient exposure 107
partial ligature 107
transection 107
complications 93 f, 107ff
intraoperative 93 f
late 94
postoperative 57, 86, 94
TM
exposure 119
location 119
transection 119
liver bed 118
2
device 22
effect 444
456
Index
Cholecystectomy
contraindications 85
conversion to open procedure 85,
443
cystic artery
bleeding 109
cystic duct
dissection 97
ligation
clip technique 108
Roeder knot 108
injuries 106
diaphragm injury 111
direction of dissection 442
dissection in Calot’s triangle 96 f,
107, 109
electrocautery
hooked bipolar 103
exploration of common bile duct
142
exposure of individual structures
442
gallbladder
aspiration 95
extraction 101
fixation 96
lysis of adhesions 96
perforation
accidental 105
retrieval
alternate method 119 ff
operative technique 122ff
complications 120
contraindications 119
indications 119
patient information 119
patient positioning 120
sterile bag 119
trocar placement 121
gallstone retrieval 106, 119
gastrointestinal tract injury 94
grasper
safety precautions 111
indications 85
limited 85
instrument trocar
handling 114
laparoscopic 85 ff, 153, 450
comments 126 f
gas-free 85
liver bed
penetration 110
venous injury 110
liver parenchyma
injury 111
loss of swab through flap valve
113
patient information 85
patient positioning 91
placement of drainage 102
position of equipment 92
position of operating team 91 f
preparation 86
presence of adhesions 103
inflammatory 103
to liver capsule 103
rendezvous maneuver 115
retrieval bag 102
retrieval technique 101f
retrograde 85ff
safety precautions 111
scissors
improper use 112
subserosal dissection of gall-
bladder 99
swab dissector use 114
transection of cystic artery 98
trocar placement 93
vascular injuries 94, 108
Cholecystitis 141
acalculous 85
acute 74, 85, 117, 153
chronic 85, 117
Cholecystojejunostomy
laparoscopic 148ff
contraindications 148
indications 148
trocar placement 149f
Choledocholithiasis 85, 128
Choledocholithotomy
laparoscopic 127
Choledochoscopy 145
intraoperative 134
Choledochotomy 142
laparoscopic 142
Cholelithiasis 85
symptomatic 85
Cholestasis 142
Circular stapler
resection of sigmoid colon 355
Clinical studies
controlled 437
Clips
faulty placement 109
cholecystectomy 94
ligation of cystic duct 98
technique
lysis of adhesions 327
avascular 321
bypass 93
CO
2
difference
CO
2
end-tidal expired/arterial 55
emphysema
CO
2
during fundoplication 254
insufflation
CO
2
intraabdominal 54
monitoring
CO
2
end-tidal 55
partial pressure, arterial 55, 57
CO
2
pneumoperitoneum, see
CO
2
pneumoperitoneum
systemic concentration 445
CO
2
Coagulation
disorders 410, 417
mesoappendix 304
Colic flexure
left, mobilization 351
Colitis 71
Colon
combined endoluminal and open
procedure 362 f
complications 362
intraoperative 362
postoperative 362
contraindications 362
indications 362
instruments 362
objectives 362
operative technique 362 f
patient positioning 362
position of operating team 362
iatrogenic perforations 364 ff
intraluminal diagnosis 366
repair 364 ff
complications 365 f
intraoperative 365
postoperative 366
contraindications 364
conventional 364
indications 364
operative technique 366 f
patient information 364
patient positioning 364 f
position of operating team
364 f
preparation 364
stapler technique 367
suture technique 367
trocar placement 364, 366
injury
during lysis of adhesions 327
during splenectomy 155
pedunculated lesions 190
perforation 74, 438
repair
comments 402
indications 402
patient positioning 402
sigmoid
assessment of mobility 338
endometriosis implants 348
extracting resected specimen
353
looping of 338
resection 348 ff
anastomosis 356
anvil introduction 355
bowel preparation 349
closed 348
contraindications 348
conversion to open procedure
349, 356
extraction of resected
specimen 353
improper joining of anvil and
cartridges 354
indications 348
lymph node dissection 352
mobilization of left colic
flexure 351
opening of proximal bowel
end 354
patient information 349
patient positioning 349
plane of dissection 351f
position of equipment 349
position of operating team
349
preparation 349
pursestring suture clamp 348
retrieval bag 348, 353
introduction 353
stapler technique 348, 355 f
transection of inferior mesen-
teric artery 352
trocar placement 350
tumor localization 351
thermal damage
during appendectomy 303
Colonoscopy
diagnostic 364
preoperative 351
Colo-rectal procedures 450
laparoscopic 364 ff
advantages 405
comments 402 ff
differences to open procedures
404
theoretical advantages 404
Colostomy
creation 335
of descending colon 334
double-lumen 329
creation 337
transverse 329
loop 334
sigmoid 334
double-lumen 338 f
temporary double-lumen 334
temporary transverse 334
terminal (single-lumen) 334, 340
attachment to epidermis 340
creation 337, 340 f
of descending colon 387
after rectum excision 398
transverse 334
Common bile duct 107, 134
see also bile duct, common
dissection 107
exploration 142ff
complications 143
drainage placement 146
entry through stump of cystic
duct 144
indications 142
patient information 142
preparation 142
trocar placement 143
with cholecystectomy 142
intraluminal endoscopic
exploration 137ff
complications 137
late 140
longitudinal incision 144
partial ligature 107
puncture by guide wire 135
stone removal 142ff
complications 143
drainage placement 146 f
indications 142
patient information 142
preparation 142
trocar placement 143
with cholecystectomy 142
Competence 439
Complications 437
Confluence
cystic-common bile duct
constriction 94
Consensus conferences 437
Constipation
rectal prolapse 367
Conversion to open procedure 1
Cooper’s ligament 415, 421
see also ligament, pectineal
Critical incidents 437
Crohn’s disease 309
localized 316
right hemicolectomy 363
disease, stenosis 227
small bowel resection 320
Crow’s foot
cephalad branch 210
Curvature
lesser
closure of serosa 212
dissection 210
of nerve strands 216
necrosis 210
Cyanotic wound edges
during small bowel resection 320
Cyst(s)
follicle, see follicle cysts
hepatic
acquired 166
aspiration 168
congenital 166
diagnosis 166
fenestration 166ff
aspiration 168
complications 166
contraindications 166
conversion to open procedure
166
indications 166
patient information 166
patient positioning 167
position of equipment 167
position of operating team
167
trocar placement 167
genuine 166
posttraumatic 166
resection of cyst dome 166
resection of cyst wall 168
parasitic
liver 166
spleen 162
splenic
aspiration 165
congenital 162
fenestration 162ff
complications 164
contraindications 163
conversion to open procedure
163
indications 162
lysis of adhesions 165
omental fold 165
patient positioning 163
position of equipment 163
position of operating team 163
Index
457
preoperative large bowel
preparation 163
trocar placement 164
genuine 162
giant 162
patient information 163
resection of cyst wall 162, 165
rupture 162
transductal drainage 190
transmural drainage 189
umbilical 310
Cystadenocarcinoma
liver 166
Cystadenoma
liver 166
Cystic duct 86, 107
access for common bile duct exploration 144
anatomic variations 88, 106
course 88
dissection
blunt 97
injury during cholecystectomy 106
introduction of catheter
intraoperative cholangiography
134
ligation technique 99
with clips 98
ultrasonography 132
Cystostomy
gastroduodeno-pancreatic
endoscopic intraluminal 188ff
transmural 188
D
Damage
thermal
during appendectomy 303
Denervation symptoms
after fundoplication 255
Denervation syndrome
after Nissen fundoplication 241
Dermatitis
peristomal 341
Diagnostics
preoperative 55
videolaparoscopic 59 ff
Diaphragm
lesions
diagnostic laparoscopy 65
perforation during cholecys-
tectomy 111
rupture 438
Diarrhea
after truncal vagotomy with
pyloroplasty 219
post-vagotomy 237
Diazepam 55
Disasters 437ff
Diverticulitis
complicated acute 375
perforated 74
Diverticulum, Meckel’s
see Meckel’s diverticulum
Dor fundoplication 253
Double-loop technique
appendectomy 300
Drainage
after abdominoperineal rectum
excision 401
after appendectomy 302
after cholecystectomy 102
endoluminal endoscopic 227
exploration of common bile duct
146 f
external transhepatic 227
procedures 194ff
Duct
cystic, see cystic duct
hepatic, see hepatic duct
thoracic, see thoracic duct
vitelline, see vitelline duct
Dukes B lesions 380
Dumping syndrome 197
Duodenal lumen
opening in pyloromyotomy 218,
221
Duodenojejunostomy
Roux-en-Y 192
Duodenum
inoperable malignant obstruction
227
proximal
muscular structure 240
Dysfunction
urogenital
after abdominoperineal rectum
excision 391
Dysphagia 262
after fundoplication 254
after Nissen fundoplication 239
persistent
after cardiomyotomy and fun-
doplasty 262
prevention 248
transient
after thorascopic truncal
vagotomy 237
E
ECG monitoring 55
Echinococcus alveolaris 16 6
Echinococcus granularis 16 6
Echinococcus infestation
spleen 162
Electrocautery
avoiding injury 444
bipolar
anterior vagal trunk 220
hooked 103
lysis of adhesions 326
avascular 321, 323
contact with instrument trocar
104
monoploar 104, 433
insulation defect 104
papillotomy incision 137
Embolism
paradoxical 56
Emphysema
abdominal wall
after preperitoneal hernia
repair 410
CO
2
during fundoplication 254
scrotal
after inguinal hernia repair 412
after preperitoneal hernia
repair 410
subcutaneous
during thorascopic truncal
vagotomy 235
Emptying disorders 200
Endo Stitch
EndoGIA
Endometriosis 83
Endoscopes 2
introduction
rigid 2
Endoscopy
combined endoluminal and intra-
endoluminal 190, 362
intraluminal
transpapillary retrograde 142
Enflurane 56
Enteritis 72
acute regional
TM
29f
TM
20
complications 2
cavitary 366
exploration of common bile
duct 137ff
complications 137
late 140
terminal ileum 293
Enterocystocele 310
Enteroenterostomy
side-to-side 318
Enterostomies
multiple 334
Erlanger method
papillotomy 137
Error analysis 437 f
advantages 438
concept 437
Errors 437
prevention 417
Esophageal pump insufficiency
246
Esophagitis 246
reflux
after gastric banding 273
Esophagogastroduodenoscopy
194
endoluminal 192
Esophagogastroscopy
preoperative 238
Esophagus
carcinoma
laparoscopic staging 75
elastic loop 242
endoscopic dilatation 238
injury
during fundoplication 253
during gastric banding 273
during gastropexy 259
during ligamentum teres repair
268
during Nissen fundoplication
238
during selective proximal
vagotomy 207
during thorascopic truncal
vagotomy 235
during truncal vagotomy with
seromyotomy 215
lower sphincter
muscular structure 240
peptic stricture 238
perforation
during truncal vagotomy with
pyloroplasty 217
stenosis
after ligamentum teres repair
268
Etomidate 55
Expired air
monitoring 57
CO
2
Exploration
videolaparoscopic 2, 59ff
Exposure
videolaparoscopic surgery 9 ff
F
Fallopian tubes 82
ampulla of 82
stenosis 83
infertility 83
stricture 83
infertility 83
Fascia
diaphragmatic
inferior 240
superior 240
internal spermatic 422
parietal pelvic 396
rectovisceral 396
rectus abdominis
posterior layer 418
transversalis 418
visceral pelvic 396
Fatty tissue
subcutaneous
contamination by trocar 113
Fecal diversion
complete temporary 329
Femoral canal 415
Fenestration
laparoscopic
hepatic cysts 166 ff
splenic cysts 162 ff
Fentanyl 56
Fibrin glue 50
sealing biliary leaks 50
sealing lymphatic leaks 50
sealing perforated ulcer 50
Fifth day syndrome 293, 306
Fistula
enterocutaneous 363
pulmonary parenchymal 235
rectal-vaginal 334
Fluorocholangiography
routine operative 127
Follicle cysts 82
retained physiological 83
Forced expiratory flow 446
Forced expiratory volume in one
second 446
Forced vital capacity 446
Fossa
inguinal
lateral 418
medial 415, 418
supravesical 418
Fundoplasty 262 ff
Fundoplication
anatomic aspects for surgery 247
complications 253 ff
intraoperative 253 f
postoperative 254 f
contraindications 248
Dor’s procedure 253
indications 247
laparoscopic 56
Lind’s procedure 253
Nissen, see Nissen fundoplication
objectives 246
partial 211, 244
anatomic aspects for surgery
247
complications 253 ff
intraoperative 253 f
postoperative 254 f
contraindications 246
indications 247
objectives 246
patient information 248
patient positioning 250
preparation 249
techniques 246ff, 252
trocar placement 250
patient information 248
patient positioning 250
preparation 249 f
re-do operation 255
techniques 246ff
trocar placement 250
Watson’s procedure 253
Fundus
mobilization
Nissen fundoplication 243
G
Gallbladder
adhesions
inflammatory 103
closure of aspiration site 96
dissection
from liver bed 100
subserosal 99
empyema 85
extraction 96
extractor 101, 93
hydrops 85
aspiration 95, 101
lymphatic drainage 87
perforated 438
during cholecystectomy 105
positional variations 87