Laparoscopic surgery in hepatic, biliary and hematologic diseases : advantages, limits and complications

Organ transplantation and laparoscopic surgery are clearly the two most recent revolutions in actual surgical practice. Laparoscopic surgery really started in 1987, when Philippe MOURET performed the first laparoscopic cholecystectomy (LC) in France. The concept of laparoscopic surgery is to create o working space by insufflating an inert gas (CO2) within the peritoneal cavity. The surgical procedure is performed though a variable number of “key-holes” by using special introduction tubes (trocars) and instruments. The operation is assessed on a video-screen via a camera connected to a rigid fiberoptic (the laparoscope). This procedure is performed on a “closed abdomen” in comparison to open surgery through a laparotomy, and for this reason has at times been called “Nintendo surgery”. Several advantages have been advocated, such as reduced postoperative pain and pulmonary dysfunction, lower stress response to surgery, shorter postoperative hospital stay, earlier return to normal activities and esthetic benefit (3-5). Based on the suggestion than laparoscopic surgery is “minimally-invasive surgery”, LC had a rapid wide spread diffusion among general surgeons all over the world and the approach has been applied to an increasing number of pathologies. According to MEDLINE, 256 publications were dedicated to laparoscopic surgery in 1990. This number rose to 1,064 in 1992, 1,954 in 1994, and 1,415 from January to November 1996n thereby confirming the exposure enthusiasm for the techniques. Almost all types of gastro-intestinal operations have been performed laparoscopically : appendectomy, inguinal hernia repair, antireflux procedures, cardiomyotomy for esophageal achalasia, vagotomies, Billroth II gastrectomy, gastroenterostomy, esophagectomy, treatment of perforated peptic ulcer and small bowel obstruction, gastroplasty for morbid obesity, all types of colorectal resections, small bowel resection for Crohn’s disease … etc. In urology, nephrectomy, adrenalectomy, ureterolithotomy, lymph nodes staging for pelvic cancer, and lymphocele drainage procedure after kidney transplantation have been reported to be feasible laparoscopically. In cardiovascular surgery, new developments include laparoscopically-assisted abdominal aortic aneurysm repair, retroperitoneal approach for aorto-illiac reconstructions, and more recently coronary artery bypass. In hepato-bilio-pancreatic, diseases, laparoscopy has also been applied to various procedures: staging of liver or pancreatic cancers, pancreatic resections, cyst-drainage operation for pancreatic pseudocysts, drainage procedures for acute necrotizing pancreatitis, partial hepatic resections, bilio-digestive anastomosis and gastro-enterostomy for unresectable pancreatic cancer. However, besides the initial data demonstrating the feasibility of the techniques, specific complications related to the techniques less commonly or not observed in open procedures have been increasingly reported : severe hypercarbia or lethal gas embolism due to CO2 insufflation; trocar injuries to the viscus or the major vessels; biliary tract injuries during LC; endobiliary migration of clips used ti secure the cystic duct during LC; intraperitoneal abscesses due to spilled gallstones; and entrapment neuropathy and small bowel entrapment after laparoscopic herniorrhaphy. Some concerns also exist regarding the potential occurrence of tumor cells seeding and trocar site implantation of malignant cells during laparoscopic procedures for malignant diseases due ti the pneumoperitoneum. Among the various procedures performed laparoscopiccaly, cholecystectomy has been the most commonly evaluates. Several consensus conferences have recognized LC as the “gold standard” for removal of the gallbladder. Additionally, prospective randomized controlled studies have proved the safety and the superiority of LC over open procedures. However, a recent controlled trial published nine years after the first LC does not show any significant advantage over open cholecystectomy in terms of hospital stay or postoperative recovery and demonstrates that LC takes longer to perform and is more expensive. Except for appendectomy and inguinal herniorrhaphy, which have been evaluated by controlled trials, most procedures performed laparoscopically have not been scientifically compared to comparable open approaches. Most multicenter evaluations demonstrate that this new approach requires adequate technology, proper and careful use and appropriate training. Moreover, senseless, inadequate, or obsolete procedures have been described in laparoscopic surgery, such as treatment of indirect inguinal hernia by laparoscopic closure of the neck of the sac, thoracoscopic vagotomy without drainage procedure for peptic ulcer disease, laparoscopic intraluminal (intragastric) surgery for early gastric cancer, laparoscopic drainage of liver hydatid in the literature have stressed the need for scientific validation, appropriate patient selection and training. We propose in this thesis to evaluate the role of laparoscopic approach in the management of a selection of patients suffering from being liver diseases (congenital liver cysts and polycystic liver disease), biliary pathologies (gallstones and common bile duct stones, focusing on the problem of biliary tract injury during laparoscopic cholecystectomy), and hematologic disorders requiring splenectomy. The main of this review is first to make a critical analysis of the current management strategies of the abovementioned pathologies, including nonsurgical and conventional surgical approaches, in order to define the exact place of laparoscopic surgery in the management of these patients. On the other hand the purpose of this work is also to define the advantages, the limitations and the complications of laparoscopic surgery using our own experience, the multicenter experience of the Belgian Group for Endoscopic Surgery (B.G.E.S.) and a review of the literatureThèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 199