The use of a modular skills center for the maintenance of laparoscopic skills.

Background: A reliable method supplying graduated experience and practice is needed to develop and refine laparoscopic skills. The laparoscopic surgeon, like the microvascular surgeon, must have ongoing training to refine and maintain his or her skills.

Methods: The authors describe a new modular training unit.

Safety evaluation of laparoscopically applied clips.

We have evaluated in vitro, the security of laparoscopically applied clips, through two commercially available clip appliers: the Endo Clip II (US Surgical) and the Ligaclip (Ethicon). The clip performance was tested with respect to dislodgment and leakage. Dislodgment was attempted both transversely and at 45 degrees with respect to the main axis of the tubular structures tested.

The use of models in laparoscopic education.

From earliest times, visual aids - from crude diagrams to complex, beautiful wax anatomical models - have been created to enhance the surgical learning process. Surgical educators realized early that suitable models could be used to develop the needed technical expertise essential to the safe performance of surgery. Practice on models also assisted in developing surgical judgment.

The laparoscopic hernia trainer. The role of a life-like trainer in laparoendoscopic education.

The safe and effective performance of laparoscopic inguinal hernia repair requires a working knowledge of pre-peritoneal anatomy. Most surgeons are unfamiliar with the retro-peritoneal view of the groin. A model has been developed which allows surgeons to learn pre-peritoneal anatomy, to practice laparoscopic inguinal herniorrhaphy and to assess their repairs.

Problem-solving in laparoscopic surgery.

The advent of the laparoscopic revolution and the wider applicability of laparoscopic procedures has caused surgeons to re-think the dynamics of intraoperative problem-solving. Problems of body habitus, previous surgery, exposure, bleeding, and anesthesia, as well as the problem cholangiogram, require new and innovative approaches, a practical approach to each of these common laparoscopic problems is presented.

Biliary lithotripsy as an adjunct to laparoscopic common bile duct stone extraction.

We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-micron(s) fiber delivering 30-70 mJ/pulse at 5-20 Hz.

Laparoscopic choledochoscopy and extraction of common bile duct stones.

Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty-three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct-common bile duct (TCD-CBD) exploration, and conventional "open" common duct exploration.

Endoscopy of the lacrimal outflow system.

Management of obstructions in the lacrimal drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles with outside diameters of from 0.

Laparoscopic cholecystectomy in acute cholecystitis.

Between August 1989 and December 1990, twenty-five patients with a preoperative diagnosis of acute cholecystitis underwent laparoscopic cholecystectomy. Twenty-one patients (84%) had abdominal tenderness, 16 (64%) had leukocytosis, and 10 (40%) had fever. Eleven patients (44%) came to the hospital with only one of these previously mentioned clinical signs.

Laparoscopic choledochoscopy: an effective approach to the common duct.

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team.

Laparoscopic exploration of the common bile duct: experience in 16 selected patients.

The authors' initial experience with transcystic duct and direct laparoscopic approaches to the exploration of the common bile duct is reported. The technique requires standard laparoscopic equipment, specialized endoscopes, and instruments developed for urologic stone manipulations. After cholangiography confirmed the presence of common bile duct stones, common duct stone extraction was performed in 16 selected patients age 20-88 years.

Biliary calculi fragmentation by a 308 nm excimer laser: a preliminary study.

The use of a 308-nm XeCl excimer laser for biliary stone fragmentation is reported. The 130-nsec laser pulses are delivered via UV grade fused silica fibers to the target stones immersed in normal saline solution and placed in direct contact with the fiber. Sixty biliary calculi, 20 cholesterol and 40 pigment, were fragmented in vitro.

Falloposcopic observations of endotubal isthmic plugs as a cause of reversible obstruction and their histological characterization.

Eighty falloposcopies were performed in fallopian tubes of women with suspected tubal disease. In three falloposcopies (4%), isthmic plugs were observed occluding the entire isthmic lumen. In all cases these plugs were mobilized by falloposcopic-directed, selected tubal cannulation and aquadissection techniques.

Falloposcopic identification of a fimbrio-ovarian mucus connection as a possible mechanism for tubal oocyte capture.

Falloposcopy combined with laparoscopy was performed in 11 women during the late follicular phase of spontaneous menstrual cycles, and a preovular follicle was confirmed to be present in each case. The fimbrial end of the tube and the ipsilateral ovary containing the preovular follicle were suspended in a fluid environment of 200 ml of lactated Ringer's solution which acted as a support medium for visualization of tubal mucus and facilitated the endoscopy procedure. As the falloposcope was passed through the fimbrial opening, it was observed to carry clear, elastic and filamentous strands of mucus material from within the distal tubal lumen in 4 of 11 procedures.

The importance of intraoperative cholangiography during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively.

Falloposcopy: a microendoscopic technique for visual exploration of the human fallopian tube from the uterotubal ostium to the fimbria using a transvaginal approach.

A transvaginal microendoscopic technique has been developed for safely exploring the human fallopian tube from the utero tubal ostium to the fimbria and adjacent peritoneal cavity. Falloposcopy was performed without complication or evidence of endotubal damage in 44 women, 38 of whom also underwent a concurrent laparoscopy. Eight women with normal tubes served as controls and 36 women with tubal damage underwent falloposcopy in an attempt to document endotubal defects.

Removal of cornual polyps with flexible hysteroscopy and a wire basket. A case report.

The hysteroscopic removal of large uterine polyps often can assist infertile women in conceiving. This report describes the removal of bilateral cornual polyps in a diethylstilbestrol-deformed, T-shaped uterus using a flexible operating hysteroscope and an 0.8-mm ureteral wire stone basket.

Falloposcopy. A microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty.

Direct visualization of the entire length of the fallopian tube lumen, from the uterotubal ostium to the fimbria, using a transvaginal approach, has been achieved. Small, flexible hysteroscopes with outside diameters (ODs) ranging from 3.3 to 4.

Fragmentation of biliary stones with a 308 nm excimer laser.

The use of a XeCl excimer laser (308 nm) for biliary stone fragmentation is reported. Laser energy is delivered via UV grade fused silica fibers to the target stones immersed in normal saline solution. Sixty biliary calculi--pigment (n = 40), and cholesterol (n = 20)--were fragmented in vitro.

Percutaneous endoscopic laser lithotripsy of retained stones in the left hepatic duct. The role of the surgeon.

A 35-year-old woman with a retained stone in a branch of the left hepatic duct was referred to us. The stone was discovered on the postoperative T-tube cholangiogram. A flexible ureteroscope was introduced into the duct, under fluoroscopic and direct endoscopic vision and the pulse dye laser was used successfully to disintegrate the calculus.

Laparoscopic cholecystectomy: instrumentation and technique.

Laparoscopic cholecystectomy is rapidly evolving as a therapeutic modality for the treatment of gallstone disease. The technical details of this procedure and the method by which the gallbladder is dissected and removed are critical to the safe, effective execution of the procedure. Our technique has been developed through extensive practice in porcine models and through experience with more than 250 patients.

Development and application of a falloposcope for transvaginal endoscopy of the fallopian tube.

A small flexible microendoscope with an outside diameter (OD) of 0.5 mm has been developed for effective visualization of the entire length of the human fallopian tube. Using a transvaginal approach, a small flexible operating hysteroscope with an OD ranging from 3.