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07 THE CURRENT STATUS OF MINIMAL ACCESS SURGERY_A Maharaj

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									                                                                                  07/2002
         THE CURRENT STATUS OF MINIMAL ACCESS SURGERY
                                    DR. A MAHARAJ

COMMENTORS: DRS. E ALIMIA
                                                        MODERATOR: MR J. MOODLEY

                                    INTRODUCTION

Minimally invasive surgery has been the most significant development in general surgery.
The introduction of LC has seen it emerge as the gold standard for the procedure. Equally
relevant, it remains the sole procedure performed by the vast majority of General
Surgeons.
Fuelled by industry, minimal invasive techniques have been adopted to accommodate
every procedure performed by the General Surgeon. This has been done with
modifications that are less than satisfactory and fortunately, have not endured.
The scepticism that embraces MIS is warranted with the majority of initial reports merely
attesting to the performance of the procedure using MIS techniques. Subsequent reports
have largely evaluated early outcomes of the MIS techniques with incongruent or
congruent open procedures suggesting a superior outcome. To date there are no
prospective randomised controlled studies critically evaluating its superiority over
traditional procedures especially in the intermediate and long-term. Two aspects have
emerged, MIS is expensive and is not universally applicable over the concomitant open
procedure.


                                     TECHNOLOGY2

Equipment
Fibre – optic rod (telescope) mated to video camera. Angled telescopes allow for
visualisation around corners. Smaller telescopes are attended with diminution of the
operative field.

Video Imaging

Currently 3 chip cameras are applied. The full impact has yet to be appreciated, as monitor
resolution has not been complementary.

Insufflators

The creation of a working space has proven to be the 1 st Achilles heel of MIS. Critical
attention to pressure in appropriate is essential especially in patients with co – morbid
factors.
Gasless laparoscopy has not evolved adequately to replace CO2 insufflators. CO2 may
not be appropriate in certain scenarios eg. borderline respiratory function and for adrenal
medullary tumours. Typical flow rates are 6 – 8 l / min and are pressure limited to
15mmHG.

Ports and instruments
                                                                                            2
A variety of ports and laparoscopic equivalent of surgical instruments are available in
reusable and disposable version in sizes from less than 3mm (needloscopic) to 10mm.
Needloscopic surgery is currently only practised by a few enthusiasts and some paediatric
centres.
The reuse vs. disposable debate rages on fuelled largely by manufacturers of equipment.
Most laparoscopic surgeons use a combination of disposables and reusable instruments.
                                 BASIC PRINCIPLES1,2,4

Positioning of the patient

Critical concept is that organ exposure is gravity assisted. This may require strapping the
patient to the table to facilitate access to the target organ. It is pertinent to remember the
while visualisation of the peritoneal cavity contents has been touted as one of its
advantages, certain procedures limit access where it may be more appropriate eg. extra –
peritoneal laparoscopic adrenalectomy.

Strategy of Port Placement

The proper placement of access ports can vastly reduce the difficulty of an MIS procedure.
The “diamond of success” takes cognisance of the optimal working distance from the
operative target.

Defining the anatomy

If there are any anatomic uncertainties, it is always best to convert the procedure to an
open approach.

                                PATIENT EVALUATION2,3,4

Contra – indications
  ABSOLUTE:
   Hypovolaemic shock, massive bleeding or haemodynamic instability.
   Severe cardio respiratory disease.

   RELATIVE
    Peritonitis
    Abdominal wall hernias
    Diaphragmatic hernias
    Uncontrolled coagulopathies
    Potential hypertension
    Multiple previous procedures / extensive intra - abdominal adhesions

BENEFITS / DISADVANTAGES

          Impact of procedure. Where the extent of exposure does not impact on
           outcome, the value of MIS is eliminated and may even prove detrimental eg.
           pancreatico- duodenectomy4.
          Magnification
          GA mandatory
          Ventilatory control. Moderate hyperventilation maybe necessary. Anticipate
           increase in airway pressure especially for deep Trendelenberg position.
                                                                                          3

   COMPLICATIONS2
       Position related
           Femoral or peroneal neuropathy from lithotomy
           Trendellenberg – pooling of blood, decreased preload and decreased
              cardiac output.
           DVT

         Trocar placement
             Bowel, solid organ, bladder and vascular injuries
             Bowel injuries increased in patients with hernias or previous surgeries
             A mortality of 5% is associated with laparoscopic bowel injuries
             Incisional hernias with port size >5mm

         Pneumo peritoneal related complications
            Pneumothorax, pneumo mediastimun, CO2 embolism, hypercarbia with
              acidosis.

                           DIAGNOSTIC LAPAROSCOPY4,7,9,11

Diagnostic laparoscopy is gaining acceptance as an alternative to diagnostic laparotomy
and as an adjunct to radiological investigations to eliminate extensive exposure in patients
in whom this may prove detrimental.

Liver tumours :
Evaluation of metastases and secondaries (30 – 40% with hepato-biliary carcinoma
undetected by CT scan)
             CT good for intra parenchymal lesions > 1cm
             Laparoscopy good for small surface lesions and peritoneal seedlings

Staging :
Role in lymphoma, pancreatic, gastric and oesophageal tumours
Lymph node assessment - The advantage is that it allows biopsy under direct vision.

Chronic liver disease:
Biopsy under vision is performed in chronic liver disease.

Equivocal abdominal exam:
 In females with RIF or Non specific abdominal pain to exclude appendicitis, chronic PID
and endometriosis.
Abdominal trauma:
Some centres advocate laparoscopy in the context of both blunt and penetrating trauma in
stable patients.
 The limitations of the technique
                      - the small bowel is difficult to assess (only 20% picked up in one
                         series)4
                      - tension pneumothorax with diaphragmatic injuries. Solutions are
                         gasless systems (these are cumbersome) and to pressure limit the
                         pneumoperitoneum to 10mmHg
                                                                                          4
Laparoscopic ultrasound4,7
                        Allows for high-resolution real time imaging of organs due to
                           direct contact of a probe with the viscera.
                        Compensates for the surgeons inability to palpate organs at
                           laproscopic surgery
                        Allows one to evaluate liver metastases, the CBD for stones
                           (as sensitive and less likely to technical failure that intra-
                           operative laparoscopic cholangiogram).


                      LAPARASCOPIC CHOLECYSTECTOMY2,3,4,9

Laparoscopic cholecystectomy is the proto type laproscopic surgical procedure and has
established itself as the gold standard therapy for symptomatic cholelithiasis

Indications

Symptomatic cholelitiasis
There is no controversy regarding the need for cholecystectomy in patients with
symptomatic cholelithiasis except when medical contra-indications to surgery exist and
percutaneous cholecystectomy may be employed as a temporary measure.

Asymptomatic cholelithiasis
There is no rationale for routine cholecystecomy either open or laproscopic in patients with
asymptomatic cholelithiasis as complication rates are low and patients progress to
symptomatic cholelithiasis before complicating. However certain relative indications exist
in asymptomatic patients4.
              Salmonella carriers
              Immuno-compromised patients
              The risk of malignancy – porcelain gall bladder, family history of gall
                 bladder cancer, residents of areas with endemic gall bladder cancer i.e.
                 Peru and Chile
              Children
              Biliary dyskinesia - patients with RUQ pain in whom there is no
                 demonstrable pathology and a gall bladder ejection function of less than
                 35% on hepato-biliary scan with cholecystokinin injection - is also
                 considered an indication 4.

Contraindications
   Any contraindications to general anaesthesia or laproscopic surgery
   Third trimester pregnancy
   A “hostile” abdomen is a relative contraindication and dependant on the experience
      of the surgeon

Technique

Performed under general anaesthesia with the patient in the reverse Trendellenberg
position. The bladder is emptied. A 3 or 4 port technique is used with the surgeon on the
left along with camera operator. The assistant stands on the right. French surgeons have
described a three port technique with the patient in lithotomy and use of a robotic arm to
operate the camera.
                                                                                                5
A pneumoperitoneum is created as previously described and the first port inserted either
blindly or with open dissection (the Hasson technique)
The gall bladder is grasped and fundus retracted to the right and upward while Hartman‟s
pouch is retracted laterally. This splays the cystic duct and CBD and makes them appear
as distinct structures. Too much upward traction could cause tenting of the CBD and
possible injury. The blunt dissection involving a tearing action to the fat and fibrous tissue
in Calots triangle will expose the cystic duct and artery. The artery is clipped and divided
before the duct in order to properly expose the duct and any variations in anatomy. It is not
necessary to expose the CBD and any attempts to routinely do so may increase the risk of
injury. After clipping and division of the cystic duct the gall bladder is dissected off the liver
and delivered through the umbilical port.
Routine laproscopic CBD cholangiography is not currently advocated. It may be indicated
in patients with abnormal LFTs, dilated ducts, multiple small stones and recent history of
pancreatits, jaundice or cholecystitis. In some centres laproscopic ultrasound is practised
as a less technically demanding but equally sensitive modality of imaging the duct.

Results
Laparoscopic cholecystectomy has proven advantages – these are:
      Shorter hospital stay
      Less time to resume normal duties
      Lower pain scores and less use of opioids
      Return to normal diet sooner
      Greater patient satisfaction
More cholecystectomies are now being done than ever before since the advent of the
laparoscope3. Initially it was thought that this was due to symptomatic patients previously
unwilling to have surgery now opting for a more acceptable procedure. However the
increase has been more than transient and this is one of the chief criticism of laparoscopic
procedures i.e. It is largely patient driven and has caused surgeons to lower this threshold
for surgery with the availability of a technique they perceive as safer but not without its
own morbidity.

COMPLICATIONS4

Morbidity ranges from 1 – 9% and CBD injuries 0,2 – 0,7% and largely depend on the
surgeons experience. Conversion rates are from 1,8 – 7,8%.
Specific complications include haemorrhage, bile leaks, retained stones, wound infections
and incisional hernias.
Other complications are pneumoperitoneum related and insertion related as described
previously.

LAPAROSCOPIC MANAGEMENT OF CBD STONES4

With the advent of laproscopic cholecystectomy efforts were made to avoid CBD
exploration and patients with suspected CBD stones were either excluded from
laproscopic cholecystectomy or underwent pre operative ERCP with clearance of the duct
and subsequent laproscopic cholecystectomy. Stones discovered intra- op or post-op were
dealt with, with post-operative sphincterotomy.
With the development of advanced laproscopic skills and equipment it is now possible to
explore the common bile duct laproscopicaly. A criticism of laproscopic CBD exploration is
that it does not allow for biliary decompression and bypass which maybe indicated in a
dilated system. Methods currently in use rely either on choledochotomy or trans – cystic
exploration after balloon dilation of the cystic duct and employ balloon trolling of the CBD,
                                                                                             6
fluoroscopic guided wire basket retrieval, ampullary balloon dilation or flexible biliary
endoscopy with wire basket retrieval.

Complications

          Perforation of the cystic duct or extra hepatic ducts, bile leaks, pancreatitis or
           persistent cholangitis
          Delayed stricture
          Retained stones or basket

                      LAPAROSCOPIC ANTI REFLUX SURGERY2,4,12

GORD and symptoms there of heartburn, dysphagia, chest pain, vomiting, asthma and
pneumonia are relatively common and usually respond to medical therapy. The goal of
therapy is to treat symptoms and prevent complications. The complication rate in those
patients who have oesophagitis is high (20%) and include Barrets oesophagitis, stricture,
oesophageal ulcer and haemorrhage.

Indications for surgery4,12

      Failure of conservative measures to control symptoms (lifestyle modification and
       diet).
      Persistence of symptoms on maximal medical therapy, usually proton pump
       inhibitors
      Non-compliance or difficulty tolerating medical therapy.
      Failure to prevent complications on medical therapy.

Prior to the advent of laparoscopic surgery few patients came to surgery largely because
of the morbidity of the open Nissens and other fundoplications done via upper midline
laparotomy for essentially a non-life threatening condition. Since the advent of laproscopic
surgery which offers a safe alternative with short hospital stay and faster return to function,
GORD surgery is now the commonest laproscopic procedure performed after a
cholecystectomy.

Technique
The technique consists of a four port access to the abdomen with the surgeon between the
patient‟s legs in the lithotomy position in steep reverse Trendellenberg. The liver is
retracted by a fixed retractor and the fundus is retracted to the right. The peritoneal
attachment to the left is divided and dissection carried out towards the spleen with the
ultrasonic scalpel.
The gastrosplenic ligament is divided next and the greater curve is displaced to the right
and caudally.
The oesophagophrenic membrane is divided along the left and then the right to mobilise
3cm of tension free intra abdominal oesophagus.
The Hiatus is closed around the oesophagus with non-absorbable sutures at 0,5 cm
intervals to approximate the Crura. The tightness of the closure may be measured using a
52FR bougie
The last step consists of creation of the fundoplication. The anterior and posterior portions
of the fundus are grasped and wrapped around the oesophagus. These are secured by
interrupted sutures over a distance of 2 – 3cm and anchored to the hiatus once complete.
                                                                                           7
Results
Symptom relief in 85 – 95% with typical symptoms being more responsive than atypical
symptoms. Objective pH monitoring demonstrates reduction in acid exposure time in
almost all patients. Risks for persistently abnormal acid exposure are those with strictures,
shortened oesophagus, Barrets oesophagus and extremely abnormal pre-operative acid
exposure. Reasons for failure include the symptoms not being caused by reflux, co-
existing illnesses whose symptoms are worsened by reflux and thus only partially respond
or permanent changes as a result of GORD. These can be minimised by careful
preoperative evaluation of symptomology with pH studies, manometery and endoscopy.
Laproscopic anti-reflux surgery is a well-established alternative to the open technique with
very few detractors. Recent reports from Scandinavia on failure of surgical therapy are a
comment on the role of surgery not on the minimally invasive approach12.

                       LAPAROSCOPIC HERNIA SURGERY2,3,4,5
Hernia surgery has always been fraught with controversy regarding the best repair. The
myriad available techniques may be divided into two types. The „tension‟ tissue based
repair and the “tension free” mesh repair. Amid all the controversy the laparoscopic
approach entered the fray with a promise of a recurrence rate of 5-10% shorter
convalescence and less pain4. Initial repairs were the ring closure, laparoscopic plug and
patch and intraperitoneal onlay mesh (IPOM). These were largely abandoned due to high
recurrences and increased incidence of intra-abdominal adhesions.

Current techniques are the transabdominal preperitoneal repair (TAPP) and totally
extraperitoneal repair (TEP) with TAPP becoming obsolete4.

TECHNIQUE OF TEP REPAIR
The surgery is carried out under general anaesthesia. An infra umbilical skin incision is
made and a balloon dissector is introduced between the peritoneum and pre transversalis
fascia. The scope is introduced and the dissection proceeds laterally to expose Coopers
ligament. Direct hernias are visualised immediately while indirect hernias are only
visualised once the internal ring is seen. The hernia is reduced with traction and may be
divided and ligated if adherent and large. A mesh 10 x 15 cm is introduced and the space
is deflated under vision to ensure that no rolling occurs. The contra lateral side can be
inspected for hernias and repaired if necessary.

DISCUSSION

For any hernia surgery to gain acceptance it has to be evaluated in a large series over
many years and compared to an equivalent operation in order to prove both its long and
short-term benefits.

Initial reports of the superiority of laparoscopic hernia surgery and its widespread
acceptance is currently undergoing a rethink. In a recent meta-analysis a few key points
have emerged.5
      Laparoscopic surgery requires a general anaesthetic
      Long-term follow-up is beginning to emerge and recurrence rates may be higher
        than thought.
      Very few studies compare laparoscopic surgery (mesh repair) to open mesh
        repairs. Most are a comparison against both mesh and tissue repairs.

 In comparison to open repair under local anaesthetic a laparoscopic repair commits one
to a mesh and a general anaesthetic with increased operating time and cost as well as
                                                                                            8
risks of nerve injury, adhesions and fistulation. It may have a limited role in the context of
recurrent or bilateral hernias in young patients, who tolerate a general anaesthetic easily.

                                  APPENDICECTOMY2,3,4

Appendicitis has been recognised since antiquity but it was not until the clinical
pathological consequences became evident that the first appendisectomy was described
in 1848. It is currently one of the more commonly performed surgical procedures and with
the advent of laproscopy it was only natural that this technique would be applied.
Indications are unchanged

Technique
A three-port technique is employed. The appendix is grasped after mobilisation of the
caecum for a retro-caecal appendix if necessary. The meso- appendix is dissected and a
stapler applied across the appendix. The meso- appendix is dealt with in the same way.
An endoloop or extra corporeal knot may also be used to achieve ligation of the appendix
stump. The appendix is placed in a plastic bag and retrieved via one of the port holes.
When the telescope is inserted a diagnostic laproscopy is done, a decision is made to
convert in the presence of a severe phlegmon or another diagnosis requiring a
laparotomy12.

Discussion
The proponents of laproscopic appendisectomy cite a shorter duration of hospitalisation,
less post op pain and better cosmesis.
Critics cite longer operative time, greater cost, no difference in hospital stay for
complicated appendicitis and increased complication rate in complicated appendicitis
(abscess formation is greater and it is speculated that this may be due to CO2 pneumo-
peritoneum). A single trocar injury may negate the minor benefits of the laproscopic
approach. The laproscopic approach also requires the availability of trained staff and
equipment at all hours. Currently laproscopic appendisectomy has not gained widespread
acceptance as a routine alternative to the open approach. It may however have a limited
role in young females in whom there is a diagnostic doubt2.


                                      SPLENECTOMY

Indications

The commonest indication for a splenectomy is trauma. This indication does not generally
lend itself to the laproscopic approach due to haemodynamic instability the duration of any
laproscopic procedure, the effects of a pneumo peritoneum on an even subtly hypotensive
patient and limitations in assessing and dealing with concomitant injuries.
The commonest indication for laproscopic splenectomy is ITP followed by a host of other
reticulo-endothelial and myelo-proliferative disorders.

Technique

The initial technique described was a trans-abdominal approach with the patient supine. A
lateral flank approach has been described and is gaining favour.
The patient is in the right lateral decubitus position and trocars are placed in the mid
clavicular, mid axillary line, mid epigastrium and umbilicus. The splenic flexure and left
                                                                                         9
colon are dissected free of the retro peritoneum with a harmonic scalpel. The short gastric
vessels are divided with a harmonic scalpel after ligation or clipping on the gastric side.
The avascular tissue is divided and the hilum is approached last. It is exposed with blunt
dissection and a linear stapling device is deployed loaded with vascular clips. The spleen
is transferred into a specimen bag brought to the skin surface and morsellized within the
bag and removed piece meal.
A search is made for accessory spleens and those are dealt with. A drain may be left
insitu. Hand assisted procedures for lager spleens have been described with the large
incision for the hand port in either the mid epigastrium or a Pfanallstien incision.

Results
The laparoscopic approach is gaining acceptance for normal size spleens. The laproscopic
approach results in longer operating time and more bleeding but boasts a shorter post
operative stay and less pain. The hand-assisted approach would seem to negate this.

                          LAPAROSCOPIC ADRENALECOMY

Indications
The laparoscopic adrenalectomy was described by Michael Gagner in 1992 and has since
been reported with increased frequency.
Most adrenal tumours are small and benign and lend themselves to the laproscopic
approach. Contraindications to the procedure include adrenal cortical carcinoma,
malignant phaeochromocytoma, large benign mass >5cm, contraindications to laproscopic
surgery in general, uncorrected coagulopathy and the need for concomitant abdominal
surgery.

Technique
Operative techniques described are either the supine or lateral flank approach or the
lateral trans abdominal approach. The retroperitoneal approach is preferred for bilateral
lesions since patients do not require repositioning while lager tumours necessitate a trans
abdominal approach.

Results
Adrenalectomy has been compared to its open versions in retrospective trails and
although has a longer operative time, is associated with shorter hospital stay, less
bleeding, rapid return to diet and resumption of normal duties 16. Complication rates are
lower and the wide spread acceptance of laproscopic adrenalectomy makes it unlikely that
prospective randomised trails will ever be conducted. Preliminary data indicate that
hormonal function in the contralateral adrenal gland returns sooner 15.

                        LAPAROSCOPIC HELLERS MYOTOMY

Oesophageal myotomy was first described by Heller in 1913 for symptomatic relief in
patients with achalasia. This required laparotomy or thoracotomy to make a single incision
on the oesophagus for symptomatic relief of a condition. In 1991 Cuschieri and colleagues
described a laproscopic version of the procedure which allows the same benefit without
the morbidity attendant to a laparotomy or thoracotomy. Studies currently support its
superiority over the open approach. Since achalasia is an oesophageal motility disorder,
reflux is common postoperative problem. A partial wrap (Dor Procedure) is often added
and has the benefit of protecting the anastomosis should the mucosal be breached as
well as keeping the myotomy open.
                                                                                        10



                     LAPAROSCOPIC SURGERY OF THE LIVER4

While laparoscopic surgery lends itself to solid organ surgery; the liver due to its sheer
size, vascularity and the limited experience in open liver surgery has limited laproscopic
approaches. In addition the considerable haemorrhage is difficult to control, the risk of
CO2 embolism and the need for advanced laproscopic skills as well as specialised
equipment (Nd: YAG laser) limit its practice to a few specialised centres where both
experimental labs and specialised equipment is available. The only laprasopic liver surgery
currently recommended is the unroofing of simple liver cysts.


                       LAPAROSCOPIC THORACOSCOPY4,13,14

The morbidity associated with a thoracotomy incision makes thoracoscopy an attractive
option for a host of procedures.
Indications include pleural disease, lung resections, pericardial disease, surgery to the
thoracic oesophagus and mediastinal procedures. Most are within the ambit of the thoracic
surgeon, but general surgical experience with thorcoscopic sympathectomy and
splanchinectomy has been extensive locally.
Initial enthusiasm for these procedures waned due to frequent recurrences and the
morbidity associated with access to the thorax but video assisted thoracoscopy and better
understanding of the anatomy of the sympathetic trunk has changed that.



THORACOSCOPIC T2 SYMPATHECTOMY
Indications
        Primary hyperhydrosis
        Chronic regional pain syndromes of the upper limb
        Vascular conditions viz. Raynauds phenomenon.

THORACOSCOPIC SPLANCHINECTOMY
Indications
    Chronic pain in pancreatits
    Chronic pain in irresectable upper GI malignancies
Locally a long pleurotomy with transection of all fibres medial to the sympathetic chain
from T5 to the diaphragm has yielded predictable results.
The thoracoscopic approach has yielded good results with shorter hospital stay less
postoperative pain and faster return to function 13,14.

                    LAPAROSCOPIC COLONIC SURGERY2,3,4,8,9,10

While initial laparoscopic procedures were restricted to the gallbladder and solid organs,
as laparoscopic skills advanced it was inevitable that surgery on hollow organs was
attempted. The principal differences of the surgery is
     Non-ablative4.
     Requires advanced skills to restore continuity of the bowel with a watertight
      anastomosis.
                                                                                         11
      Involves mobilization of a segment with dissection of the mesentery and division of
       the blood supply.
Most procedures are laparoscopic assisted and hemi-colectomies, subtotal-total, total
colectomies and AP resection. Initial concerns were longer operating times, concerns
about extent of lymph node dissection and margins of resections, and increased port site
recurrence. Proponents cite decreasing operating time with increasing experience and
similar margins of resection and lymph node dissection 2,10. These are from preliminary
series using highly selected groups of patients.

The appropriateness of laparoscopic surgery in general and in the context of colorectal
malignancy in particular is still under debate.10


                                          CONCLUSION
The initial enthusiasm for laparoscopic surgery which saw attempts to adapt it to every
form of surgery has been replaced by a more pragmatic approach to a technology that is
finding its niche. There are few laparoscopic procedures that are firmly established, some
whose suitability is still being investigated and yet others that have demonstrated complete
unsuitability to the laparoscopic approach.

                                      REFERENCES

   1. Brunt LM, Soper NJ. Laparoscopic Surgery. In: Zine – MJ Schwartz SI, ed.
       Maingots Abdominal Operations. 10th ed Vol 1. Appleton and Lange. 1997: 239-
       85.
   2. Terry ML, Hunter JG. Minimally invasive Surgery. In Cameron JL, ed. Current
       Surgical Therapy. 7th Edition. Mosby Inc. 1998: 1364-1476.
   3. Scott Conner CE. Laparoscopic Surgery. Surg Clinics N Am. June 1996: 76 (3):
       437-639.
   4. Eubanks WS, Swanson LL, Soper NJ, ed:               Mastery of Endoscopic and
       Laparoscopic Surgery. Philadelphia, 2000, JB Lipptincott.
   5. Cheek CM, Black NA, et al. Grain Hernia Surgery: A Systematic Review. Ann R
       Coll Surg. Engl 1998; 80 Suppl 1: 51-80.
   6. Bowrey DJ, Petis JH Laparoscopic surgery of the oesophagus. Surg Clinics North
       America. 2000 Aug; 80 (4) : 1213-42.
   7. Luck AJ, Madden EJ. Intra operative abdominal ultrasonography. Br J Surg 1999
       Jan; 86 (1): 5-16.
   8. Seminar Laparoscopic Surg. Laparoscopic colectomy for malignancy.2000
       Jun;7(2):101-17.
   9. Anesthesiology Clin North America Surgical aspects and future developments of
       laparoscopy . 2001 March; 19 (1): 107-29.
   10. Fuchs KH. Minimally invasive surgery. Endoscopic 2002; 34: 154-159.
   11. Karnam US, Reddy R. Diagnostic laparoscopy. Endoscopy 2002‟ 34: 146-18
   12. Koop H. Gerd and Barrets oesophagitis. Endoscopy 2002; 34: 97 – 103
   13. Singh B, Moodley J, Haffejee AA. The current status of sympathectomy in General
       surgery. Hospital supplies May 1998: 3-11.
   14. Singh B, Haffejee AA, Moodley J et al.           Endoscopic transthoracoscopic
       sympathectomy – The Durban Experience. SAJS Feb 1996; 34 (1): 11-18.
   15. Shen WT,et al: Laparoscopic vs. open adrenalectomy for the treatment of primary
       hyperaldersteronism, Arc Surg 134:628,1999
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16. Brunt LM,et al.: laparoscopic compared to open adrenalectomy for benign adrenal
    neoplasms, J AM Coll of surgery 183:1,1996. Laproscopic

								
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