OBJECTIVES To quantify the complexity of each of three skills used in laparoscopic colon surgery and to quantify the relative complexity of seven laparoscopic colon procedures on a graduated complexity scale. DESIGN Five surgeons used a scale of 1 through 6 to measure the relative complexity of three laparoscopic skills (intracorporeal mobilization, intracorporeal devascularization, and intracorporeal anastomosis) to assess the relative difficulty of seven laparoscopic procedures (right colon resection, sigmoid colon resection, low anterior resection, Hartmann's procedure, left colon resection, abdominoperineal resection, and transverse colon resection) using detailed evaluation of their first 100 laparoscopic colon resections. SETTING Three private community hospitals. MAIN OUTCOME MEASURES The complexities of intracorporeal mobilization, intracorporeal devascularization, and intracoporeal anastomosis were recorded for seven laparoscopic colon procedures. RESULTS The least complex procedure was right colon resection, followed in increasing complexity by sigmoid colon, Hartmann's procedure, low anterior resection, abdominoperineal resection, left colon resection, and transverse colon resection. The addition of each laparoscopic skill increased the complexity during each procedure. All three skills were not required for every procedure. CONCLUSIONS Since all procedures do not require all three skills, skills can be learned sequentially if patients are chosen judiciously. A sequence of laparoscopic procedures performed by surgeons is recommended. The relative complexities for each procedure suggest an outline (map) for surgeons to use during laparoscopic colon surgery.

The technique of laparoscopic cholecystectomy is, in many areas, replacing the standard open cholecystectomy as the method of choice. Many surgeons are accustomed to the use of peritoneal drainage following cholecystectomy. The authors have developed a simple, effective, and rapid, yet controlled method of placing drains into the abdominal cavity, using laparoscopic techniques.

The successful application of laparoscopic surgery to gallbladder disease and acute appendicitis has encouraged clinical investigators to develop this technology further in an attempt to manage other pathologic disorders of the gastrointestinal (GI) tract. After gaining experience with various laparoscopic skills while performing clinical biliary tract surgery, appendectomy and then in a controlled animal laboratory, a pilot program for laparoscopic colonic surgery was initiated. Twenty patients with ages ranging from 43 to 88 years (mean age of 57 years) underwent laparoscope-assisted colon resection. In nine patients, a right hemicolectomy was performed and a sigmoid colectomy in eight. A low anterior resection, Hartman's procedure, and abdominal perineal resection were each performed in one patient. Indications for surgery were large villous adenomas or adenocarcinoma in 12, diverticular disease in 5, sigmoid endometrioma in 1, cecal volvulus in 1, and inflammatory bowel disease in 1. Eighty percent of patients were able to tolerate a liquid diet on the first postoperative day and 70% were discharged within 96 h eating a regular diet and having normal bowel movements. There were three operative complications: a 3 unit postoperative bleed managed without surgery, one patient developed marked edema of the rectosigmoid anastomosis requiring decompression with a rectal tube, and one individual with metastatic colon cancer was operated on for a mechanical small bowel obstruction 7 days after the initial laparoscopic surgery. Although laparoscope-assisted colonic surgery may still be considered a procedure in evolution, we feel that in time it has the potential to be as popular as laparoscopic cholecystectomy.

The experience of laparoscopic cholecystectomy in 79 patients with acute cholecystitis is described. This group is subdivided into acute and severe acute cholecystitis. These categories are defined. Six percent of our patients with acute disease and 30% of our patients with severe acute disease were converted to open cholecystectomy. Those patients who were converted to open cholecystectomy are discussed. The four port technique and decompression of the gallbladder is described. We conclude that acute cholecystitis should not be a contra-indication to the well-trained laparoscopic surgeon.

Common duct stones present a special problem to the surgeon when he performs a laparoscopic cholecystectomy. We describe a method of exploring the common duct and extracting stones. The procedures for opening of the common duct, removal of stones, and the placement of a T-tube are carefully outlined.