From April 1997 till June 1999, 136 patients suffering from gallbladder stone and polyp disease were operated on by laparoscopic cholecystectomy with the use of 2-mm grasps (2 cases among them were converted to open cholecystectomy halfway). The operation was performed through four ports; a 10-mm umbilical video port; a 5-mm subxiphoid working port; a 2-mm mid-clavicular retraction port; and one anterior axillary retraction port. Intraoperative cholangiography was performed in 132 cases (98.5%) with the use of a C-arm X-ray instrument in real time. In 134 cases except the 2 cases which were converted to open cholecystectomy, the operative time was 107±31.7 min, for 31 cases with a thick gallbladder wall; 84, 5±21.5 min, for 103 cases without a thick wall, Though one patient among them had pulmonary embolism as critical complications on the first day after operation, the patient recovered successfully. In conclusion, laparoscopic cholecystectomy with the use of 2-mm grasps turned out to be as feasible as conventional laparoscopic cholecystectomy, and also to be much safer and more reliable by performing intraoperative cholangiography at the same time.

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Laparoscopic traps-cystic-duct stone extraction, laparoscopic choledocholithotomy with cystic tube (C-tube) drainage and choledocholithotomy with ENBD-tube drainage are well in postoperative QOL compared with that of conventional open choledocholithotomy with T-tube drainage. We mention about clinical circumstances of laparoscopic surgery for choledocholithiasis including about our devisis that, using the gasless method in a scene of attack to the cystic duct and the common bile duct should allow to apply common operative tools and technique of the open surgery.

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Ten patients who were diagnosed as early gastric cancer have been successfully treated with laparoscopy-assisted distal gastrectomy (LADG) at our institute from July 1998 to June 1999. Compairing the LADG group with another ten patients group who underwent conventional open distal gastrectomy (ODG), the various parameters such as operation time 258±42 min, 220±51 min; perioperative blood loss 110±87 ml, 342±238 ml, and size of the incision 5±2 cm, >15 cm, respectively, indicate that the LADG group is less invasive. On the other hand the post operative stay is approximately the same in both groups, but in regard to the post operative pain the LADG group is painless. All the patients in LADG group resulted in early gastric cancer without resional lymphnode metastasis and have been performed curative A operations. They are all alive and free from cancer recurrence. In conclusion, LADG will be the standard gastrectomy for gastic cancer in the near future.

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Since June 1994, we have successfully treated 15 patients with early gastric cancer and one submucosal tumor (leiomyoma) by using two different procedures: laparoscopic wedge resection of the stomach i. e.: lesion-lifting method (n=14) and endo-organ access technique (n=2). The advantages of these methods are minimal invasiveness, sufficient surgical margin, feasibility of detailed histology and early professional recovery with shorter hospital stay. In contrast, these are several problems to be solved such as preoperative diagnostic accuracy of the depth and width of cancer invasion, possibility of reoperation in case of final histology and possibility of postoperative stenosis after the resection near pylorus or cardia and incidence of metachronous multiple gastric cancer. In conclusion, if the indication is properly selected, these laparoscopic procedures are curative and could be considered as minimally invasive treatment for early gastric cancer.

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We have positively performed laparoscopic low anterior resection for the patient with rectal cancer. Its indication is early and advanced (depth of MP) rectal cancer. Our operative procedure is 1) mobilization of descending colon, sigmoid colon and rectum. 2) mobilization of sigmoid mesocolon and mesorectum, 3) ligation of inferior mesenteric artery and vein, 4) resection of rectum, 5) anastomosis. This procedure is according to the procedure of open low anterior resection. This paper presents clinical and technical data.

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Laparoscopic hepatectomy is a good indication of the treatment for hepatocellular carcinoma, because most of the patients with hepatocellular carcinoma are in bad condition. However, this therapy had been carried out in only 72 cases up to December 31, 1997, because of many complications such as gas embolism, bleeding and bile duct injury. Only easy lateral segmentectomy and partial hepatectomy for the tumor near the surface of the liver have been perform and done in this method according to the fourth survey of Japan Society for Endoscopic Surgery.
We applied a microwave coagulation needle oriented for a deep lesion to coagulate the surrounding tissues of the tumor. A wide indication of laparoscopic hepatectomy could be made in this technique, which made the direction of insertion free and control of the depth of coagulation easy. The prognosis of the seven patients to whom applied this technique was remarkably good without any serious complication.
We hope that safety of laparoscopic hepatectomy will be established and this method will apply to many patients with hepatocellular carcinoma.

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Laparoscopic surgery for inguinal hernia is divided into 2 approaches; totally extraperitoneal preperitoneal repair (TEPP) and transabdominal preperitoneal repair (TAPP). Laparoscopic hernia repair in my institute has been mainly done by TEPP because of its ease of performance and excellent outcomes. TAPP is positioned as a complemental approach to TEPP when TEPP can not be applied. Therefore, in this article, I focused on TEPP from a practical point of view and only provided a brief outline of TAPP. The practice of laparoscopic surgery for pediatric inguinal hernia was also mentioned.

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The influence on hemodynamics and pediatric surgical feasibility of gasless laparoscopic surgery was assessed using infantile pigs prior to the clinical application in the National Children's Hospital. The gasless method showes good surgical feasibility and more stable hemodynamics compared to pneumoperitoneum method, which has been the goldstandard for laparoscopic surgery also in the pediatric field. Similar results were obtained also in the early clinical experiences of the gasless method, suggesting that the method could be most suitable for the pediatric laparoscopy-assisted surgery. Also the method was applied in the fetal endoscopic surgery as the gas/lifting hybrid method for fetal access. The potential advantages of the gasless method should be pursued in the future studies.

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Laparoscopic hysterectomy is now widely applied to benign uterine disorders. In contrast to decreasing numbers and percentages of patients receiving abdominal hysterectomy, those receiving laparoscopic hysterectomy have been steadily increasing in Kyoto National Hospital. Both the mean weight of resected uterus and intraoperative hemorrhage by laparoscopic hysterectomy were intermediate of those by abdominal and vaginal hysterectomies. While it required the longest operation period, the patient's request for postoperative analgesics was minimal and the hospital stay was shortest following laparoscopic hysterectomy. Laparoscopic hysterectomy is a favorable mode of operation from the view point of surgical invasiveness and cosmetics. It is likely that the surgical complications increase as laparoscopic hysterectomy is performed by increasing numbers of gynecologists and applied to increasing numbers of patients. A ceaseless training is not avoidable to reduce surgical complications associated with laparoscopic hysterectomy.

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