Laparoscopy in gynaecological cancer

The use of laparoscopy in the management of gynaecological malignancies has significantly increased over the last 5 years. Patients with cervical, vaginal, endometrial and ovarian cancer can be managed laparoscopically either for staging or for treating. The feasibility of procedures through the laparoscope (such as hysterectomies, bilateral oophorectomies, pelvic and para aortic lymphadenectomies, omentectomies, colostomies, bowel resections, oophoropexies, radical hysterectomies and ovarian cancer debulking) has been demonstrated by skilled gynaecologists. Many of these procedures have been heralded as avant garde 'surgical standards' without appropriate evaluation of efficacy, effectiveness and efficiency. Larger series of patients have now replaced case reports to try to answer the numerous unanswered questions regarding the value of these procedures. Several prospective trials were begun to compare laparotomy and laparoscopy. If the results of these trials confirm the hope, laparoscopic management of gynaecological malignancies will leave the limited club of specialists to become a widely used technique. But the patients will benefit from laparoscopic procedures only when in the hands of well-trained surgeons.     

Laparoscopy in perforated gastroduodenal ulcers

The authors have performed operations on 32 patients with perforated ulcers of the duodenum and 7 patients with perforated ulcers of the stomach. The diameter of the perforations was 2-8 mm. In 10 of the 39 patients the perforation defects could not be sutured by the laparoscopic method. The authors consider that of great significance for the decision to make laparoscopic operations was the diagnosis of peritonitis, size and localization of the perforation, the surgeon's experience with endoscopic operating. The technique of laparoscopic suturing the perforations is described. Special attention is paid to the special disposition of the surgeon and his assistant at the operating table.     

Laparoscopy in high-risk cardiac patients

Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.     

Laparoscopy in abdominal injuries]

The desire to deliver protein and peptide biopharmaceuticals conveniently and effectively has led to intense investigation of site-specific drug-delivery systems. Despite challenges, progress towards the convenient noninvasive delivery of proteins and peptides has been achieved through specific routes of administration. In addition, the delivery of proteins and peptides to specific sites of action has been utilized to lower the total delivered dose, to gain access to specific organs or body compartments and to concentrate a therapeutic dose at a specific site of pharmacological action.     

Laparoscopy and thoracostomy in children

A variety of biologic products derived from bacteria, inflammatory cells, and active degraded proteins have been identified as having chemotactic activity essential for polymorphonuclear leukocyte (PMN) recruitment to the site of inflammation. Little is known, however, concerning factors responsible for regulating the intensity and duration of PMN recruitment. Evidence is growing that proteinase inhibitors modify the migrating ability of PMNs, although the physiologic implications of this have eluded clarification. In an attempt to hypothesize a role of alpha 1-proteinase inhibitor (alpha 1-Pi) in PMN recruitment to inflammatory sites, we examined the effects of alpha 1-Pi in different physiologic concentrations on PMN migration with a microchemotaxis chamber technique. Alpha 1-proteinase inhibitor had both stimulatory and inhibitory effects on cell migration, depending on its concentration. The inhibitor was active in inducing both directed locomotion (chemotaxis) and nondirected locomotion (chemokinesis) in concentrations of 0.02, 0.2, and 2 mg/ml, with maximum potency in both cases at 0.2 mg/ml (corresponding to the normal alveolar surface fluid level in the lung). Alpha 1-proteinase inhibitor impaired chemotactic responsiveness to known chemoattractants at 2 and 10 mg/ml (corresponding to normal and inflammatory blood levels, respectively) in order of potency. These results suggest that alpha 1-Pi may play a role in regulating inflammatory processes, especially in the lung, through its stimulatory and inhibitory effects, depending on its concentration.     

Laparoscopy in chronic pelvic pain]

Levofloxacin bactericidal activity was compared to ciprofloxacin and ofloxacin against 10 strains of Moraxella catarrhalis. The cidal action (by kill-curve analysis) was slightly more rapid for levofloxacin, but all tested fluoroquinolones were considered bactericidal for all strains tested, including those producing BRO-1 and 2 beta-lactamases.     

Laparoscopy for Crohn's disease in children

Traditionally, the diagnosis of Crohn's disease is established by colonoileoscopy and radiology. With these techniques the main area of interest, the distal ileum, is not easily reached. Also, the outer aspect of the bowel is ignored and there is no appreciation of the involvement of other intra-abdominal organs. Laparoscopy provides additional information. This may establish a more precise diagnosis, better standardization in comparative studies, and more specific therapy.     

Laparoscopy in the treatment of intussusception in children

PURPOSE: The technique and outcome of minimally invasive laparoscopic treatment of various forms of intussusception in children after ineffective attempt at conservative treatment are described. METHODS: Ninety-eight patients from 2 months to 11 years of age were analyzed. RESULTS: Suggested scheme of surgical treatment using laparoscopic technique was successful in 64 patients (65.3%), and conversion to open procedure occurred in 34 (34.7%). There was no mortality or intraoperative complications in our series. CONCLUSION: Practically every form of intussusception without bowel necrosis, including the most complex forms, can be reduced now using modern videolaparoscopic equipment and atraumatic instruments.     

Laparoscopy for the undescended testis

The authors show their experience in the use of the laparoscopic approach in 18 cases of unilateral exploratory anorchia. They highlight the advantages that this method offers in efficiency, speed, security and minimal aggression compared with conventional exploration of the inguinal channel in the search of the undetectable testis. In the 18 cases studied through the insertion of 5 mm lense in the umbilical area, it was established that a testicular hypoplasia was present in 8 cases. In another 5 cases testicular agenesia was diagnosed, and in the remaining 5, intraabdominal testis were found. In four of these testicles, a laparoscopic approach helped in their correct placement and also in the removal of the fifth in a patient with recurrent leukemia.     

Laparoscopy for chronic abdominal pain

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.     

Laparoscopy for ovarian pathology in infancy and childhood

INTRODUCTION: Nonparasitic splenic cysts are a rare finding: they can be distinguished into true cysts (epidermoid or epithelial) cysts or false (pseudocysts), depending on the presence/absence of an inner epithelial lining. They are usually found during the second and third decade of life, although they can also appear during childhood. They grow bigger in children, becoming clinically apparent due to the symptoms of compression of adjacent structures. The diagnosis is radiological, made with ultrasonography (US) and computed tomography (CT). We report the US and CT patterns of splenic cysts to differentiate true from false cysts. MATERIAL AND METHODS: Our series consists of 5 patients, aged 5-17 years, all examined with US and CT; one of them was also submitted to plain abdominal radiography. Conventional CT was used in 2 cases and helical CT in the extant 3. RESULTS: All examinations yielded useful clinical informations. The only radiograph showed the rightward displacement of the gastric gas bubble US always identified the cyst and its pertinence to splenic parenchyma, although failing to assess the liquid/solid nature of a highly echogenic cyst in one case. CT confirmed the cystic nature of all masses and showed the lack of contrast enhancement of cyst walls and the presence of septa or parietal calcifications. DISCUSSION: Radiological examinations, particularly US and CT, can diagnose splenic cysts unquestionably, correctly defining the relationships with adjacent organs. CT is more sensitive than US in detecting septa or calcifications, which are definitely useful findings to distinguish true from false cysts, since internal septa are more frequent in true cysts while parietal calcifications are typical of pseudocysts. The final diagnosis, however, is made at histology.     

Laparoscopy improves outcomes for pediatric splenectomy

BACKGROUND: Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method. METHODS: A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital. RESULTS: The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05). CONCLUSIONS: Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.     

Laparoscopy in the management of the impalpable undescended testis

BACKGROUND: This study evaluates the role of laparoscopy for managing the intra-abdominal testis. METHODS: Over 30 months, 48 children (six with previous groin explorations) underwent laparoscopy for a unilateral impalpable undescended testis. The patients' age ranged from 1 to 9 years. RESULTS: Eleven children required insertion of 'working ports' for mobilization of obscuring colon before the diagnosis could be established. Twenty-eight children had an absent testis. In nine, vas and vessels entered the internal ring. In 19, vas and vessels ended blindly above the internal ring. Twenty children had an intra-abdominal testis. Ten underwent a laparoscopic single-stage orchidopexy (eight without and two with ligation of vessels); at a minimum follow-up of 2 years, one testis in this group had atrophied, three were located in the lower half of the scrotum and six in the upper half. The remaining ten children underwent a laparoscopic two-stage Fowler-Stephens operation. At a minimum follow-up of 6 months, eight of these testes were palpable in the lower half and two in the upper half of the scrotum. CONCLUSION In the majority of cases, laparoscopy obviates the need for groin exploration. Technically a first-stage Fowler-Stephens procedure can be performed easily and effectively via the laparoscope. However, the second-stage Fowler-Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide sufficient length to the testicular attachment.     

Laparoscopy in the management of diaphragmatic rupture due to blunt trauma

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH2O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH2O), reimplantation with bladder augmentation is recommended.     

AIDS manifestations in otorhinolaryngology

The otorhinolaryngological signs of AIDS are reviewed (both analysis and synthesis) following the chronological order of the literature. The earliest clinical pictures, their frequency and time of onset, are described by the authors studied. In 1986 the ENT signs of this disease were well known, and in our region the same multiple, polyfacetic aspects are seen. Personal experience of this is described, emphasizing how seldom the diagnosis has been made, except early on. Usually the cases seen and diagnosed by the Department of Infectious Diseases were referred for specialist opinion. The commonest findings were, amongst the opportunist infections: oropharyngeal and oesophageal candidiasis, and tuberculous adenopathies. Classical ENT pathology was represented by sinusitis and to a lesser extent by otitis and tonsillitis. The tumours seen were non-Hodgkin lymphomas, but no Hodgkin's or Burkitt's lymphomas. There was an unusual case of 'high grade centroblastic lymphoma', localized to the tonsil and presenting as necrotic tonsillitis and peritonsillar abscess. Recently a patient with a large pharyngeal tumour (still being investigated) has been provisionally diagnosed as having a cavernous angioma. Both these patients were diagnosed by us, since we saw the first sign of the disease. We have seen few Kaposi's sarcomas, since cutaneous and oral lesions are not usually referred to us.