The effect of 12 months'' treatment with eicosapentaenoic acid in five children with cystic fibrosis

BACKGROUND: The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation. CASE REPORT: We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, non-distended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure. CONCLUSION: This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.     

Postoperative hemorrhage due to avulsion of perihepatic adhesions after pneumoperitoneum

Serious laparoscopic injury is rare, occurring in less than 1/1000 procedures. To our knowledge, no liver injuries have been reported to date, but avulsion of hepatic adhesions may be a source of postlaparoscopic bleeding. A woman with chronic pelvic pain unresponsive to medical management underwent an uncomplicated diagnostic laparoscopy with extensive pelvic adhesiolysis. Adhesions of Fitz-Hugh-Curtis syndrome were seen over the right lobe of the liver. At the completion of the procedure no bleeding was noted, and the patient was discharged to home in stable condition. She returned 12 hours later with a significant hemoperitoneum necessitating laparotomy. It is important to consider this as a source of bleeding after laparoscopy in a patient with perihepatic adhesions.     

Cryoablation of liver tumours

The role of laparoscopy in the management of solid-organ intraabdominal injuries has still not been fully elucidated. The following is a case report of successful laparoscopic control of a bleeding liver laceration, grade III (following CT-guided liver biopsy), after unsuccessful attempts at angiographic embolization.     

Gastric re-resection in emergency

BACKGROUND/AIMS: We reviewed a consecutive series of patients with acute complications following gastric resection, in order to evaluate the role of gastric re-resection as the operation of choice in emergency. METHODOLOGY: Records of 90 patients with acute complications following gastric resection observed from January 1991 to January 1996 were retrospectively analyzed. RESULTS: Hemorrhagic events occurred in the vast majority of cases (87), either as acute complications after a long time since surgery (78 cases) or as early postoperative complications (9). Among late acute complications, three cases were related to bleeding cancer of the gastric stump. Anastomotic obstructions presenting as acute complications occurred in 3 cases. Emergency surgery was indicated in three cases of acute obstruction, in 1 case of bleeding cancer of the gastric stump, in 9 (12%) out of the 75 remaining late acute hemorrhagic complications and in 1 (11%) out of 9 early hemorrhagic complications. Completion gastrectomy was chosen in the one case of bleeding cancer of the gastric stump with indication for emergency surgery. Gastric re-resection was performed in 11 cases: 9 for hemorrhagic complications and 2 for obstructive acute complications. In two cases, one for hemorrhage and one for occlusion, other surgical procedures were carried out. CONCLUSIONS: Gastric re-resection can represent the most suitable operation in acute complications following gastric resection.     

Adaptation of a fiber-reinforced restorative system to the rehabilitation of endodontically treated teeth

OBJECTIVE: Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias. METHODS AND PROCEDURES: A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh. RESULTS: At follow-up at one and six weeks postoperatively, the patient's complaints of pain had completely resolved. CONCLUSION: The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

Complications of laparoscopic surgery

The potential complications of a laparoscopic procedure include those related to laparoscopy and those related to the specific operative procedure. The majority of these complications occur during the early learning phase for laparoscopy. They also may occur, however, during procedures performed by surgeons who have considerable laparoscopic experience. As new applications for laparoscopy continue to emerge, it is important for the surgeon to be familiar with the possible complications associated with the various laparoscopic procedures. Only through an appreciation of the potential complications of a procedure can their overall incidence be reduced to a minimum.     

Transient lupus anticoagulants associated with hemorrhage rather than thrombosis: the hemorrhagic lupus anticoagulant syndrome

Lupus anticoagulants (LAs) represent a diverse group of antibodies directed against phospholipids. Patients with LAs may be free of symptoms but can have thrombotic complications including stroke, placental infarction, and fetal loss. Rarely hemorrhagic symptoms have been reported. We describe six previously healthy children who were first seen with clinical bleeding and prolonged activated partial thromboplastin time. Laboratory evaluation revealed positive results on mixing studies and evidence of phospholipid dependence of the anticoagulant, suggesting LAs. Four of six patients had anticardiolipin antibodies, and all four who were tested had reduced factor II activity levels. In all patients, bleeding symptoms resolved spontaneously within 3 months, and laboratory findings returned to normal within 6 months. The hemorrhagic LA syndrome should be considered in previously healthy children with new-onset bleeding and prolonged activated partial thromboplastin time. This clinical entity probably represents pathogenic mechanism distinct from thrombotic LA syndromes.     

Alignment of the umbilical axis: an effective maneuver for laparoscopic entry in the obese patient

BACKGROUND: In obese patients, a panniculus may cause a caudal deviation in the vertical axis of the umbilicus and make laparoscopic entry difficult. TECHNIQUE: First, the presence or absence of caudal deviation of the umbilical axis is ascertained by measuring the distance between the external umbilical orifice and the anterior superior iliac spines along the length of the patient. Second, the caudally deviated umbilicus is displaced cranially by manual pressure on the panniculus so that the external umbilical orifice rests approximately 8 cm above the level of the anterior superior iliac spines. Third, open laparoscopy is performed through the base of the umbilicus by elevating it with clamps and incising skin, fascia, and peritoneum in a vertical axis. EXPERIENCE: In an 18-month period, 67 consecutive obese women (weight range 99-213 kg) underwent surgery by the authors for gynecologic conditions requiring primary intraperitoneal evaluation or treatment. All of these patients were scheduled for laparoscopy and underwent the assessment, alignment, and entry technique described above to commence the operations. Laparoscopic entry by this technique was successful and rapid in all 67 cases and was not complicated by preperitoneal insufflation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. CONCLUSION: Umbilical axis assessment and alignment safely facilitates laparoscopy in obese patients.     

Discriminability in length of lines in the Müller-Lyer figure

OBJECTIVE: To compare patients' health-related quality of life after systemic methotrexate therapy versus laparoscopic salpingostomy for tubal pregnancy. DESIGN: Multicenter randomized clinical trial. SETTING: Departments of obstetrics and gynecology of six Dutch hospitals. PATIENT(S): Hemodynamically stable patients with a laparoscopically confirmed unruptured tubal pregnancy without signs of active bleeding, who were randomly assigned to undergo either systemic methotrexate therapy or laparoscopic salpingostomy. INTERVENTION(S): Standard health-related quality of life questionnaires administered before and 2 days, 2 weeks, 4 weeks. and 16 weeks after confirmative laparoscopy. MAIN OUTCOME MEASURE(S): Health-related quality of life. RESULT(S): Health-related quality of life was impaired most severely 2 days after confirmative laparoscopy in both treatment groups and improved during follow-up. Health-related quality of life was impaired more severely after systemic methotrexate therapy than after laparoscopic salpingostomy. Medically treated patients had more limitations in physical functioning, role functioning, and social functioning; had worse health perceptions, less energy, more pain, more physical symptoms, and a worse overall quality of life; and were more depressed than surgically treated patients. CONCLUSION(S): Systemic methotrexate therapy had a more negative impact on patients' health-related quality of life than did laparoscopic salpingostomy. This negative impact on patients' health-related quality of life of systemic methotrexate therapy should be taken into account when deciding on the appropriate therapy for tubal pregnancy.     

Open laparoscopy without special instruments or sutures. Comparison with a closed technique

An important advantage of open laparoscopy over closed techniques is the avoidance of placing a sharp trocar blindly into the peritoneal cavity. Although an open technique theoretically minimizes the risk of major retroperitoneal vessel injury and bowel injury, most laparoscopies are performed using a closed technique. In an effort to simplify open laparoscopy, a technique was developed that can be done without special equipment or sutures and nearly as quickly as a closed technique. To compare the effectiveness of this open laparoscopic technique to a closed technique, a prospective, observational, cohort study was carried out on 66 women undergoing laparoscopy for either infertility or pelvic pain. The open technique was performed on 35 consecutive patients and compared to a closed technique performed on 31 patients on a different service during the same period. Evaluation included total duration of the procedure, length of the incision, incidence of CO2 leakage and complications. The open technique took slightly longer, and the incision was slightly longer. CO2 leakage occurred in 5 of 35 of the open cases but in none of the 31 closed cases. Leakage was controlled effectively in every case by application of a towel clip to the skin incision. No complications occurred with either technique. This study suggested that an open technique that requires no special equipment or sutures may be a useful alternative approach for laparoscopy when insertion of a sharp trocar is undesirable.     

The pharmacokinetics of pancuronium bromide in infants, children and adults

Laparoscopic retroperitoneal lymph node dissection is a new surgical procedure used to enhance staging in men with clinical stage I nonseminomatous germ cell tumors of the testis. The procedure has been performed in a limited number of patients at several centers with extensive laparoscopic experience. Laparoscopic retroperitoneal lymphadenectomy is a technically demanding procedure which can be successfully completed in the majority of patients. However, the risk of complications is greater than in patients who undergo standard open retroperitoneal lymph node dissection. The primary advantage of a laparoscopic approach is shortened hospitalization and rapid return to normal activity. The role of laparoscopy in the management of patients with testis malignancy has not been defined. The use of this staging procedure may help minimize the need for surveillance studies following surgery and may be best utilized in men with a lower likelihood of nodal metastases. Ultimately, prospective study in large groups of patients will be necessary to determine the role of laparoscopic retroperitoneal lymph node dissection in patients with testis cancer.     

Laparoscopic appendectomy. A comparison with open appendectomy

PURPOSE: As laparoscopy becomes a greater part of a general surgeon's practice, each new application must be analyzed. The purpose of this article is to report a four-year experience with laparoscopic appendectomy, with special attention to complications. METHODS: All patients undergoing appendectomy by members of the General Surgery Department of Columbia Hospital between December 20, 1990, and December 24, 1994, were included (n = 434). Medical records were reviewed, and data were analyzed using multiple regression analysis, analysis of variance, and Pearson's chi-squared test. RESULTS: The number of post-operative intra-abdominal abscesses following laparoscopic appendectomy tended to be higher; however, this did not reach statistical significance. Conversely, all other complications combined demonstrated a rate of 4.3 percent for laparoscopic procedures and a rate of 8.5 percent for open procedures. Again this tended toward, but did not reach, statistical significance. Advantage in length of stay was approximately two days, with a mean length of stay for patients undergoing laparoscopic appendectomy of 3.3 days, whereas that for open appendectomy was 5.7 days. CONCLUSION: Laparoscopic appendectomy has significant advantages in terms of patient comfort and length of stay, and its overall complication rate seems to be lower than with open procedures; however, its rate of intra-abdominal abscess may actually be higher. Further study is recommended.     

Pre-syncope and syncope at the operating table--diagnostic and therapeutic possibilities

OBJECTIVES: The aim of this study is to compare the initial experience at two different urologic centers of the 20 first laparoscopic nephrectomies performed either by transperitoneal laparoscopy (10 cases) in one center or by retroperitoneal laparoscopy (lumboscopy, 10 cases) in the other center. METHODS: 5 males and 15 females with a mean age of 36 years (range 3-74) were operated on the right side in 8 cases and on the left side in 12 cases. Nephrectomies were indicated in 18 cases for benign renal disease, and in 2 cases for ureteric tumor (1 patient in each group). The techniques of these two approaches are described. RESULTS: The mean operating time was shorter with lumboscopy (173 min) than with laparoscopy (210 min), probably due to the direct approach to the renal compartment without intraperitoneal dissection with lumboscopy. There were no severe intraoperative or postoperative complications, but one hematoma of the renal area in the laparoscopic group. The mean postoperative hospital stay was identical following lumboscopy and laparoscopy (4.3 and 4.2 days, respectively). CONCLUSION: These two approaches can be used to perform nephrectomy. In this initial experience, the results appear to be equivalent in terms of morbidity and postoperative hospital stay, but the operating time appears to be shorter with lumboscopy. Larger studies comparing respective nephrectomy conversion rates would provide other arguments in favor of one or other of these techniques.     

In vitro activity and clinical evaluation of cefixime in urinary tract infection

BACKGROUND: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. METHODS: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. RESULTS: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. CONCLUSIONS: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.     

Laparoscopic nephropexy: 3-year experience

PURPOSE: Operative treatment of nephroptosis is rarely performed and is indicated only in select patients. Postoperatively approach related symptoms and morbidity often limit therapeutic success. We evaluated the technique and outcome of laparoscopic nephropexy in patients with symptomatic nephroptosis. For comparison the records of patients who underwent open nephropexy were reviewed. MATERIALS AND METHODS: Since 1993, 22 women and 1 man 16 to 56 years old (mean age 29) underwent laparoscopic nephropexy at our hospital. Preoperatively excretory urography and radioisotope renography were performed with the patient supine and erect, and careful pain evaluation was also done. For laparoscopic nephropexy the transperitoneal approach was used in all patients. The kidney was completely mobilized by dissection of the perirenal fat. The upper pole and convexity of the kidney were fixed to the muscle using single nonabsorbable sutures and an extracorporeal technique for tying. Between 1984 and 1994, 12 patients underwent open nephropexy at our hospital. The results of this group were reviewed and compared with those treated by laparoscopy. RESULTS: Mean operative time in the laparoscopy and control groups was 61 (range 40 to 85) and 49 minutes (range 28 to 70), respectively. In patients who underwent laparoscopic nephropexy mean analgesic use was 15 mg. morphine equivalent intravenously and 550 mg. ibuprofen orally. Postoperatively 3 minor complications (13%) were noted. Hospital stay was 3.7 days (range 2 to 9) and patients returned to work after 19 days (range 4 to 30). Six weeks after nephropexy excretory urography showed a correctly positioned kidney. At a mean 13-month followup pain intensity had improved in 21 patients (91%). According to these parameters laparoscopic nephropexy was superior to the open approach except for operative time. CONCLUSIONS: Laparoscopic nephropexy is safe and effective in the select group of patients in whom nephropexy is indicated.     

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.     

Active electrode monitoring. How to prevent unintentional thermal injury associated with monopolar electrosurgery at laparoscopy

BACKGROUND: In recent years, the use of minimally invasive surgery (MIS) has expanded to a wide variety of surgical specialties. The increased popularity of the procedure, however, has been accompanied by its share of complications, including trocar lacerations and inadvertent thermal injuries to nontargeted tissues during monopolar electrosurgery. METHODS: A survey on electrosurgical thermal injuries and three case studies are presented. The new technology of active electrode monitoring (AEM) is described. RESULTS: AEM eliminates stray currents generated by insulation failure and capacitive coupling. CONCLUSIONS: To reduce the incidence of injury by monopolar electrosurgery at laparoscopy, there is a need for advanced technology, such as AEM. In addition, laparoscopic surgeons should be encouraged to study the basic concepts of the biophysics of electrosurgery.     

Laparoscopic splenectomy in beta-thalassemia major patients. Advantages and disadvantages

BACKGROUND: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. METHODS: Laparoscopic splenectomy was undertaken in 12 beta-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. RESULTS: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3-6 days. CONCLUSIONS: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications.     

Telesurgical consultation

PURPOSE: We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. MATERIALS AND METHODS: Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. RESULTS: In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or post-operative complications. CONCLUSIONS: Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.     

Surgical trauma induced by laparoscopic cholecystectomy

The objective demonstration of improved postoperative recovery suggests that surgical injury induced by the laparoscopic approach is less intense than that after open surgery. Forty-two patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated on by laparoscopy (LC, n = 21) or open surgery (OC, n = 21). Both surgical procedures induced significant changes of investigated parameters (acute-phase response, free radical mediated reactions, neutrophil functions). Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response, a more attenuated oxidative stress characterising by free radical mediated reactions and that is less disruptive to neutrophil function. The results and the data from the literature suggest that surgical injury causing by the laparoscopic cholecystectomy is less intense than that after open cholecystectomy, which can explain partially the better clinical outcome following laparoscopic versus open procedure.