Primary experiences with laparoscopic appendectomy

The material comprises 77 patients with suspected appendicitis seen in a district community hospital. In the presence of a surgeon with laparoscopic experience laparoscopy was performed in 23 patients. In two patients the laparoscopy was only diagnostic, and in two patients adhesions or friable gangrenous appendicitis necessitated conversion to conventional appendicectomy. Nineteen patients thus had a laparoscopic appendicectomy performed with a median operation time of 63 minutes and a median hospital stay of two days. One patient with gangrenous appendicitis and a periappendicular abscess was readmitted after three weeks because of deep infection, which resolved after antibiotic treatment. The remaining 54 patients had a conventional appendicectomy performed, with a median operation time of 40 minutes and a median hospital stay of three days. There were six complications in this group. We conclude that laparoscopic appendicectomy is a safe alternative to open operation with benefits for the patient in form of lesser pain, shorter hospital stay, fewer complications, better cosmetic outcome, and shorter time to normal activity.     

Early appendectomy versus an interval appendectomy for appendiceal abscess in children

We retrospectively compared the results of an early appendectomy and an interval appendectomy at a later date after initial conservative treatment in children demonstrating perforated appendicitis with a localized abscess. The preoperative conditions were similar for both groups. The early group (n = 8) showed a statistically significant longer operation time and a greater but not significant blood loss were noted while a larger number of postoperative complications were also observed. On the other hand, in the late operation group (n = 6) initial conservative management including triple antibiotic therapy proved successful without the need to drain the abscess, and thus the interval appendectomy was safely completed without any complications. There were no significant differences between the two groups with respect to length of hospital stay or medical costs. Based on these findings, we thus recommend that initial conservative treatment followed by an interval appendectomy about three months later is a useful strategy for the treatment of appendiceal abscesses in children. However, whether or not an interval appendectomy is appropriate in all patients whose inflammation is suppressed with antibiotics still needs to be clarified.     

Appendiceal mucocele. Contraindication to laparoscopic appendectomy

Indications and contraindications to laparoscopic surgery continue to be refined. Laparoscopic appendectomy for acute appendicitis is frequently selected by patients and surgeons, and clinical studies show it to be a reasonable alternative. In this case study, laparoscopic surgery was used to resect an appendiceal mucocele caused by a nonperforated mucinous adenocarcinoma. Implants of mucinous tumor were found widely disseminated on peritoneal surfaces at laparotomy 9 months later. As a result of this case study, the authors suggest that when an appendiceal mucinous tumor is encountered at laparoscopy, a special situation requiring totally atraumatic appendectomy is indicated. This clinical situation should be considered an indication for conversion to open appendectomy. All appendiceal tumors, including the most benign-appearing adenomas, can result in diffuse peritoneal implantation. This is the first report of an appendiceal mucinous tumor resected by laparoscopy associated with subsequent diffuse peritoneal carcinomatosis. This patient presentation reaffirms that dissemination of cancer may be associated with laparoscopic resection of structures containing a malignancy.     

Miliary tuberculosis associated with subcutaneous tuberculous abscess

A 62-year-old woman was admitted because of a tumor on her right thigh, fever, generalized lymphadenopathy, and diffuse nodular shadows on chest X-ray films. She was given a diagnosis of miliary tuberculosis based on the findings of a cervical lymph-node biopsy and a broncho-alveolar lavage. Acute respiratory failure and disseminated intravascular coagulation developed, but resolved after the start of anti-tuberculous therapy. The tumor on the right thigh was diagnosed as a subcutaneous tuberculous abscess because tuberculous bacilli were detected in tumor tissue samples obtained by aspiration. The patient's fever disappeared and the abnormal shadows on her chest X-ray films receded significantly after drainage of the subcutaneous abscess. These findings suggested that miliary tuberculosis was associated with the subcutaneous tuberculous abscess in this case.     

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Simplified appendectomy without stump embedding. Experiences of 20 years conventional and 5 years laparoscopic application

Since 1975, the Department of Surgery in the Grevenbroich Community Hospital (Germany) has applied a simplified technique of open appendectomy. The inhouse modified procedure without stump embedding has been performed in 3,448 cases to date. The same approach has been used in 1,463 laparoscopic appendectomies since 1991. In the laparoscopic procedure the stump is ligated solely with Roeder's loop. None of the 4,911 patients who have undergone either open or laparoscopic appendectomy have developed stump inadequacy or stercoral fistulae. According to the special literature, the complication rate after appendectomies without stump embedding is lower than that after standard procedures. In retrospect, laparoscopic appendectomy with simple ligation has confirmed the results achieved with simple ligation in open appendectomies. The technique should therefore become more common practice in open appendectomies, as well.     

预注帕瑞昔布对腹腔镜阑尾切除术患者术后疼痛和炎性反应的影响

目的 观察预注帕瑞昔布对腹腔镜阑尾切除患者术后疼痛和炎性反应的影响.方法 于行腹腔镜阑尾切除术患者麻醉前静注帕瑞昔布40mg.术后对腹部及肩背部疼痛进行评估.抽血测定白细胞计数和C反应蛋白(CRP)浓度.结果 术后各时点腹部VAS评分、肩背痛的发生率和程度实验组均低于对照组(P＜0.05);术后1 d白细胞计数和CRP浓度实验组均低于对照组(P＜0.05).结论 预注帕瑞昔布可抑制腹腔镜阑尾切除术患者术后疼痛和早期炎性反应.     

Pneumothorax and pneumomediastinum after laparoscopic surgery

Thromboembolic complications are a very important part of neoplastic diseases. In these complications specific processes participate which are the result of the action of substances produced by the tumour or they are formed as a consequences of the reaction to the neoplastic disease, its complications or treatment. A special role in this respect is played by the tissue factor and cancer procoagulant which are very important procoagulant proteins. Post-mortem evaluation reveals thromboembolic manifestations in as many as 50% of all oncological patients. Considerable attention is paid to the prevention of thromboembolic episodes or their progression and patterns for their prevention and treatment were elaborated. One of these provisions is the use of anti-thrombotic drugs, their introduction being motivated by an attempt to check coagulation and eliminate its tendency towards hypercoagulation. In this respect the importance of heparin is beyond doubt, i.e. of non-fractionated as well as low-molecular heparin.     

Partial hepatectomy after post-traumatic liver abscess

Post-traumatic pyogenic liver abscess is a rare disease. We present the case of a 38-year-old man with multilocular liver abscess and pleural empyema following blunt abdominal trauma. The patient had a prodrome lasting 3 months before presenting in our department. The therapy included partial hepatectomy and pleural drainage. Clinical signs, diagnosis and possible therapy are discussed in this case report.     

Late iris abscess after cataract extraction

A 73-year-old woman underwent an uneventful intracapsular lens extraction. Two years later, an iris abscess, hypopyon, strong flare, corneal edema, and elevated intraocular pressure developed. Visual acuity diminished from 6/6 (20/20) with aphakic correction to hand movements. Gram-positive cocci sensitive to erythromycin and chloramphenicol were cultured from the anterior chamber. The hypopyon and the iris abscess reabsorbed because we administrated erythromycin at the beginning of the illness. Final visual acuity was 6/6 (20/20) and only a small hole remained in the iris at the site of the abscess. She was in good health four years later.     

Tuberculous Addison''s disease complicated by a recurrent subcutaneous cold abscess during treatment for tuberculosis

We describe the case of a patient with necrotizing fasciitis due to Vibrio alginolyticus in a patient with cirrhosis following an injury inflicted by a stingray. The patient was successfully treated with aggressive surgical debridement and a combination of ciprofloxacin and amoxicillin-clavulanate. Cases of invasive V. alginolyticus reported in the literature were reviewed.     

Postoperative fatigue after laparoscopic surgery

Postoperative fatigue (POF) appears to be less following laparoscopic surgery but this has not been proven previously. This study compared a group of patients who had undergone open cholecystectomy with a group undergoing laparoscopic cholecystectomy. Postoperative fatigue was found to be decreased in duration in the patients having laparoscopic surgery, returning to pre-operative fatigue levels by 14 days, compared to 28 days for open surgery. Postoperative pain in the first 24 h and the early metabolic response to surgery were similar for both groups. The authors conclude that laparoscopic surgery is associated with decreased POF and that this is unlikely to be accounted for by a decrease in the early metabolic response to surgery.     

Randomized, single-blinded trial of laparoscopic versus open appendectomy in children: effects on postoperative analgesia

BACKGROUND: The benefit of laparoscopy to patients has been clearly established in adults undergoing cholecystectomy. Results are less clear for appendectomy. The current study was undertaken to compare the respective 3-day postoperative periods after laparoscopic and open appendectomy in children. METHODS: Sixty-three children (aged 8-15 yr) scheduled for appendectomy were randomly assigned to two groups: open and laparoscopic. Postoperative evaluation included delay of postoperative recovery (walking and feeding), pain assessment by visual analog scale during the 3 subsequent days, amount of nalbuphine administered via a patient-controlled analgesia system during the first 48 h and responses by children, parents, and nurses on the overall quality of analgesia. RESULTS: There was no difference between groups for demographic data (particularly macroscopic aspect of appendix) analgesia, sedation, delay before eating and walking, incidence of urinary retention, nausea, vomiting. Operative time was long (P < or = to 0.05) in the laparoscopic group (54 +/- 17 min) than in the open group (39 +/- 18 min). Thirty five percent of the children had pain at the shoulder in the LAP group versus ten percent in the open group (P < or = 0.05). CONCLUSIONS: Laparoscopy did not improve analgesia and postoperative recovery after appendectomy in children.     

Aortic aneurysm developing after umbilical artery catheterization

A variety of complications of umbilical vessel catheterization in the newborn have been reported by earlier investigators. This paper describes a case in which umbilical artery catheterization probably gave rise to an aortic aneurysm. The histological findings suggested that the hypoxic changes in the aortic wall as well as the mechanical effect of the catheter were involved in the origin of the aneurysm.     

Outcome after incision and drainage with fistulotomy for ischiorectal abscess

Concomitant anal fistulotomy (F) and incision and drainage (I&D) of ischiorectal abscesses (IA) are often avoided, for fear of irreversibly impairing anal continence. However, failure to identify and treat the frequently associated trans-sphincteric anal fistula dooms the patient to recurrent anal suppurative disease. We have employed an aggressive approach of performing I&D and F for IA at the time of initial presentation. Adequate drainage is assured by placement of counterincisions and Penrose drains to minimize the time for healing of the perianal wound. Drainage is followed by a careful examination of the anal canal for fistula localization followed by fistulotomy, or less frequently by cutting seton placement. We present our experience with this approach to IA, with special attention paid to the evaluation of recurrence rates and anal continence. This paper represents a retrospective review of 80 patients with IA managed from 1983 to 1996. Operative records and office records were reviewed, and follow-up data were obtained by telephone interview. Internal fistulous openings were identified in 55 (68.8%) patients. Surgeries included: 38 (47.5%) I&D and F, 8 (10%) I&D and seton, and 34 (42.5%) I&D alone. Follow-up data were available on 99 per cent of patients; mean, 44.3 months. Results showed a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F. 11.8 per cent of patients treated with I&D experienced a change in their level of continence postoperatively as compared to 15.8 per cent treated with I&D and F. The results indicate that an aggressive approach to IA allows identification of a trans-sphincteric fistula in 57.5 per cent of patients with IA. Therefore, optimal surgical management for IA appears to be I&D and F, resulting in a lower recurrence rate and comparable morbidity as compared to I&D alone.     

Retropharyngeal abscess after blunt trauma in an adolescent

Retropharyngeal abscess is an unusual infection in teenagers, and it is rarely associated with blunt trauma. We present the case of 17-year-old male who developed signs and symptoms of retropharyngeal abscess soon after being struck by a car. The case illustrates that retropharyngeal abscess should be considered, even in an adolescent, if the patient has fever, neck stiffness, and sore throat with symptoms out of proportion to the oropharyngeal findings.     

Extensive iatrogenic adenomyosis after laparoscopic myomectomy

The levels of N-acetylaspartylglutamate (NAAG) were determined by HPLC in untreated or lipopolysaccharide (LPS) activated pure astrocyte, oligodendrocyte, and microglial cultures derived from developing rat brain. Oligodendrocyte cultures expressed 1.52+/-0.12 nmol/microg protein of NAAG, whereas astrocyte cultures (0.04+/-0.08 nmol/microg protein) and untreated microglial cultures (0.05+/-0.09 nmol/microg protein) contained only trace amounts of the dipeptide. After stimulation of microglial cultures for 24 h with LPS, NAAG levels increased significantly to 0.37+/-0.12 SD nmol/microg protein. NAAG levels in astrocyte and oligodendrocyte cultures remained unchanged after LPS treatment. The findings indicate that NAAG is localized to specific glial cell types. Further our results suggest that NAAG biosynthesis is induced in microglia, activated by specific stimuli.