Journal of laparoendoscopic surgery最新文献

A case of bleeding gastric polyp in an elderly woman with compromised respiratory function was treated successfully as an emergency by the gasless laparoscopic technique after endoscopic means failed to control the bleeding. The application of laparoscopic mechanical stapling devices allows rapid gastrotomy and resection, with simultaneous hemostasis that is beneficial in acute bleeding condition. The use of gasless laparoscopy also allows continuous suction to be applied for identification of the bleeding pathology and it also reduces the risk of pneumoperitoneum in patients with poor cardiorespiratory reserve. The operative approach and technique are fully discussed.

Objective: To determine the efficacy of transillumination for locating abdominal wall vessels prior to trocar placement during laparoscopy.

Design: Prospective clinical descriptive study.

Setting: Normal human volunteers in an academic research environment.

Patients: Forty-seven white and 21 black women of various weights undergoing laparoscopy for clinical indications unrelated to this study.

Interventions: None.

Main outcome measures: The location and number of abdominal wall vessels visible by transillumination were recorded for each patient.

Results: In women of normal weight, a single vessel could be seen approximately 5 cm from the midline in > 90% of the patients, and second vessel approximately 8 cm from the midline could also be seen in 51%. The more medial vessels did not correlate with the course of the inferior epigastric vessels seen laparoscopically. The ability to see vessels was decreased significantly by the patients' weight but not by skin color.

Conclusions: Superficial abdominal wall vessels may be located by transillumination in the majority of women of normal weight regardless of skin color, but is of less value in overweight and obese women. However, the deep (inferior) epigastric vessels cannot be effectively located by transillumination, and thus other techniques should be used to minimize the risk of injury to these vessels.

The authors prospectively examined the cardiorespiratory changes seen with general anesthesia using the laryngeal mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. Anesthesia consisted of halothane in 50% oxygen/air and a caudal epidural block. The patient was allowed to ventilate spontaneously without assistance. Baseline measurements of heart rate, systolic blood pressure (SBP), end-tidal CO2 (ETCO2), tidal volume, respiratory rate, and oxygen saturation were recorded every 1 min for 5 min prior to the start of laparoscopy and every minute during the laparoscopic procedure. A total of 15 patients were enrolled in the study ranging in age from 15 to 90 months (35.5 +/- 23.8 months) and in weight from 10 to 26.4 kg (14.9 +/- 4.9 kg). The length of the laparoscopy varied from 3 to 9 min (6.1 +/- 2.1 min). Although clinically insignificant, there was an increase in the heart rate from a baseline value of 141 +/- 9 to 148 +/- 9 beats/min (p = 0.0016) and in the SBP from a baseline value of 97 +/- 6 mm Hg to 101 +/- 7 mm Hg (p = 0.0087). The baseline tidal volume prior to the start of laparoscopy was 5.2 +/- 1.1 mL/kg and increased to 6.4 +/- 1.4 mL/kg during laparoscopy (p < 0.0001) while the respiratory rate increased from 32 +/- 4 to 40 +/- 6 breaths/min (p < 0.0001). ETCO2 increased from a baseline value of 47 +/- 6 to 53 +/- 6 torr (p = 0.0059). The maximum value of the ETCO2 was 55 torr or greater in 6 patients, exceeded 60 torr in 3 patients, with a maximum value of 63 torr. The increased ETCO2 returned to baseline within 2 to 7 min (4.7 +/- 1.5 min) following completion of the laparoscopy. There was no significant change in oxygen saturation. Our initial experience suggests that general anesthesia may be provided using the laryngeal mask during brief laparoscopic inspection of the peritoneum.

This is the first report, to our knowledge, of a case of massive subcutaneous emphysema during totally preperitoneal laparoscopic hernia repair causing a "respiratory acidosis" with a systemic pH 7.20 and a pCO2 of 64 and PO2 of 84. The acidosis was corrected by increased mechanical ventilation. It appears that because of its lack of defined borders, the preperitoneal space is particularly vulnerable to the formation of massive subcutaneous emphysema. Thus, there is a large potential surface area for CO2 absorption. The complication may be prevented by increased attention to the length of fascial incisions, inflation of balloon expanding devices, and securing gripping devices in the port sites.

In a 71-year-old female marked left-sided ureteral stenosis secondary to retroperitoneal fibrosis was diagnosed. Since conservative therapy with cortisone had failed, laparoscopic ureterolysis was performed. Following tracheal intubation the lungs were ventilated with 40 vol% O2 in air and isoflurane 0.5-2%, using a positive end-expiratory pressure of 6 cm H2O. A CO2 pneumoperitoneum was established with a pressure-controlled high-flow insufflator; the intraabdominal pressure during the procedure was 14 mm Hg. Two hours after gas instillation, the peak airway pressure increased from 22 to 40 cm H2O, and the PaCO2 from 45 to 70 mm Hg. Breath sounds over the right lung were no longer heard, and subcutaneous emphysema was noted over the neck and face. An intraoperative chest X-ray confirmed a right pneumothorax. Following peritoneal gas evacuation, the PaCO2 returned to 35 mm Hg, the subcutaneous emphysema diminished, and a repeat chest X-ray showed complete resolution of the pneumothorax. The course of this event led us to the conclusion that the pneumothorax was due to diffusion of CO2 from the peritoneal to the pleural cavity through congenital defects in the diaphragm. Ureterolysis could be continued by laparotomy.

A simplified one-time bilateral thoracoscopic T2-T3 sympathicolysis technique using single-lumen endotracheal intubation with high frequency jet ventilation and electrocautery destruction ("sympathicolysis") of the sympathetic ganglia was applied in 100 consecutive patients with severe essential hyperhidrosis (EH). Providing a pleural space can be created, this technique was proven simple and safe, and short-term clinical results were excellent: palmar hyperhidrosis was cured in 98% of patients, and axillar and plantar improvement was achieved in 62 and 65% of patients, respectively. Side-effects and complications were minor (compensatory hyperhidrosis) or self-limiting (pain). These data confirm the safety and efficacy of thoracoscopic sympathetic interventions for the treatment of EH, and support the evolution toward simplified methodologies.

A technique for second-look laparoscopy in an obese patient suffering from acute mesenteric ischemia is described. A device composed of a 10-mm trocar-sleeve and a large Foley catheter was used, which enables its proper fixation through the abdominal wall, without causing any intestinal damage.

A hernia of Morgagni was successfully repaired laparoscopically by reducing the hernia, mobilizing the peritoneum around the perimeter of the defect, and stapling polypropylene mesh onto the surrounding fascia. This type of repair is technically easy and should give a high probability of success.

One hundred consecutive patients requiring elective cholecystectomy in one surgeon's practice were booked as outpatients between April 1994, and July 1995. Two patients had massive adhesions and 18 had acute disease. Outpatient surgery was successful for 94 patients, who spent an average of less than 6 h in hospital. Six patients required postoperative admission, four because of conversion and two for other causes. There were three readmissions, unrelated to outpatient status: one to treat a wound infection, one to drain a subphrenic abscess, and one to repair an umbilical hernia. Complications were one subphrenic abscess, one case of significant atelectasis, and, at the umbilical incision seven wound infections, one hematoma and one postoperative hernia. Advanced age and increased comorbidity correlated significantly with the need for hospital admission, but were not contraindications, either alone or in combination, to outpatient surgery. Patient satisfaction was high.