1,721,063 research outputs found
Complications following cholecystectomy
No full textLaparoscopic cholecystectomy is considered the gold standard for cholelithiasis. Nevertheless possible complications must not be underestimated. In this department, from 1 July 1991 to 30 November 1995, 1005 patients with cholelithiasis underwent videocholecystectomy. There was no peri-operative mortality. In 36 cases (3.6%) the procedure was changed to laparotomy. In four cases (0.4%) conversion was mandatory due to severe complications: in three patients while introducing a trocar (one aortic lesion, one middle colic vein injury and one visceral perforation) and in one patient due to bleeding in the hepatic hilar region. In 32 cases (3.2%) conversion was carried out electively. This was due to technical difficulties or to choledocholithiasis (22 patients), anaesthesiological problems (three cases), biliodigestive fistula (one), bile spillage from accessory hepatic ducts (three), unexpected colonic cancer (one), instrument malfunction (two cases). Twenty-four patients (2.4%) experienced post-operative complications: one with pneumothorax, two with bile leakage (one bile duct damage, and one cystic duct leakage), eight with haemoperitoneum, five with subphrenic abscess, three with anaemia, three with intraparietal collections, one with bilateral basal bronchopneumonia, one with perforated duodenal stress ulcer. Of these, 11 patients (1%) underwent reintervention: five re-laparoscopies, three conversions, and three open laparotomies. This study demonstrates the safety of videolaparocholecystectomy. Complications are relatively rare and can be often dealt with conservative treatment or re-laparoscopy. Complications are often linked to insertion of a blind trocar or to the induction of a closed pneumoperitoneum. Meticulous technique or open laparoscopy minimize these risks. Conversion must not be considered a defeat but a wise decision in the face of major difficulties. Under these principles, videocholecystectomy is safe and represents the best treatment of gallbladder stones
Video-assisted thoracoscopic surgery (VATS) major pulmonary resections: the Italian experience
No full textVideoendoscopic lobectomies or pneumonectomies are infrequently performed, mostly because of technical difficulties, concern for intraoperative accidents, and radicality in case of malignancy. The work diffusely describes technical details and a personal experience of videothoracoscopic major pulmonary resections (MPRs). All patients are first explored thoracoscopically. The procedure can then be completed thoracoscopically or converted. Videothoracoscopic exploration was performed in 211 candidates to MPR. Six patients' cases became nonresectable owing to pleural carcinomatosis or mediastinal infiltration, 171 patients completed a thoracoscopic MPR (165 lobectomies and 6 pneumonectomies), and 34 required conversion for technical (20) or oncological (10) reasons. Video MPRs were performed for benign disease (24), for lung metastases (5) and for preoperatively staged T1N0 or T2N0 primary lung cancer (142). No perioperative mortality was recorded. In 154 patients (90%), postoperative course was uneventful. One patient died after 33 days because of contralateral pneumonia; 15 elderly patients had prolonged air leaks. One patient developed partial dehiscence of the bronchial stump (healed conservatively) after a severe respiratory insufficiency on his third postoperative day had required mechanical ventilation. Even though video MPR can present remarkable difficulties, its undeniable advantages will benefit from further improvement of instrumentation. In case of tumors, larger series and longer follow-up will allow evaluation of long-term survival and local recurrence
Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse of the rectum: a prospective study
No full textPURPOSE : At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demostrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids. This prospective study was designed to evluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy.
METHODS: Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy. Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of synptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated.
RESULTS: At a mean follow-up of 27.2 (range, 24-34)months symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess,requiring surgery.
DISCUSSION: The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years. Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition
A simple method to save on costs in pulmonary emphysema operations
No full textThe hazard of prolonged air leaks causing protracted postoperative hospital stay increases the already high costs of lung volume reduction operations for severe emphysema. To solve the problem, Cooper [1] proposed to reinforce the staple line with bovine pericardial strips. Subsequently, an inert material, such as expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Associates, Inc, Flagstaff, AZ), was introduced, displaying the same advantages of bovine pericardium but apparently of more practical use [2].
Lung volume reduction operations can be performed either through sternotomy or videothoracoscopy. The use of videothoracoscopy is increasing as the reduced trauma seems particularly desirable in such compromised patients, although automatic staplers further increase costs. Each unilateral lung volume reduction procedure usually requires 8 to 12 loading units, and the number of cartridges doubles with bilateral procedures.
Also because of our experience with more than 1,700 thoracoscopic procedures, we opted for videothoracoscopy within our department. It was immediately apparent that polytetrafluoroethylene sleeves specifically designed for automatic endoscopic staplers further increased the expenses, as each loading unit of polytetrafluoroethylene reinforcing sleeves costs about 66 US. Considering the number of reinforcing strips required (8 to 12 for unilateral lung volume reduction operation, 16 to 24 for bilateral lung volume reduction operation) the expense is relevant.
Following the instructions of the manufacturer, the polytetrafluoroethylene sleeve (SEAMGUARD Staple Line Reinforcement Material; W.L.Gore & Associates) is positioned on a 45-mm Endopath stapler (Ethicon Endosurgery Inc, Cincinnati, OH), and after firing, the exceeding part of the sleeve is grasped distally to the jaws, removed and discarded.
We developed our own technique to reuse these parts of the sleeve to reinforce three more staple lines. The two remaining parts of Seamguard are sectioned with straight scissors along the folding lines of the residual sheets of Gore-Tex, thus producing three wide and three narrowe strips (Fig 1). One of the larger strips is now laid on the cutting surface of the stapler’s cartridge jaw and tied to it with two Vicryl 4-0 precut threads (Ethicon) (Fig 2). The narrower strip is fixed to the stapler’s anvil in the same way. It is important to check that the two knotted threads are positioned within the limits of the cut line and the knots are kept externally with long edges. The Gore-Tex sheet exceeding the cutting zone of the stapler must be sectioned (see dotted line in Fig 2) to prevent the polytetrafluoroethylene lamina flaps from folding back while the stapler is applied onto the parenchyma. Sometimes the distal thread is pushed forward by the stapler blade without being sectioned. Grasping one of the two longer edges of the thread and sectioning it with endoscopic scissors overcomes the problem (Fig 3). The same steps are repeated until the entire parenchyma line is stapled, reusing every part of each new Seamguard sleeveOur hospital pays 66 for each set of Seamguard. At an average of 8 to 12 (for unilateral operation) and 16 to 24 units (for bilateral operations) is required, the expense can reach 792 or 1,584, respectively. With our technique the cost for reinforcing the staple lines is reduced to one fourth (ie, 198 [for unilateral procedures] to 396 [for bilateral procedures]). Because the cost of the stapler and its reloading units cannot be reduced, the marked reduction of expenses for reinforcing the staple line with Seamguard allows us to cope with the economic aspect of this operation. The slightly longer time required for fashioning and tying the stripes is overcome by its economic advantage; furthermore, the cutting and tying time decreases progressively as experience increases
Techniques of pneumonectomy. Video-assisted thoracic surgery pneumonectomy
No full textThoracoscopic major pulmonary resections such as lobectomies or pneumonectomies are the most difficult operations that can be attempted thoracoscopically, and still have limited routine application in thoracic surgical practice. The precise indications for thoracoscopic pneumonectomy are very rare and have not yet been defined precisely; we limited the procedure only to double tumors, small tumors infiltrating the fissure, and small tumors at the secondary carina not amenable to a bronchoplasty procedure. Although the technique still has very limited applications, the advantages include reduced surgical trauma and consequent minimal postoperative pain, a shortened hospital stay, and a rapid resumption of normal activities which ultimately reduces costs. Wider acceptance, larger series, and a more extensive follow-up will assess the role of thoracoscopic anatomical lung resection in modern thoracic surgical practice
Thoracoscopic technique for pulmonary lobectomy and pneumonectomy
No full textMajor pulmonary resections are undoubtedly the most difficult operations to perform thoracoscopically. from May '91 to March '97 1048 videothoracoscopic operations were performed at our department. The majority of patients were operated on for lung cancer (83%) and the others for benign diseases (14%) or metastases located too deeply in the parenchyma and nota amenable to wedge resection. Out of 211 patients candidate to videolobectomy 16% required converse due to oncological reasons (16%) or technical problems (70%), mainly diffuse adhesions (7 pts), thick fissures (20 pts. and bleeding (6 patients).Infiltration of the parietal pleura and unexpected N2disease were the most frequent oncological causes. Postoperative course was uneventful in 90% of cases. larger series and longer follow up are required to assess the validity of the procedure
State of the art in thoracoscopic surgery
No full textBackground
Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.
Methods
Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n=910), wedge resections (n=261), lobectomies (n=221), pneumonectomies (n= 6) the diagnosis and treatment of pleural diseases (n=200), the treatment of pneumothorax (n=170), giant bullae (n=57), lung volume reduction surgery (LVRS) for emphysema (n=41), the diagnosis and treatment of mediastinal diseases (n=133), the treatment of esophageal diseases (n=39), and 30 other miscellaneous procedures.
Results
A review of the literature indicates that video-thoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.
Conclusions
Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers
Videothoracoscopic approach to primary mediastinal pathology
No full textStudy objectives: Personal results and validity of videothoracoscopic (VTS) approach to primary mediastinal diseases are analyzed.
Design: Retrospective review of personal experience.
Setting: Department of Surgery, San Giuseppe Hospital, University of Milano, Italy.
Patients: From September 1991 to January 1999, of a personal series of 1,653 VTS procedures, 118 regarded primary mediastinal diseases. In 47 cases, diagnostic videothoracoscopy was performed to obtain large biopsy specimens or to carry out accurate staging; in 71 cases, full resection was anticipated.
Interventions: The patient, intubated with a double-lumen Carlen’s tube and in the lateral decubitus position, underwent videothoracoscopy. Two ports and a small anterior utility thoracotomy were completed. Thorough exploration of the mediastinum and, if possible, complete resection of the lesion were accomplished.
Measurements and results: Videothoracoscopy yielded adequate diagnosis or staging in all patients operated on for diagnostic purposes. Of 71 patients operated on with resective intent, 66 had complete thoracoscopic resection (22 stage-I thymomas, 4 thymic cysts, 21 myasthenia gravis associated with thymic hyperplasia, 19 miscellaneous tumors). Conversion was required in five cases, mostly for invasion of mediastinal structures. Complications included the following: one patient developed intraoperative bleeding controlled endoscopically, two patients experienced postoperative bleeding requiring re-thoracoscopy, and one patient had postoperative pneumonia requiring assisted ventilation. One recurrence of malignant thymoma occurred 4 years postoperatively.
Conclusions: Videothoracoscopy can attain a leading role in obtaining large samples in lymphatic mediastinal diseases. Dysembriomas, schwannomas, simple cysts, and similar lesions can benefit from VTS removal. Total thymectomy for myasthenia gravis associated with thymic hyperplasia can be performed thoracoscopically. Further data and more extensive experience are needed
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