Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital

Introduction  The aim of this study is to determine the efficacy of preoperative ureteral catheterization as a prophylactic measure to prevent ureteral injury and related complications. Methods  All major gynecologic operations performed between January 1996 and December 2007 were included and prospectively randomized into with and without catheterization groups. The medical records allowed the identification of all urinary tract complications and ureteral injuries. Results  Bilateral prophylactic ureteral catheterization was performed in 1,583 patients. A ureteral injury occurred in 19 (1.20%) out of 1,583 patients. Seventeen ureteral injuries (1.09%) occurred out of 1,558 patients without prophylactic ureteral catheterization. There was no statistically significant difference in the incidence of ureteral injury between the different interventional groups (p = 0.774). Conclusion  The use of prophylactic ureteral catheters did not eliminate ureteral injuries in our patients. The presence of ureteral catheters should not supplant meticulous surgical techniques and direct visualization of the ureters during gynecologic surgery.     

Reflux anuria after prophylactic ureteral catheter removal: a case description and review of the literature

In an attempt to reduce iatrogenic ureteral injury, urologists are frequently called on for placement of prophylactic ureteral catheters in difficult pelvic surgeries. Reflux anuria, which may be more appropriately termed catheter-induced obstructive anuria, has been reported as a complication of ureteral catheter placement and is characterized by the absence of urine output after ureteral manipulation because of edema and obstruction. We report a case of obstructive anuria after bilateral ureteral catheter removal and review the literature regarding this rare complication. Medline was searched for all relevant case reports, case series, and trials that included prophylactic ureteral catheters and described complications of their use. Published series report varying incidence of obstructive anuria after prophylactic ureteral catheter removal from 0% to 7.6%. There are no proven strategies for prevention of obstructive anuria after prophylactic ureteral catheter removal, but staged removal has shown a trend toward reduced incidence. When encountered, most cases of anuria after catheter removal resolved with medical management alone; however, indwelling stent placement has been advocated while ureteral edema resolves.     

输尿管导管在妇科腹腔镜手术中预防输尿管损伤的应用

目的探讨盆腔粘连患者行腹腔镜手术时放置输尿管导管预防输尿管损伤的可行性。方法随机选取盆腔粘连患者27例,实验组15例于术前在膀胱镜下放置输尿管导管,对照组12例按正常程序实施手术。结果实验组避免输尿管损伤有效率为100％,对照组有效率为91.67％,差异有统计学意义（P〈0.05）。在子宫次全切除术及子宫全切除术中,实验组手术时间均明显短于对照组（P〈0.05）,差异有统计学意义。结论盆腔粘连患者行腹腔镜手术时放置输尿管导管,可有效防止输尿管损伤,手术操作安全,快捷。     

腹腔镜子宫肌瘤切除术380例报告

目的:总结腹腔镜子宫肌瘤切除术的手术经验及应用价值.方法:回顾分析2009年7月至2010年7月为380例患者施行腹腔镜子宫肌瘤切除术的临床资料.多发性子宫肌瘤切除术术前超声定位,术中必要时联合应用宫、腹腔镜,宫颈肌瘤、阔韧带肌瘤术中放置输尿管导管,以防止损伤输尿管.结果:380例手术均获成功,无一例中转开腹,未发生输...     

Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma

BACKGROUND: Occult diaphragmatic injury following penetrating thoracoabdominal trauma can be difficult to diagnose. Radiographic findings are often non-specific or absent. Undetected injuries may remain clinically silent, only to present later with life-threatening complications associated with diaphragmatic herniation. Diagnostic laparoscopy allows for the evaluation of trauma patients lacking clinical indications for a formal laparotomy. The purpose of this study was to evaluate the incidence of occult diaphragmatic injury and investigate the role of laparoscopy in patients with penetrating thoracoabdominal trauma who lack indications for exploratory laparotomy except the potential for a diaphragmatic injury. METHODS: Haemodynamically stable patients with penetrating thoracoabdominal trauma without indications for laparotomy (haemodynamic instability, evisceration, or peritonitis on exam) and evaluated with diagnostic laparoscopy to determine the presence of a diaphragmatic injury were retrospectively reviewed. Thoracoabdominal wounds were defined as wounds bounded by the nipple line over the anterior and posterior chest superiorly and the costal margin inferiorly. RESULTS: One hundred and eight patients were evaluated for penetrating thoracoabdominal injuries (80 stabs and 28 gunshots) over the study period. 22 (20%) diaphragmatic injuries were identified. These were associated with injuries to the spleen (5), stomach (3) and liver (2). There was a greater incidence of haemopneumothorax (HPTX) in patients with diaphragmatic injury (32%) compared to those without injury (20%). 29% of patients with a HPTX had a diaphragmatic injury. However, 18% of patients with a normal chest radiograph were also found to have a diaphragmatic injury. CONCLUSIONS: The incidence of diaphragmatic injury associated with penetrating thoracoabdominal trauma is high. Clinical and radiographic findings can be unreliable for detecting occult diaphragmatic injury. Diagnostic laparoscopy provides a vital tool for detecting occult diaphragmatic injury among patients who have no other indications for formal laparotomy.     

Laparoscopic placement of the Tenckhoff catheter for peritoneal dialysis

Continuous ambulatory peritoneal dialysis catheters can be inserted by open laparotomy as well as by laparoscopy. A prospective randomized study was scheduled to investigate the results of the laparoscopic versus open laparotomy technique for placement of continuous ambulatory peritoneal dialysis catheters. Fifty patients were enrolled and randomly allocated into two groups of 25 patients each. Group A underwent continuous ambulatory peritoneal dialysis catheter placement via the open laparotomy technique. In 22 patients, catheters were inserted via midline incision, and in 3 patients with histories of previous catheterization, a paramedian incision was used. Continuous ambulatory peritoneal dialysis was started 24 to 48 hours later. Group B underwent laparoscopic placement of the catheter with fixation into the pelvis and suture closure of the port wounds. In 21 patients, this catheter placement was the first such placement, and in 4 patients, a previous catheter had been inserted by the open technique and removed for dysfunction. Continuous ambulatory peritoneal dialysis was started at the end of the procedure. The mean operative time was 22 minutes in group A and 29 minutes in group B (P < 0.001). Fluid leakage was observed in eight patients in group A, but in no patients in group B (P < 0.005). Peritonitis occurred in five patients in group A and in three patients in group B (P > 0.1). Tip migration occurred in five patients in group A and no patients in group B (P < 0.005). In group B, two patients underwent a simultaneous cholecystectomy and one underwent incisional hernia repair. Laparoscopic placement of a Tenckhoff catheter leads to better function than does the open procedure; it allows immediate start of dialysis without fluid leakage and permits simultaneous performance of other laparoscopic procedures.     

Complications of laparoscopic radical hysterectomy and lymphadenectomy for invasive cervical cancer: experience based on 317 procedures

Background This report presents the incidence of complications and conversions during laparoscopic radical hysterectomy and lymphadenectomy performed for invasive cervical carcinoma. The data are analyzed, and strategies to help prevent future complications are discussed. Methods From July 2000 to December 2005 at the authors’ institution, 317 laparoscopic radical hysterectomy and lymphadenectomy procedures for invasive cervical carcinoma were performed. The authors reviewed the database of patients who underwent laparoscopic radical hysterectomy and lymphadenectomy to examine complications and analyze factors associated with conversion to an open surgical procedure. Results All but four surgical procedures were laparoscopically completed. Pelvic lymphadenectomy was performed for all the remaining 313 patients, 143 of whom underwent paraaortic lymphadenectomy. Major and minor intraoperative complications occurred for 4.4% (n = 14) of the patients. The overall conversion rate was 1.3% (n = 4), including 3 emergencies and 1 elective conversion. Seven patients had vessel injuries, five of which were repaired or treated laparoscopically. One left external iliac vein required laparotomy, and one patient underwent laparotomy to control bleeding sites. Operative cystotomies occurred in five patients, which were repaired laparoscopically. Two patients underwent laparotomy because of hypercapnia and ascending colon injury. Postoperative surgery complications occurred in 5.1% (n = 16) of the patients, including 5 patients with ureterovaginal fistula, 4 with vesicovaginal fistula requiring reoperation, 1 with ureterostenosis treated by placement of a double-J ureteral stent, and 6 with bladder dysfunctions (retention) that exhibited complete resolution within 3 to 6 months by intermittent training and catheterization. Conclusions Laparoscopic radical hysterectomy and lymphadenectomy is becoming a routine procedure in the armamentarium of many gynecologists. Complications unique to laparoscopy do exist, but they decrease with repeated training of the procedure and gradually enriched experiences.     

The effect of suprapubic catheterization versus transurethral catheterization after abdominal surgery on urinary tract infection: a randomized controlled trial

BACKGROUND/AIM: Transurethral catheterization is generally associated with a higher incidence of urinary tract infections than suprapubic catheterization; however, suprapubic catheterization is associated with other disadvantages such as higher costs and a more difficult technique, and at the moment there is no consensus about the use of both catheter systems. Therefore, a prospective randomized study was performed to investigate the effects of suprapubic catheterization and transurethral catheterization in patients undergoing surgery on the incidence of urinary tract infections and patient satisfaction. METHODS: Patients who underwent an elective laparotomy were randomized and received a suprapubic or transurethral catheter. The primary end point was urinary tract infection. Other parameters of urinary tract infection, as well as duration of catheterization, hospital stay, and number of recatheterizations and of relaparotomies were monitored. Treatment 'per protocol' was also analyzed after exclusion of patients receiving another catheter than randomized for. Patients were asked for their satisfaction with the catheters and complaints during and after catheterization. RESULTS: 165 patients were eligible, of whom 19 patients had to be excluded. 75 patients were allocated to receive the suprapubic catheter and 71 the transurethral catheter. There was no difference in the incidence of a urinary tract infection between the suprapubic group (n = 9/75; 12%) and the transurethral group (n = 8/71; 11%). Most patients (6/9) who developed a urinary tract infection in the suprapubic group, however, underwent recatheterization because of postoperative complications/sepsis and relaparotomy. The incidence of urinary tract infections in patients who received a suprapubic catheter and not a transurethral catheter was 3/59 (5%). The patients did not differ with respect to satisfaction and complaints. Being a men, recatheterization and duration of catheterization are risk factors. CONCLUSIONS: The incidence of a urinary tract infection between a suprapubic catheter and a transurethral catheter in patients undergoing major surgery was not different. A potential advantage of the suprapubic catheter (reduction of urinary tract infections) is probably partly negated, because transurethral catheters were used if recatheterization was indicated during the postoperative stay or due to complications.     

Laparoscopic placement and revision of peritoneal dialysis catheters.

Chronic peritoneal dialysis is an option for many patients with end stage renal disease. Laparoscopy offers an alternative approach in the management of dialysis patients. Over an 18-month period, laparoscopy was used for placement or revision of seven peritoneal dialysis catheters. All were placed in patients with end stage renal disease for chronic dialysis. Two catheters were initially placed using the laparoscope, and in five other patients, the position of the catheter was revised. Of the two patients who had their catheters placed initially, one patient had a previous lower mid-line incision and underwent laparoscopic placement of a catheter and lysis of pelvic adhesions. The second patient had hepatitis C and chronically elevated liver function tests. He underwent laparoscopic placement of a peritoneal dialysis catheter and liver biopsy. Five patients had laparoscopic revision for non-functional catheters. Four were found to have omental adhesions surrounding the catheter. Three patients were found to have a fibrin clot within the catheter, and in one patient the small bowel was adhered to the catheter. All seven patients had general endotracheal anesthesia. There were no operative or anesthetic complications. The average operative time was 56 minutes. Four patients had their procedure in an ambulatory setting and were discharged home the same day. One patient was admitted for 23-hour observation, and two patients had their procedure while in the hospital for other reasons. In follow-up, there was one early failure at two weeks, which required removal of the catheter for infection. One catheter was removed at the time of a combined kidney/pancreas transplant eight months after revision. The other five catheters are still functional with an average follow-up of ten months. These results suggest that laparoscopy is another method for placement of peritoneal dialysis catheters and more importantly for revision in patients with nonfunctional catheters secondary to adhesions. It also provides an opportunity to evaluate the abdomen and perform concomitant procedures.     

COMPARATIVE EXPERIENCE OF A SIMPLE TECHNIQUE FOR LAPAROSCOPIC CHRONIC AMBULATORY PERITONEAL DIALYSIS CATHETER PLACEMENT

Background : Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. Methods : A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. Results : Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P= 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P= 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient'death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). Conclusions : This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.     

Left upper quadrant entry during gynecologic laparoscopy

The use of the left upper quadrant technique in establishing a pneumoperitoneum during gynecologic laparoscopy was reviewed retrospectively in 267 patients who underwent gynecologic laparoscopy. The study population included all patients presenting to the University of Louisville Hospital outpatient surgery unit for laparoscopic gynecologic surgery from January 1994 to March 2002. Data sheets were prospectively compiled for each patient that included their demographics as well as the intraoperative insufflation technique used and the number of attempts necessary to achieve successful insufflation. All recognized complications associated with establishment of the pneumoperitoneum or insertion of the primary trocar were recorded. The database included 3314 patients of which 267 underwent insufflation via the left upper quadrant technique. Failure to achieve insufflation using this technique occurred in 4 patients (1.5%). There were no bowel or vessel injuries. Puncture of the left lobe of the liver occurred in 3 patients (1.12%). All injuries were managed without laparotomy, and the patients fully recovered without sequelae. The left upper quadrant entry technique is an effective means of establishing a pneumoperitoneum in patients undergoing gynecologic laparoscopic procedures.     

Urological injuries in conjunction with gynecologic surgery-10 years' experience

A 10-year evaluation (1983–1992) of 23 patients (mean age 49 years) with urologic injuries in conjunction with gynecologic surgery is presented. There were nine vesicovaginal fistulas, eight ureteral injuries, three bladder lesions, two posterior urethrovaginal fistulas and one vesicocervical fistula. The total incidence of urologic injuries from all major gynecologic operations (n=16 400) was 0.09% and that of abdominal hysterectomies (n=4082) 0.17%. Vesicovaginal fistulas and ureteral injuries comprised two-thirds (17/23) of all injuries. All vesicovaginal fistulas followed abdominal hysterectomy, whereas almost half (3/8) of ureteral injuries were recognized after radical hysterectomy. Of nine vesicovaginal fistulas two were cured by prolonged transurethral catheter drainage: the other seven underwent successful transabdominal repair at first attempt. All the eight ureteral injuries were cured successfully at the first attempt, five of them by ureteroneocystostomy and the others with ureteral stent placement. One of the urethrovaginal fistulas was repaired successfully at the first attempt, the other required a second repair. At follow-up (mean 4 years) all patients were doing well. Urologic injuries after gynecologic surgery are extremely rare (0.09% in our series) but when they occur they can be consistently repaired by modern surgical techniques.Editorial Comment: This report of a 10-year experience with various types of fistula and ureteral injury indicates a very low incidence as well as a very high success rate in their management. Of note is the high frequency of fistulas following urethral diverticulectomy (18%). Care must be taken when closing the anterior vaginal wall in this procedure. There must be no tension and adequately vascularized tissue must be present. The preparation of flaps is usually possible as the dissection of the diverticulum proceeds, with the goal of having enough tissue to allow a vest-over closure in one or two layers. If there is any doubt about the closure a bulbocavernosus fat pad graft should be prepared and placed as an additional layer prior to closure of the vaginal wall.     

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.     

Retrospective analysis of traumatic bladder injury: does suprapubic catheterization alter outcome of healing?

The role of suprapubic catheters in traumatic bladder injuries is not well defined. Current literature suggests that suprapubic catheters are only necessary with large intraperitoneal bladder ruptures. The purpose of this study is to show that all bladder injuries can be managed with transurethral catheterization alone with a similar leak rate, morbidity, and healing time. Retrospective analysis was done of all patients with traumatic bladder injuries at a level I urban trauma center from June 1992 through June 2003. Medical records were reviewed and data analyzed according to type of bladder catheterization (i.e., transurethral or suprapubic). All patients with urethral injuries were excluded. Fifty-six patients met inclusion criteria. Twenty-seven patients suffered penetrating bladder injuries, and 29 bladder injuries were secondary to blunt trauma. Forty-seven patients were treated with transurethral catheter drainage, two were treated with suprapubic catheters, and seven were treated with both transurethral and suprapubic catheters. Forty patients had follow-up cystograms prior to catheter removal. Of the 47 patients treated with transurethral drainage alone, 3 (6%) developed urinary leaks. Of the 9 patients with suprapubic catheters, 2 (22%) developed urinary leaks. The mean time to removal of transurethral catheters was 15 days. The mean time to removal of suprapubic tubes was also 15 days. All study patients successfully healed their bladder injuries regardless of catheterization method. Suprapubic catheter drainage may increase morbidity without improving healing time. These results effectively support the decision to use transurethral catheter drainage alone in all patients with traumatic bladder injuries.     

Evaluation of perioperative antibiotics at the time of dialysis catheter placement

The effect of prophylactic antibiotics on the occurrence of peritonitis in the 14 days following surgical peritoneal dialysis catheter placement was evaluated. Medical records from 73 pediatric patients who had 89 Tenckhoff catheters inserted over 6 years were reviewed. Twelve catheter procedures were excluded for rapid catheter loss, unavailable charts, eosinophilic peritonitis, and antibiotic administration >3 h postoperatively. Chi-squared analysis for non-continuous variables compared factors at the time of catheter placement with outcome (peritonitis). Thirteen patients developed postoperative peritonitis when 77 catheter insertions were analyzed (17%). Peritonitis was significantly more common in patients who did not receive perioperative antibiotics (7 of 16 catheter placements) (λ² = 12.48, P≤0.001). The reduced incidence of peritonitis was not specific to any one antibiotic class. Using step-wise logistic regression analysis, no association was found between peritonitis incidence and nephrotic syndrome, immunosuppression, recent surgery (<14 days), acute versus chronic use, year of catheter placement, surgeon, or patient age. Catheter type, implantation technique, exit site care, and operative wound care did not vary. These results indicate that perioperative peritonitis episodes can be significantly reduced by the use of prophylactic antibiotics prior to or at the time of surgery. Received August 27, 1996; received in revised form and accepted October 2, 1997     

Mini-laparoscopy-assisted placement of Tenckhoff catheters: an improved technique to facilitate peritoneal dialysis

BACKGROUND AND PURPOSE: Despite its overall efficacy and patient satisfaction with it, peritoneal dialysis has a history of significant complications, which has contributed to the evolution in the technique from open laparotomy to minimally invasive placement of the catheters. Our goal was twofold: (1) to review our early experience with a technique of mini-laparoscopy-assisted (MLA) placement of dialysis catheters compared with open placement and (2) to demonstrate that urologists are able to provide a satisfactory procedure while concurrently developing and maintaining laparoscopic skills within a residency training program. PATIENTS AND METHODS: The charts of the first 14 consecutive patients who underwent MLA placement of Tenckhoff dialysis catheters by a single surgeon (LCM) from January 1, 2000, through March 31, 2001, were reviewed. Postoperative narcotic analgesia, length of hospital stay, operative times, days until cycling, and rates of leakage, infection, and malfunction necessitating removal of catheters were compared with the corresponding data from 12 consecutive patients who underwent traditional open placement during the same time period. A telephone survey was performed to corroborate and supplement the findings from the chart review. RESULTS: Differences in complications necessitating catheter removal were not significant. The difference in the mean operative times of 41.7 minutes in the MLA group and 55.7 minutes for open placement was statistically significant. Postoperatively, the MLA group used less narcotic analgesia, had shorter hospital stays, and returned earlier to usual activities. The incidence of leakage after catheter placement was greater in the open group, although this difference was not statistically significant. CONCLUSIONS: The MLA technique of dialysis catheter placement appears to have similar or greater efficacy than the open technique. It is a viable teaching procedure, and with reusable 3-mm ports and shorter operative times, it is cost efficient as well.     

腹腔镜辅助阴式子宫切除术并发脏器损伤

目的探讨腹腔镜辅助阴式子宫切除术（laparoscopic assisted vaginal hysterectomy,LAVH）脏器损伤的原因及处理。方法 2009年3月～2010年12月我院行317例LAVH,7例发生脏器损伤。腹腔镜下处理附件后,经阴道缝扎子宫血管、主骶韧带及缝合阴道残端。结果脏器损伤7例,发生率2.2%（7/317）：膀胱损伤3例,直肠损伤2例,输尿管损伤2例。3例膀胱损伤术中行修补术,术后留置导尿2周拔管。2例直肠损伤术中行破口修补缝合,术后流质饮食,排便后正常饮食。2例输尿管损伤,1例术中行输尿管断端缝合术并放置双J管,1例术后25 d开腹探查行输尿管膀胱植入放置双J管治愈。7例术后随访1～3个月,愈合良好,无并发症发生。结论 LAVH并发周围器官损伤与手术难度及手术操作有关。加强手术医师技巧培训及术前评估、注意术后观察,有利于减少并发症、及时发现病情变化。     

Longterm central venous access in gynecologic cancer patients

BACKGROUND: To assess the utility and safety of three different longterm indwelling intravenous catheters in patients with gynecologic malignancies. STUDY DESIGN: A retrospective review was performed of the records of all women with gynecologic malignancies who required longterm venous access catheters and ports between 1990 and 1997. RESULTS: Two hundred sixty-eight women underwent placement of 308 indwelling catheters, of which 305 were available for analysis. Of those, 68 (22%) were Hickman catheters, 162 (53%) were infusaports, and 75 (25%) were Peripheral Access System (PAS) ports. Venous access was obtained percutaneously in 152 (50%) patients and by cutdown in 153 (50%). Prophylactic anticoagulation was used with 96 catheters (31%). Catheter placement was associated with 12 (4%) immediate complications and 87 (29%) delayed complications. The average duration of a catheter in place was 5.6 months for the Hickman, 12.5 months for the infusaport, and 16.0 months for the PAS port (p < 0.001). Bacteremia was more likely to develop in patients with Hickman catheters when compared with those with infusaports and PAS ports (19% versus 6% and 5%, respectively, p = 0.002). Thrombosis was significantly less likely to develop in patients receiving prophylactic anticoagulation (11% versus 4%, p = 0.004). Overall, the complication rate was lower with cutdown versus percutaneous access (p = 0.004). There was no statistically significant difference between the frequency of complications when correlated with the stage of disease, patient age, body mass index, or type of malignancy. CONCLUSIONS: Infusaports and PAS ports were associated with a lower risk of infection and have a longer life than Hickman catheters. The cutdown approach was associated with a lower complication rate. Low-dose prophylactic anticoagulation should be given to all patients with longterm central venous catheters.     

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT.     

Robotic catheter ventriculostomy: feasibility, efficacy, and implications

OBJECT: Robotic applications hold great promise for improving clinical outcomes and reducing complications of surgery. To date, however, there have been few widespread applications of robotic technology in neurosurgery. The authors hypothesized that image-guided robotic placement of a ventriculostomy catheter is safe, highly accurate, and highly reproducible. METHODS: Sixteen patients requiring catheter ventriculostomy for ventriculoperitoneal (VP) shunt or reservoir placement were included in this retrospective study. All patients underwent image-guided robotic placement of a ventricular catheter, using a preoperatively defined trajectory. RESULTS: All catheters were placed successfully in a single pass. There were no catheter-related hemorrhages and no injuries to adjacent neural structures. The mean distance of the catheter tip from the target was 1.5 mm. The mean operative times were 112 minutes for VP shunt placement and 42.3 minutes for reservoir placement. The mean operative times decreased over the course of the study by 49% for VP shunts and by 19% for reservoir placement. CONCLUSIONS: The robotic placement of a ventriculostomy catheter using a preplanned trajectory is safe, highly accurate, and highly reliable. This makes single-pass ventriculostomy possible in all patients, even in those with very small ventricles, and may permit catheter-based therapies in patients who would otherwise be deemed poor surgical candidates because of ventricle size. Robotic placement also permits careful preoperative study and optimization of the catheter trajectory, which may help minimize the risks to bridging veins and sulcal vessels.