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1.
R. J. Fitzgibbons Jr. A. Tseng H. Wang A. Ryberg N. Nguyen K. L. Sims 《Surgical endoscopy》1996,10(12):1180-1184
Background: Most of the literature dealing with the surgical management of acute cholecystitis bases patient selection on pathological
diagnosis, either exclusively or using it as a major selection criteria or as a confirmation of diagnosis. The purpose of
this study was to examine the correlation between preoperative clinical findings, intraoperative gross findings, and postoperative
pathological findings.
Methods: A retrospective review of 493 consecutive laparoscopic cholecystectomies performed by a single surgeon (RJF) in a single
institution was done. Four different sets of criteria were used to define four groups of patients as having acute cholecystitis:
(1) preoperative acute cholecystitis based on defined criteria (PA); (2) intraoperative gross findings of acute or subacute
cholecystitis based on surgeon assessment of inflammation (IA); (3) initial pathological evaluation by a staff pathologist
(IP); and (4) expert pathological (EP) review using strictly defined histological criteria.
Results: Of 41 patients, 40 (97.6%) were classified as having acute cholecystitis by IA, 21 (51.2%) by IP, and 17 (41.5%) by EP. Of
the 75 patients classified as having acute cholecystitis by IA, 40 (53.0%) were classified acute by PA, 34 (45.0%) by IP,
and 17 (22.7%) by EP. Of the 72 IP patients, 34 (47.2%) were classified as acute by IA, 15 (20.8%) by EP, and 24 (33.3%) were
PA. Of the 32 EP patients, 21 (65.6%) were classified as acute by IA, 14 (43.8%) by IP, and 18 (56.3%) were PA.
Conclusion: The correlation between the pathological diagnosis and intraoperative findings is poor. Preoperative clinical findings of
acute cholecystitis are highly reliable for predicting intraoperative gross findings. However, intraoperative findings of
acute cholecystitis are commonly found in the absence of preoperative clinical signs. Recommendations for surgical therapy
should be based on studies which use either operative findings or the preoperative clinical findings as the basis for patient
selection.
Received: 29 March 1996/Accepted: 12 June 1996 相似文献
2.
Background: In spite of the emergence of laparoscopic cholecystectomy as the gold standard for treatment of symptomatic gallstones, questions
still remain regarding its overall cost effectiveness, especially at low-volume centers where operating room (OR) time and
operative complications are higher. We hypothesize that the presence of a well-organized, dedicated laparoscopic OR team will
improve surgical outcomes for this procedure. This study compares the operative results of an advanced and a basic laparoscopic
surgeon using either a designated laparoscopic operating team or a nondesignated team.
Methods: The hospital records for 71 elective laparoscopic cholecystectomies with cholangiograms were retrospectively reviewed and
anesthesia times and conversion rates were analyzed. Procedures were performed either at a hospital with a dedicated laparoscopy
team or a hospital with nondedicated OR personnel. All procedures were done by an advanced laparoscopic surgeon or a basic
laparoscopic surgeon.
Results: Case characteristics were evenly matched between sites and surgeons. The mean total anesthesia time at the dedicated site
was 120.8 min, compared to 152.3 min at the nondedicated site with a mean difference of 31.5 min (p= 0.001). A 12% conversion rate was documented at the nondedicated site. There were no conversions at the site with a dedicated
laparoscopy team. No major complications were encountered in this series.
Conclusion: This study demonstrates that having a designated laparoscopic trained team provides a time savings to both advanced and basic
laparoscopic surgeons. Although no major complications were encountered, there was a significant conversion rate for the less
experienced surgeon operating without the support of a trained team. The end result from having a dedicated team in endoscopic
surgery is decreased operative time, an improvement in patient care, and decreased costs to the patient and institution.
Received: 5 July 1996/Accepted: 9 January 1997 相似文献
3.
L. Fernández-Cruz A. Sáenz G. Benarroch L. Sabater P. Taurá 《Surgical endoscopy》1996,10(11):1088-1091
Background: Patients with hypertension, with catecholamine hypersecretion, and with cortisol excess may associate intraoperative cardiovascular
instability and postoperative complications.
Methods: To compare the outcome of laparoscopic adrenalectomy (LpA) in patients with aldosterone adenoma (11), Cushing's adenoma (six),
Cushing's disease (four), pheochromocytoma (Pheo) (11), and nonfunctioning tumor (five). Intra- and postoperative parameters
were studied and in patients with Pheo intraoperative catecholamine plasma levels were correlated with cardiovascular derangements.
Results: Operative time, estimated blood loss, hospital stay, analgesic requirements, and time to return to normal activity were significantly
higher in patients undergoing total bilateral adrenalectomy for Cushing's syndrome compared with other groups undergoing unilateral
adrenalectomy, but these latter groups showed no significant differences among themselves in all parameters analyzed. One
patient with nonfunctioning tumor and another with Cushing's adenoma were converted to open surgery, and two patients with
Cushing's disease had urinary infection. Isolation of Pheo was associated with significant release of catecholamines but not
with hemodynamic changes.
Conclusion: LpA may be the most suitable method for removing functioning adrenal tumors.
Received: 20 March 1996/Accepted: 28 May 1996 相似文献
4.
Laparoscopic removal of a swallowed toothbrush 总被引:1,自引:1,他引:0
Toothbrush swallowing is an uncommon occurrence. Unlike most cases of foreign-body ingestion, there have been no cases of
spontaneous passage reported. Consequently, prompt removal is recommended before complications develop. We report a case of
toothbrush ingestion which failed attempted endoscopic removal. This patient was managed successfully with laparoscopic assisted
removal via gastrotomy. We recommend this approach for the removal of any ingested foreign bodies when surgical intervention
is indicated.
Received: 20 December 1995/Accepted: 1 March 1996 相似文献
5.
Background: Clinically relevant surgical outcomes are usually monitored by surgeons only for new and/or high-volume procedures. Prospective
outcomes audit studies are rarely done on 100% of procedures performed by a single surgeon, a surgical practice, or an institution.
Therefore, we set out to determine the resource utilization and accuracy of a well-validated system at its introduction into
a North American university surgical practice.
Methods: The Otago Surgical Audit, which has been validated in a wide spectrum of surgical practices in Australasia, was applied to
a university practice in general and laparoscopic surgery. Data were recorded by the surgeon on the day of operation, at discharge,
and during any subsequent readmission. Resource utilization was determined by timing the important steps in data acquisition
and computer entry. Data accuracy was assessed by an independent chart review of 22% of all records. Case capture was audited
by reviewing operating room case logs.
Results: Over 1 year, from October 1, 1996 to September 30, 1997, 338 procedures were performed. Data recording and coding by the
surgeon required 2 min per form, or a total of 676 min (11.3 h) annually. Data entry required 2.11 min per form, or a total
of 713 min (11.9 h) for the year. Eight percent of cases were returned to the surgeon for additional information. In the medical
record audit, no additional mortality or readmissions were discovered, and one minor complication was recorded in the hospital
record but not the outcomes audit. One complication and three operations recorded in the audit database were omitted from
operating room records. Two minor procedures on the operating room log were omitted from the audit database. Operating time
reported by the surgeon averaged 19 min less than recorded in the operative log. Data accuracy and coding accuracy improved
significantly between the 1st month (month 4) and the 2nd month audited (month 12), (p < .01).
Conclusions: It is possible to perform a 100% clinical outcome audit with the use of minimal resources. When the surgeon is involved with
data acquisition and coding, the accuracy and completeness of the log may outstrip the medical record, but a learning curve
of 4–6 months may be required to achieve this goal.
Received: 15 May 1998/Accepted: 12 February 1999 相似文献
6.
Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy 总被引:1,自引:2,他引:1
Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt
to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty
during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux
and a large (≥8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty
was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (≤11 months) the patients are
doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement
of the repair with PTFE mesh.
Received: 5 March 1996/Accepted: 3 June 1996 相似文献
7.
The outcome of unretrieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy 总被引:5,自引:0,他引:5
Background: Gallbladder perforation during laparoscopic cholecystectomy (LC) with spillage of bile and gallstones occurs in a substantial
number of patients (up to 40%). Most surgeons believe that free intraperitoneal stones are not a justification for conversion
to laparotomy even if a large number of stones are left in situ. There are, however, a number of reports demonstrating that, on occasion, these unretrieved gallstones may cause infection
or abscess, inflammation, fibrosis, adhesions, cutaneous sinuses, small bowel obstruction, or generalized septicemia. The
aim of this study was to determine the outcome of unretrieved gallstones in the peritoneal cavity after gallbladder perforation
during LC.
Methods: In a 7-year period between 1989 and 1996, prospective data were maintained on 856 patients who underwent LCs by a single
surgeon (R.J.F.). Of the 856 patients, 165 (16%) had gallbladder perforations resulting in lost gallstones in the peritoneal
cavity. A concerted attempt was made to remove the lost stones using a variety of extraction devices. Of these 165 patients,
106 (64%) were available for follow-up through mail (76%) and by telephone (24%). The mean age of these patients was 64.9
years (range, 18 to 98 years), and the mean follow-up was 44.8 months (range 4.9 to 92.3 months).
Results: Of the 106 patients with unretrieved gallstones, we identified four patients with short-term complications and one patient
with a long-term complication. The first patient with a short-term complication had pyrexia for 10 days postoperatively. Diagnostic
evaluation, which included computed tomography (CT) scan, failed to reveal any abnormality. The patient was treated conservatively
with a course of oral antibiotics. In the second patient, cellulitis developed at a drain site after its removal, which resolved
with oral antibiotics. The third patient acquired an umbilical wound abscess, which drained spontaneously, requiring no treatment.
A sterile subphrenic collection developed in the fourth patient 1 month postoperatively, which was treated with percutaneous
drainage under CT guidance. The only long-term complication was spontaneous erosion of a gallstone from the back of a patient
with a questionable history of inflammatory bowel disease 8 months postoperatively. All of the patients made complete recoveries.
Conclusions: In most patients, unretrieved gallstones are of no consequence, but complications occur occasionally. It is therefore advisable
to retrieve as many gallstones as possible during LC short of converting to a laparotomy.
Received: 21 July 1998/Accepted 12 February 1999 相似文献
8.
P. R. Schauer W. H. Schwesinger C. P. Page R. M. Stewart B. A. Levine K. R. Sirinek 《Surgical endoscopy》1997,11(1):8-11
Background: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe.
Methods: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications
and deaths occurring up to 30 days following the procedures.
Results: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality
rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication.
Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each
resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period.
Conclusions: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity
and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of
common complications and application of appropriate precautions and instruction are critical for minimizing complications.
Received 25 March 1996/Accepted: 24 April 1996 相似文献
9.
Background: A technique of fully thoracoscopic pulmonary lobectomy with rib-segment resection for specimen extraction is described, and
preliminary results in 18 patients are presented.
Methods: Surgery is performed through four 15-mm ports. For all lobes except one, the surgeon operates in front of the patient, where
the rib spaces are widest and rib-space trauma is less. When lobar dissection is complete, specimen extraction is performed
after resection of a rib segment proportional to tumor size. Muscle section is kept to a minimum. There is no rib retraction.
Results: There were no deaths, three conversions to open surgery, and three major complications. Average postoperative stay was 5.4
days for patients without complications and 9.6 days for patients with complications. In total six patients presented with
some degree of air leaks, and two had post-thoracotomy pain (>2 month's duration). The literature is reviewed to analyze current
techniques and to define parameters of a truly minimally invasive pulmonary lobectomy.
Conclusions: This technique is safe and promising; however, thoracoscopic lobectomy still needs refining. Before valid randomized studies
comparing thoracoscopic lobectomy and muscle-sparing thoracotomy or posterolateral thoracotomy can be credible, technical
issues related to the production of a truly minimally invasive procedure should be resolved.
Received: 20 August 1996/Accepted: 19 September 1996 相似文献
10.
Stanisław B. Bartkowski Jan Zapała Mariusz Szuta Henryk Podziorny Krzysztof Kuchta 《Aesthetic plastic surgery》1999,23(4):292-295
In our department from 1995 to 1998, 30 patients were operated on under general anesthesia via tracheosubmental intubation
(TSI). No local or general complications were observed. Operating in the field free from the intubation tube is very comfortable
for a surgeon, while for an anesthesiologist the safety of the tube and efficiency of ventilation are very important. TSI,
as a technically simple, safe, and efficient procedure, is extremely helpful in the surgical treatment of patients with simultaneous
multifragmentaric and comminuted fractures of the maxilla and mandible, and in orthognathic and aesthetic plastic surgery
of the face, where assessment of facial symmetry and occlusion is especially important. 相似文献
11.
Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases 总被引:9,自引:3,他引:6
E. Chelala G. B. Cadiére F. Favretti J. Himpens M. Vertruyen J. Bruyns L. Maroquin M. Lise 《Surgical endoscopy》1997,11(3):268-271
Background: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study
was to analyze the complications of this approach.
Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique.
A minimally invasive procedure using five trocars was performed.
Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in
eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations
and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications:
There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis.
One fatality on the 45th day in a patient with a Prader-Willi syndrome.
Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence
may be reduced by improving the technique and by considering pitfalls of the procedure.
Received: 28 May 1996/Accepted: 25 July 1996 相似文献
12.
Ileocutaneous fistula formation following laparoscopic polypropylene mesh hernia repair 总被引:6,自引:1,他引:5
A rare case of enterocutaneous fistula caused by chronic erosion of polypropylene mesh after laparoscopic repair of a recurrent
inguinal hernia is described. Successful treatment was achieved by fistulectomy, total resection of the implanted mesh, and
small-bowel segmental resection. The patient recovered well postoperatively, and at follow-up 18 months later, the herniorrhaphy
has remained intact. This complication needs to be added to the differential diagnosis in patients who present inflammation,
abscess formation, or cutaneous fistula following laparoscopic hernia repair.
Received: 7 October 1996/Accepted: 14 October 1996 相似文献
13.
A. J. Voitk 《Surgical endoscopy》1997,11(12):1147-1149
Background: This study was done to determine the safety of outpatient cholecystectomy for the higher-risk patient.
Methods: All patients over age 70 or with American Society of Anesthesiologists physical status classification of 3 or greater, from
all 515 consecutive patients booked for elective cholecystectomy between April 1, 1994, and March 31, 1996, were reviewed.
Results: Of 85 higher-risk patients, 77 were booked as outpatients. Sixty-one were successfully completed as outpatients, with no
complications or readmissions related to their outpatient status. Of 24 admitted patients, 15 had specific indications for
hospitalization. Nine were admitted for reasons of ``precaution.' One of these developed a complication, possibly related
to her inpatient status. The other eight could have been managed as outpatients.
Conclusions: Outpatient cholecystectomy is safe for the higher-risk patient. Patients who recover uneventfully from surgery can be discharged
without harmful effects. ``Precautionary' hospitalization may be harmful.
Received: 26 December 1996/Accepted: 2 April 1997 相似文献
14.
Background: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic
gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared
to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal
cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery.
Methods: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy
was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach,
and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated
medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric
bypass was performed.
Results: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of
the stomach and surrounding upper abdominal organs.
Conclusions: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to
decrease operation time.
Received: 18 September 1996/Accepted: 26 December 1996 相似文献
15.
Laparoscopic anatomy of the region of the esophageal hiatus 总被引:1,自引:0,他引:1
16.
Bile duct injuries during laparoscopic cholecystectomy 总被引:17,自引:2,他引:15
D. Olsen 《Surgical endoscopy》1997,11(2):133-138
Background: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times
that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the ``learning curve,' many
occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today.
Methods: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct
injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports
and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray
studies, including interoperative cholangiograms and ERCPs, were reviewed.
Results: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy.
This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were
performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of
the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which
a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon.
Conclusions: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic
cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery;
NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but
if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence
of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge
and skills from his open experience to the laparoscopic technique.
Received: 14 May 1996/Accepted: 1 July 1996 相似文献
17.
Determinants of outcomes in laparoscopic colorectal surgery 总被引:3,自引:3,他引:0
18.
Familial hypocalciuric hypercalcemia (FHH) is often considered in the differential diagnosis of hyperparathyroidism, but
is rarely diagnosed. So far, FHH has not been documented in Israel. This report presents preliminary evidence for the occurrence
of FHH in Israel.
Received: 11 June 1996 / Accepted: 31 December 1996 相似文献
19.
Background: The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University
of California, San Francisco.
Methods: The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated
open splenectomy patients (OS).
Results: Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients
(mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted
exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group
(mean $8,939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall
conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications
occurred. Complication rates and transfusion requirements did not differ between OS and LS patients.
Conclusions: Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in
patients of all ages.
Received: 16 April 1996/Accepted: 5 July 1996 相似文献
20.
Laparoscopic renal surgery usually involves the use of five or six trocars. This report concerns the authors' technique for
performing such surgery through only three trocars. Semilateral patient positioning, along with additional table rotation,
is utilized to facilitate visceral rotation and optimize exposure of the kidney. Four laparoscopic renal procedures were performed:
one renal cyst decortication and three upper pole partial nephrectomies with ureterectomies for duplications of the collecting
system. Mean operative time was 148 min with no conversions; there were no intra- or postoperative complications. All patients
tolerated a liquid diet on postoperative day 1, and the median hospital stay was 2 days. In selected cases laparoscopic renal
surgery may be approached safety through three trocars.
Received: 29 March 1996/Accepted: 1 July 1996 相似文献