Port-Site Closure Using a Modified Aptos Needle

Background and Objectives:

Trocar-site incisional hernias are the most common complications in laparoscopic surgery. Fascial closure of port sites represents a challenging issue in laparoscopic surgery.

Methods:

We describe a simple easy technique for fascial closure of port sites using a double-tip needle (Lasheen needle). This study included 100 patients who underwent laparoscopic surgery from January 2009 through August 2011 in the General Surgery Department, Zagazig University Hospital, Zagazig, Egypt. The mean follow-up period was 2 years for any wound complications at these trocar sites.

Results:

The mean age of the patients was 39.5 years, and the mean time for placement of one suture was 2 minutes. No trocar-site herniation occurred with our technique during the period of follow-up. Infection developed at the trocar site in 3 patients.

Conclusion:

This technique is easy, simple, safe, fast, inexpensive, and effective for fascial closure of trocar sites.     

Vascular Complications Following Laparoscopy: Two Unusual Cases

Background:

Vascular complications following laparoscopic techniques may often be attributed to the incomplete control of bleeding sites at laparoscopy. When con-fronted with post-laparoscopy symptoms of hemodynamic insufficiency, the surgeon may infer the existence of hemorrhagic complications neglected at the laparoscopic session.

Methods:

The author reviewed two otherwise normal cases of laparoscopic procedures that were complicated by bleeding disorders of unknown origin.

Results:

Diagnosis and treatment of the hematologic complications revealed causes other than operator-inflicted injury.

Conclusions:

While laparoscopists should remain vigilant concerning the very real threat of overlooked vascular injury following laparoscopy, some patients may exhibit hemorrhagic symptoms unrelated to the laparoscopic procedure.     

Non-Gynecologic Laparoscopy in Second and Third Trimester Pregnancy: Obstetric Implications

Purpose:

To review the effect of non-gynecologic laparoscopic procedures performed during the second and third trimesters of pregnancy on pregnancy outcome.

Materials and Methods:

A review of the patient log for the antenatal obstetrical unit was used to identify the patients in this series from January 1, 1997 to December 31, 1997. Medical records were then analyzed to identify estimated gestational age at surgery and delivery, type of delivery, use of tocolysis, and complications from surgery.

Results:

Nine patients were identified as having non-gynecologic laparoscopic surgery (without conversion to laparotomy) during the second or third trimester of pregnancy. The median estimated gestational age at surgery was 25 weeks (mean 24 weeks). The most common procedure performed was laparoscopic cholecystectomy (6 patients). Five patients received tocolysis after the initial procedure. All patients delivered at greater than or equal to 37 weeks estimated gestational age (median 38 weeks). No infants were admitted to the neonatal intensive care unit.

Conclusions:

Laparoscopic procedures appear safe in second and third trimester pregnancy. In this study, laparoscopic cholecystectomies were performed as late as 34 weeks estimated gestational age without any adverse effects on pregnancy outcome.     

Nerve Transfers for Treatment of Isolated Axillary Nerve Injuries

BACKGROUND:

The most common neurological defect in traumatic anterior glenohumeral dislocation is isolated axillary nerve palsy. Most recover spontaneously; however, some have persistent axillary neuropathy. An intact rotator cuff may compensate for an isolated axillary nerve injury; however, given the high rate of rotator cuff pathology with advancing age, patients with an axillary nerve injury are at risk for complete shoulder disability.

OBJECTIVE:

To review reconstruction of the axillary nerve to alleviate shoulder pain, augment shoulder stability, abduction and external rotation to alleviate sole reliance on the rotator cuff to move and stabilize the shoulder.

METHODS:

A retrospective review of 10 patients with an isolated axillary nerve injury and an intact rotator cuff who underwent a triceps nerve branch to axillary nerve transfer was performed. Patient demographics, surgical technique, deltoid strength, donor-site morbidity, complications and time to surgery were evaluated.

RESULTS:

Ten male patients, mean age 38.3 years (range 18 to 66 years), underwent a triceps to axillary nerve transfer for isolated axillary nerve injury 7.4 months (range five to 12 months) post-traumatic shoulder dislocation. Deltoid function was British Medical Research Council grade 0/5 in all patients preoperatively and ≥3/5 deltoid strength in eight patients at final follow-up (14.8 months [range 12 to 25 months]). There were no complications and no donor-site morbidity.

CONCLUSION:

A triceps to axillary nerve transfer for isolated axillary neuropathy following traumatic shoulder dislocation improved shoulder pain, stability and deltoid strength, and potentially preserves shoulder function with advancing age by alleviating sole reliance on the rotator cuff for shoulder abduction and external rotation.     

Use of peripheral nerve transfers in tetraplegia: evaluation of feasibility and morbidity

Background

Peripheral nerve transfers are being used to improve upper extremity function in cervical spinal cord injury (SCI) patients. The purpose of this study was to evaluate feasibility and perioperative complications following these procedures.

Methods

Eligible SCI patients with upper extremity dysfunction were assessed and followed for a minimum of 3 months after surgery. Data regarding demographics, medical history, physical examination, electrodiagnostic testing, intraoperative nerve stimulation, recipient nerve histomorphometry, surgical procedure, and complications were collected.

Results

Seven patients had surgery on eight limbs, mean age of 28 ± 9.9 years and mean time from SCI injury of 5.1 ± 5.2 years. All patients had volitional elbow flexion and no volitional hand function. The nerve to the brachialis muscle was used as the expendable donor, and the recipients included the anterior interosseous nerve (AIN) (for volitional prehension), nerve branches to the flexor carpi radialis, and flexor digitorum superficialis. Two patients underwent additional nerve transfers: (1) supinator to extensor carpi ulnaris or (2) deltoid to triceps. No patients had any loss of baseline upper extremity function, seven of eight AIN nerve specimens had preserved micro-architecture, and all intraoperative stimulation of recipient neuromuscular units was successful further supporting feasibility. Four patients had perioperative complications; all resolved or improved (paresthesias).

Conclusion

Nerve transfers can be used to reestablish volitional control of hand function in SCI. This surgery does not downgrade existing function, uses expendable donor nerve, and has no postoperative immobilization, which might make it a more viable option than traditional tendon transfer and other procedures.     

Endoscopic management of biliary hydatid disease

Objective

To determine the effect of endoscopic sphincterotomy in the management of biliary hydatid disease.

Design

A case study between January 1992 and December 1994.

Setting

A university-affiliated hospital in Adana, Turkey.

Patients

Five patients with biliary hydatid disease, in which the cyst had ruptured into the biliary tree. The follow-up ranged from 3 to 12 months.

Intervention

Endoscopic sphincterotomy.

Main Outcome Measures

Morbidity, mortality and recurrence of the disease.

Results

All patients underwent successful endoscopic sphincterotomy, including removal of daughter cysts. During the follow-up period, ultrasonography and laboratory investigations showed complete cure in all patients. There were no complications due to endoscopic sphincterotomy.

Conclusion

Endoscopic sphincterotomy is the treatment of choice for the management of hydatid cysts that have ruptured into the biliary tract causing obstructive jaundice.     

Indications for intensive care unit care after carotid endarterectomy

Objectives

To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions.

Design

A retrospective case study.

Setting

The ICU of a university hospital.

Patients

One hundred and one patients who required carotid endarterectomy over a 15-month period.

Intervention

Carotid endarterectomy (bilateral procedures in 11 patients).

Outcome Measures

Demographic data including Goldman’s cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications.

Results

Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation ) TISS score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%.

Conclusions

The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.     

Laparoscopy and natural orifice surgery: first entry safety surveillance step

Background and Objective:

We are sharing information regarding the surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopy surgeries. However, we are not analyzing techniques or other surgical findings.

Method:

In this study, 160 women with previous abdominal pelvic surgeries underwent laparoscopic surgery, 145 patients underwent transvaginal Minilaparoscopy Assisted Natural Orifice Surgery (hybrid), and 3 patients underwent pure natural orifice transvaginal endoscopic surgery (pure). For those patients who had laparoscopy and hybrid procedures, the surveillance was from a laparoscope or gastroscope placed in a secondary port. Surveillance in pure cases was done using a gastroscopic retro view to see the pouch of Douglas.

Results:

The laparoscopic procedures were gynecological procedures. The hybrid procedures included gynecological procedures as well as appendectomies and cholecystectomies; the pure procedures were cholecystectomies. There were a few minor vascular and bowel injuries in the laparoscopy group. There were no injuries in the transvaginal hybrid or pure procedures groups.

Conclusion:

The surveillance of the first entrance port can be an effective precautionary step. The cumulative experience suggests that using such surveillance in cases involving patients with prior surgery may assist in recognizing complications that might otherwise be missed.     

Direct Trocar Insertion for Laparoscopy

Background:

The Veress needle (VN) technique for establishing pneumoperitoneum in laparoscopic surgery is widely used and yet is associated with slow insufflation rates and potentially life-threatening complications. Although these complications have been rarely reported, they represent a major source of morbidity and mortality from laparoscopic procedures and a major reason for conversion to open surgery. The open laparoscopy (OL) is an alternative to the VN technique, being relatively safer, even if considered cumbersome by many authors. Recently, the direct trocar insertion (DTI) technique of establishing pneumoperitoneum has been reported as an alternative to both techniques, but it is largely confined to gynecologic procedures. We report a case-series study where we evaluate the patients who underwent a DTI entry for laparoscopy during a recent 5-year period, focusing attention on feasibility, safety, and the benefits of DTI.

Methods:

This is a case series of 2175 different laparoscopic procedures (1456 [66.9%] scheduled cases and 719 [33%] emergencies). In 2091 (96.1%) of them (1425 [68.1%] scheduled cases and 666 [31.8%] emergencies), pneumoperitoneum was established with DTI, either in the umbilicus or in Palmer''s point.

Results:

There were no injuries, either minor or major. Peritoneal access and the creation of a laparoscopic workplace were obtained quickly and efficiently by DTI.

Conclusion:

Our results suggest that DTI is a fast, safe, and reliable alternative to traditional techniques for pneumoperitoneum establishment and should be regarded as a part of the surgical armamentarium of a trained laparoscopic surgeon.     

Single-Incision Laparoscopic Combined Cholecystectomy and Appendectomy

Background and Objectives:

Single-incision laparoscopic surgery is becoming more widely used, but few combined procedures have been reported. Herein we share our experience with single-incision laparoscopic combined cholecystectomy and appendectomy.

Methods:

We reviewed data from 26 patients who underwent single-incision laparoscopic combined cholecystectomy and appendectomy between May 1, 2009 and June 1, 2013 at Shengjing Hospital. All the procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

Results:

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

Conclusions:

Single-incision laparoscopic combined cholecystectomy and appendectomy appear to be a technically feasible alternative to the standard laparoscopic procedure in simultaneous management of coexisting benign gallbladder and appendix pathologies. Larger studies are required to confirm these findings.     

Extensor indicis proprius opponensplasty for isolated traumatic low median nerve palsy: A case series

INTRODUCTION:

The standard opponensplasty for isolated low median nerve palsy in nonleprosy patients uses the flexor digitorum superficialis of the ring finger.

OBJECTIVE:

To report the results of extensor indicis proprius (EIP) opponensplasty in 15 consecutive nonleprosy patients with isolated traumatic low median nerve palsy.

METHODS:

A retrospective study of the author’s cases of EIP opponensplasty for isolated traumatic median nerve palsy over the past 15 years was conducted. The author used the EIP to restore thumb opposition in all cases of isolated median nerve palsies when the following conditions were present: protective sensibility in the median nerve distribution; normal power of EIP; supple hands; and full passive range of opposition with no contracture of the first web space. There were a total of 15 patients with a mean age of 30 years (range 20 to 45 years). They all had traumatic isolated low median nerve palsy with recovery of at least protective sensation and no recovery of opposition. The tendon was harvested just proximal to the extensor expansion, the flexor carpi ulnaris was used as a pulley and the insertion was to the tendon of abductor pollicis brevis.

RESULTS:

There were no postoperative complications or extension lag of the donor finger. Using previously published criteria, 12 patients experienced excellent results while the remaining three had a good result.

CONCLUSIONS:

In nonleprosy patients with isolated traumatic low median nerve palsy, the results of this transfer are consistent and there is no need to harvest the EIP tendon distal to the extensor expansion because a single insertion to the abductor pollicis brevis is sufficient.     

Entrapment of the saphenous nerve at the adductor canal affecting the infrapatellar branch – a report on two cases

Objective:

To present 2 cases of entrapment of the saphenous nerve at the adductor canal affecting the infrapatellar branch, and to provide insight into the utilization of nerve tension testing for the diagnosis of nerve entrapments in a clinical setting.

Rationale:

Saphenous nerve entrapments are a very rare condition within today’s body of literature, and the diagnosis remains controversial.

Clinical Features:

Two cases of chronic knee pain that were unresponsive to previous treatment. The patients were diagnosed with an entrapment of the saphenous nerve at the adductor canal affecting the infrapatellar branch using nerve tension techniques along with a full clinical examination.

Intervention and Outcome:

Manual therapy and rehabilitation programs were initiated including soft tissue therapy, nerve gliding techniques and gait retraining which resulted in 90% improvement in one case and complete resolution of symptoms in the second.

Conclusion:

Nerve tension testing may prove to be an aid in the diagnosis of saphenous nerve entrapments within a clinical setting in order to decrease time to diagnosis and proper treatment.     

Feasibility of Nerve Stimulator as a Supplemental Aid for Lumbar Transforaminal Epidural Block

Background

The purpose of this study was to evaluate the clinical feasibility of an electric nerve stimulator in a lumbar transforaminal epidural block.

Methods

Using an electric nerve stimulator, transforaminal epidural blocks were performed in 105 segments of 49 patients who presented with lower back pain with radiating pain to lower extremities. The contrast medium was injected to delineate the nerve root after positioning an insulated needle at the intervertebral foramen under fluoroscopic guidance. Then, the nerve root was electrically stimulated with the insulated needle to confirm whether or not the same radiating pain was evoked.

Results

Of the 105 foraminal segments, the same radiating pain was evoked at 0.5 mAh in 47 segments (44.8%), at 1.0 mAh in 22 (21.0%), at 1.5 mAh in 3 (2.9%), at 2.0 mAh in 15 (14.3%), at 2.5 mAh in 4 (3.8%), and at 3.0 mAh in 5 (4.8%). No response was observed in 9 segments (8.6%). The fluoroscopy revealed successful positioning of the needle in the patients with an evoked radiating pain over 2.0 mAh. The visual analogue scale (VAS) obtained for pain improved from a mean of 7.5 to 2.7 after the block (p = 0.001). In the 9 cases without response to electrical stimulation, the patients showed an improvement on VAS from 7.8 to 3.4 (p= 0.008) also.

Conclusions

A nerve stimulator can help to predict the accuracy of needle positioning as a supplemental aid for a successful lumbar transforaminal epidural block. It is sufficient to initiate a proper stimulation amplitude of the nerve at 2 mAh.     

Incorrect radiographic evaluation after vascularized bone grafting for scaphoid fracture or nonunion

PURPOSE:

The present study is a review of patients with scaphoid non-unions treated with a dorsal vascularized bone graft. The study highlights a subset of patients incorrectly diagnosed as graft failures.

METHODS:

A retrospective review of patients who received vascularized grafts for scaphoid nonunions was performed over a four-year period. The vascularized graft of choice for this group was the dorsal radial extensor compartment artery.

RESULTS:

Five patients from a scaphoid fracture group who were treated with vascularized grafts were diagnosed as being failures (average of five months). None of these patients had tenderness on palpation of the scaphoid, and they were scheduled for revised vascularized grafts. All patients at the time of surgery were found to have healed. These patients were treated with arthrolysis, resulting in healing and full range of motion.

CONCLUSIONS:

Scaphoid vascularized grafts may have a markedly delayed radiographic healing time. Reoperation to perform secondary vascularized procedures may result in unnecessary surgery. Early imaging following a scaphoid vascularized graft may be inaccurate and may demonstrate a continued nonunion.     

Retroperitoneal Transdiaphragmatic Robotic-Assisted Laparoscopic Resection of a Left Thoracolumbar Neurofibroma

Objective:

Robotic technology has been used in a variety of surgical procedures for its 3D magnification and precision. Minimally invasive techniques have already become common in neurosurgery; however, robotic-assisted procedures in neurosurgery are still a relatively new frontier. This report describes the first use of robotic technology to resect a left thoracolumbar neurofibroma.

Case Report:

A 19-year-old male with a family history of neurofibromatosis was diagnosed with a suspected 3-cm x 4-cm neurofibroma in the T12-L1 left paraspinal area. His only complaint was back pain requiring narcotic analgesics. He had no other findings on physical examination or laboratory/radiologic workup.

Methods:

After consulting urologic robotic surgeons, it was agreed to use the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) for the resection of this mass. Following retroperitoneal laparoscopic access, the urologic surgeons opened the diaphragm and began the initial mobilization of the mass laparoscopically. The robot was docked, and the neurosurgeon operated the robot at the console to resect the mass from its nerve origin. There were no complications, and the mass, a confirmed neurofibroma, was completely removed. The patient was discharged on postoperative day 2; his back pain resolved, requiring no analgesia by the end of the first postoperative week.

Conclusion:

This case provides early evidence that robotic assistance can be successfully used for the resection of a paraspinal neurofibroma.     

Laparoscopic-Assisted Percutaneous Endoscopic Transgastrostomy Jejunostomy

Background and Objectives:

New therapeutic protocols for patients with end-stage Parkinson disease include a carbidopa/levodopa combination using continuous, modulated enteral administration via a portable pump. The typical approach involves a percutaneous endoscopic transgastrostomy jejunostomy (PEG-J), which requires a combination of procedures designed to ensure that no organ is interposed between the abdominal wall and the gastric surface. Lack of transillumination in maximal endoscopic light settings is a major contraindication for PEG-J, and we decided to use a different approach to establish enteric access for long-term medication delivery via pump, using a minimally invasive procedure.

Methods:

In all patients, we performed a laparoscopic-assisted percutaneous transgastrostomy jejunostomy (LAPEG-J) after an unsuccessful endoscopic transillumination.

Results:

Five patients with end-stage Parkinson disease were referred to our department after successful therapeutic testing with administration of levodopa/carbidopa via naso-jejunal tube. All patients failed the endoscopic transillumination during the endoscopic procedure and were considered for LAPEG-J. In all patients, the LAPEG-J procedure was uneventful. The most common reason identified for failed transillumination was a high position of the stomach, followed by interposition of the liver or colon between the stomach and anterior abdominal wall. There were no complications regarding the LAPEG-J procedure, and all patients were discharged during the second postprocedural day.

Conclusions:

LAPEG-J provides a simple and safe option for placing a jejunostomy after an unsuccessful PEG-J attempt.     

Surgical treatment of hydatid cysts of the lung: analysis of 405 patients

Objective

The choice of operation, postoperative success and complications of surgery in patients with pulmonary hydatid cysts.

Design

A series of patients seen over 15 years.

Setting

A university clinic.

Patients

Four hundred and five patients (209 male, 196 female) ranging in age from 4 to 72 years (mean 29 years). Most (367 patients) had isolated lung cysts; 38 had both liver and lung cysts.

Interventions

A variety of procedures to remove cysts, including enucleation and capitonnage, wedge resection, segmentectomy, lobectomy and pneumonectomy. Six patients with bilateral cysts were operated on through a median sternotomy approach. Others underwent posterolateral thoracotomy.

Main outcome measures

Value of diagnostic tests, the most efficacious approach for cyst removal and recurrence and death rates.

Results

Chest radiography gave a correct diagnosis in 99% of patients. The Casoni and Weinberg tests were discontinued because of high false-negative rates (up to 35%). Hospital mortality was 1.2% and postoperative complications occurred in 5.2%. The recurrence rate was 1.5%.

Conclusions

Lung-preserving surgical interventions are the treatment of choice for pulmonary hydatid disease. In patients with bilateral cysts, the median sternotomy approach is preferred, and in the patients with right lung disease and coexisting liver cysts the transdiaphragmatic approach is the one of choice to remove cysts in 1 stage.     

Intraoperative Management of Robotic-Assisted Versus Open Radical Prostatectomy

Background and Objectives:

Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, post-anesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent robotic-assisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP).

Methods:

A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008.

Results:

Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred.

Conclusions:

Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors.     

The risk of cerebrovascular accident in patients with asymptomatic critical carotid artery stenosis who undergo open-heart surgery

Objective

To investigate whether the presence of asymptomatic critical carotid stenosis (ASCCS) increases the risk of perioperative stroke during open-heart surgery, which carries a well-established risk of cerebrovascular accidents.

Design

A case series.

Setting

A university-affiliated hospital that is a major referral centre for cardiovascular surgery.

Patients

Forty-six patients with ASCCS who underwent open-heart surgery between January 1992 and January 1996. Of this group, 27 had bilateral and 19 had unilateral critical carotid artery stenosis.

Interventions

Various cardiac procedures were performed on the 46 patients: 33 underwent coronary bypass grafting, 12 had valve replacement and 1 had heart transplantation.

Main outcome measure

Neurologic deficit.

Results

None of the patients had any perioperative neurologic deficit up to the date of discharge.

Conclusions

Cardiac procedures, without prior carotid artery surgery, can be done in patients with AS-CCS with no significant added risk of stroke. To achieve this, blood pressure should be kept stable intraoperatively, at slightly higher than normal pressure.