Principles and safety measures of electrosurgery in laparoscopy

Background:

Electrosurgical units are the most common type of electrical equipment in the operating room. A basic understanding of electricity is needed to safely apply electrosurgical technology for patient care.

Methods:

We reviewed the literature concerning the essential biophysics, the incidence of electrosurgical injuries, and the possible mechanisms for injury. Various safety guidelines pertaining to avoidance of injuries were also reviewed.

Results:

Electrothermal injury may result from direct application, insulation failure, direct coupling, capacitive coupling, and so forth.

Conclusion:

A thorough knowledge of the fundamentals of electrosurgery by the entire team in the operating room is essential for patient safety and for recognizing potential complications. Newer hemostatic technologies can be used to decrease the incidence of complications.     

Circulatory collapse during laparoscopy

This case report details the intraoperative course of a patient, in her early pregnancy, who had a cardiac arrest during transvaginal insufflation of carbon dioxide (CO2) for laparoscopic tubal ligation. Modern monitoring methods and their ability to detect gas embolism and aid in the diagnosis and treatment of this rare but life-threatening complication are discussed.     

Blood loss and operative duration using monopolar electrosurgery versus ultrasound scissors for surgical preparation during thoracoscopic ventral spondylodesis: results of a randomized,blinded, controlled trial

Purpose

Monopolar electrosurgery is the gold standard for surgical preparation in thoracoscopic spine procedures. However, use of ultrasound scissors could decrease blood loss, accelerate the preparation time and improve patient safety, while minimizing operative costs. This trial compares both preparation techniques for ventral thoracoscopic spondylodesis.

Methods

The study design is an open, prospective, randomized, and double-blinded two-armed clinical trial performed in two centres. Forty-one patients with vertebral body fractures from T10 to L2 were included. Primary endpoint: preparation time. Secondary endpoints: blood loss, organ injuries, duration of hospitalization.

Results

Primary and secondary endpoints did not differ significantly between groups (p level 0.05). Increased blood loss (150 ml or more) was eliminated with ultrasound scissors (p = 0.0014).

Conclusions

Primary and secondary endpoints did not differ significantly between the two preparation techniques. The use of either ultrasound scissors or electric scalpel offers safe and effective preparation for thoracoscopic spine surgery.     

不同剂量右美托咪定对妇科腹腔镜手术围术期炎症因子的影响

目的探讨不同剂量右美托咪定对妇科腹腔镜手术围术期炎症因子的影响。方法选择2012年1月至2013年12月择期妇科腹腔镜手术患者90例,按照随机数字表法将其分为高剂量右美托咪定组(D1组)、低剂量右美托咪定组(D2组)和对照组(C组),每组30例。D1组和D2组分别于麻醉诱导后持续静脉输注右美托咪定0.5和0.2μg·kg-1·h-1,C组则以等容量生理盐水代替。记录麻醉诱导前10 min(T1)、气管插管后1 min(T2)、气腹后1 min(T3)、术毕(T4)的MAP和HR,并检测血清TNF-α、IL-6、IL-10水平。结果与T1时比较,T2~T4时D2组和C组MAP明显升高,D1组HR明显减慢,T2、T3时C组HR明显增快(P0.05)。与C组比较,T2~T4时D1组和D2组MAP明显降低,HR明显减慢(P0.05)。与T1时比较,T2~T4时三组TNF-α、IL-6和IL-10水平明显升高(P0.05)。与C组比较,T2~T4时D1组和D2组TNF-α和IL-6水平明显降低,但D1组IL-10水平明显升高,T2、T3时D2组IL-10水平明显降低(P0.05)。结论持续输注右美托咪定可减轻妇科腹腔镜手术围术期炎症反应,且0.5μg·kg-1·h-1较0.2μg·kg-1·h-1更为明显。     

腹腔镜手术出血并发症的原因分析

目的:分析腹腔镜手术发生出血并发症的原因。方法:回顾分析施行腹腔镜手术过程中发生出血并发症22例的临床资料。结果:依手术时间可分为术中出血17例,术后出血5例,依出血位置可分为腹壁出血8例,手术区域出血14例。结论:手术操作仔细和及时处理是避免出血并发症的关键。     

Intra-ocular pressure changes during gynaecological laparoscopy

Laparoscopic surgery carried out under general anaesthesia is associated with physiological changes, which also determine changes in intra-ocular pressure. We measured intra-ocular pressure at each phase of gynaecological laparoscopy, carried out under propofol-alfentanil-isoflurane general anaesthesia, in young women of ASA 1 status, with no pre-existing eye disease. Measurements were made with a Perkins applanation tonometer. Mean arterial pressure and end-tidal CO, tension were kept constant throughout the study. Intra-ocular pressure decreased significantly after induction of anaesthesia, remained unchanged after a pneumoperitoneum of up to an intraperitoneal pressure of 15 mmHg had been created, increased significantly with head down tilt, but did not increase significantly above pre-induction values. Adequate depth of anaesthesia compensated for the intra-ocular pressure increase caused by head down position. Plateau airway pressure, considered as reflecting intrathoracic pressure, increased with intraperitoneal pressure elevation. However, such changes did not correlate with intra-ocular pressure changes.     

Trocar and Veress needle injuries during laparoscopy

Background: Inadvertent lesions of the intraabdominal organs and vessels caused by trocars and Veress needles are rare but serious complications of laparoscopic surgery. Establishing the pneumoperitoneum is believed to be the most dangerous step. Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing various standard laparoscopic procedures between 1995 and 1997. This database was investigated with special regard to intraabdominal complications caused by trocars and Veress needles. Results: There were 22 trocar and four needle injuries (incidence, 0.18%). Nineteen lesions involved visceral organs; the remaining seven were vessel injuries. The small bowel was the single most affected organ (six cases), followed by the large bowel and the liver (three cases each). All vascular lesions, except for one laceration of the right iliac artery, occurred as venous bleeding of either the greater omentum or the mesentery. Fourteen trocars were inserted under direct vision. Nineteen trocar injuries were recognized intraoperatively; diagnoses of two small bowel and one bladder injuries were made postoperatively. Needle injuries were all diagnosed intraoperatively. Only five injuries could be repaired laparoscopically; the remaining lesions were repaired openly. Four patients underwent an open reoperation, and another patient needed five reoperations. There was one death (4.0%). Conclusions: Trocar and needle injuries are rare complications of laparoscopy. However, if not recognized intraoperatively and repaired immediately, they induce increased morbidity and mortality. Both open and closed establishment of the pneumoperitoneum are related to a potential danger of perforating lesions, but inserting the first trocar under direct vision allows early recognition and immediate repair.     

The factors that influence intraoperative blood loss during total hip replacement]

Fifty cases of total hip replacement performed by one surgeon were reviewed to compare the effects of epidural and general anesthesia. The blood pressure in patients under epidural anesthesia was significantly lower (P less than 0.001; t-test). There was a highly significant correlation between the operation time and the intraoperative blood loss (P less than 0.005, r = 0.67). A significant correlation was noted between the blood pressure and the minute loss of blood (P less than 0.01, r = 0.43). It is concluded that epidural anesthesia is to be recommended rather than general anesthesia in patients undergoing total hip replacement.     

Methemoglobinemia induced by methylene blue pertubation during laparoscopy

Methylene blue is used to check tubal patency during laparoscopy. A case of methemoglobinemia which was induced by methylene blue is presented. Methemoglobinemia is usually treated with methylene blue; however, in patients with glucose-6-phosphate dehydrogenase deficiency, methylene blue can induce methemoglobinemia.     

腹腔镜下微波治疗妇科疾病

作者自１９９０年５月至１９９５年３月，在腹腔镜下应用特制微波组织治疗仪治疗多种妇科疾病２４０例。全部手术采用局部麻醉及表面麻醉。随诊１２～６８个月。结果：子宫内膜异位症１９３例，合并不孕８９例，术后妊娠５４例（６１％）；合并卵巢巧克力囊肿１０１例，术后囊肿消失７９例（７８％），总有效率９７％；主诉疼痛１６９例，术后疼痛完全缓解１１２例（６６％），总有效率９３％。４１例卵巢囊肿，８例输卵管妊娠及３例浆膜下子宫肌瘤亦均手术治愈，疗效满意，无手术并发症。局部麻醉用于妇科腹腔镜手术具有安全，并发症少，恢复快，费用低等优点。用微波治疗优点是可以凝固、止血并切割组织，烧灼准确、安全易行，疗效好。手术中不产烟，视野清楚，价格低廉。     

Delayed recognition of inadvertent gut injury during laparoscopy

Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. They are generally recognized either immediately or a few days after the operation. We present a case of laparoscopic perforation of the small intestine in a patient who had undergone previous pelvic surgery for an ovarian carcinoma. On ultrasound (US), the patient had multiple hepatic lesions resembling hepatic metastases. To confirm the diagnosis, laparoscopy with guided liver biopsy was performed on the grounds that this procedure is regarded as more appropriate than CT- or US-guided hepatic biopsy. Veress needle and trocar insertion were performed at a proper distance from the abdominal scar. However, the abdominal cavity was not visible after the trocar's insertion due to the unexpected presence of adhesions. This precluded the continuation of the procedure. In the following days, the patient experienced only mild abdominal discomfort. However, 2 weeks after laparoscopy, the patient presented signs of peritoneal reaction and underwent laparotomy. Adhesion-fixing jejunal loops to the anterior abdominal wall were discovered at the site of the trocar puncture. Moreover, two hiatuses of these loops were observed and sutured. The follow-up was uneventful. As this case illustrates, laparoscopic bowel injuries remain an unpredictable event. Recognition of this complication may occur several days after the procedure, as the tamponating effect of adhesions on the jejunal hiatus delays the involvement of the peritoneum.     

Morse-type tapers: factors that may influence taper strength during total hip arthroplasty

We studied the effect of varying impaction force, repeated impactions, and fluid contamination on the disassembly strength of Morse-type tapers in 4 commercially available, modular femoral total hip components. The effect of varying techniques of taper assembly on the distraction force was studied. Our results show a reproducible and linear relationship between the taper impaction force and the disassembly force. The force necessary to separate the taper for a given impaction force varied, however, among manufacturers. Repeated impactions added little strength, and we found that when multiple impactions of varying force are used, the strength is roughly equivalent to the expected strength from the single strongest blow. Fluid contamination at the taper interface had unpredictable effects on taper strength.     

A review of laparoscopy for non-obstetric-related surgery during pregnancy

PURPOSE: Similar to the general population, parturients (and their fetuses) could benefit from the reduced manipulation associated with laparoscopy. The purpose of this article is to review the current state of knowledge (both clinical and experimental) with respect to the fetal effects of maternal laparoscopy for non-obstetric-related surgery during pregnancy. METHODS: Human and experimental animal results are examined, and we present preliminary data from our own laboratory. CONCLUSIONS: Future experiments are proposed to further develop and refine standards of care for general surgeons and obstetricians who are presented with gravid females in abdominal distress.