Laparoscopic surgery in urology

At the present time minimally invasive surgery is present in all the standards of quality of a surgical service. Laparoscopic surgery, the basis of this minimally invasive surgery, is revolutionizing the teaching and handling of many surgical pathologies. In the urological sphere, although with a delay of 5 years with respect to neighbouring countries, laparoscopy has become established as a prevalent technique in many processes of the urinary-genital apparatus. At present it is the chosen technique for the surgical treatment of the suprarenal, and it is rapidly becoming established in different pathologies such as renal tumours, prostate tumours, staging in neoplastic diseases of the testicles, benign surgical pathology and in reconstructive surgery. Since 1995, the Urology Service at the Hospital de Navarra has been a pioneer in the employment of this type of technique, and, since 1998, it has been a pioneer of so-called advanced laparoscopic surgery, in which it is a national reference point in some of the procedures, such as laparoscopic adrenalectomy. At present, all of the laparoscopic procedures are incorporated in the service, with a learning curve that has been surpassed. All of this has made it possible to improve patient care, to obtain a reduction in postoperative pain and in length of hospital stay, and a rapid return to labour activity with oncological results that can be equivalent on those of open surgery.     

Laparoscopy in acute biliary pancreatitis.

BACKGROUND: The high mortality rates (20-30%) still occurring in some forms of acute pancreatitis demands adequate clinical and instrumental protocols in order to establish the most suitable therapeutic option to employ. The use of laparoscopic surgery can reduce hospital stay and time for functional recovery. METHODS: The study enrolled 73 patients referring for acute biliary pancreatitis in whom staging with clinical, laboratory and instrumental criteria was performed. According to Ranson classification 63 patients (86.3%) had a mild-moderate acute biliary pancreatitis, 10 (13.6%) a severe one. In the first group laparoscopic cholecystectomy with retrograde cholangiography was performed within seven days of admission, in the second group surgical procedure followed medical treatment between eight and 30 days after the onset of the disease. No preoperative ERCP was performed. RESULTS: The rate of main biliary tract calculosis was 8.2% in group A: six cases all treated through laparoscopy. Two switches (2.7%) due to intolerance to the pneumoperitoneum, eight major postoperative complications (10.9%), and two deaths (2.7%) occurred and a mean hospital stay of 7.4 days was observed in group A versus 8.2 days in group B. CONCLUSIONS: The management suggested in this study for mild-moderate acute biliary pancreatitis showed consistent results with those of the recent literature, as far as morbidity (6.3%) and mortality (1.5%) are concerned. A higher number of severe biliary pancreatitis (10 cases) should be observed to assess the role of ERCP with endoscopic sphincterotomy rather than laparoscopic or combined treatment.     

Laparoscopic cholecystectomy. Initial experiences]

Between February 1991 and July 1991, 74 laparoscopic cholecystectomies were performed. The number of all cholecystectomies during this period was 168. Two surgeons performed the operations. Stone in the common bile duct, old age, acute cholecystitis, severe obesity and heart rhythm disorders were regarded as contraindications. The duration of the operation was 45-210 min. (mean 127 min). The intervention was diverted to open cholecystectomy in 2 instances (2.7%). Early postoperative complications were observed in 2 cases (2.7%): biliary discharge and bleeding. Reoperation was necessary in one patient (1.3%) because of bleeding. There was no operative mortality. The mean duration of hospitalization was 5.6 days, and the mean postoperative period was 2.7 days. It is considered that, laporoscopic cholecystectomy can be carried out only by specialists in both bile surgery and laparoscopic techniques, provided that all the personal and technical conditions necessary for traditional cholecystectomies are at hand. Both medically and economically, the laparoscopic cholecystectomy results attain or even exceed those of the traditional open technique.     

子宫内膜异位症相关不孕的治疗进展

子宫内膜异位症是引起育龄女性不孕的重要因素之一,引起不孕可能的原因有:患者腹腔液性质的改变、盆腔解剖结构异常、卵巢功能下降和子宫内膜容受性降低等。目前手术仍是主要的治疗方式,手术时机、手术方式、子宫内膜异位症手术分期及不同类型、程度子宫内膜异位症对术后妊娠结局均有影响,手术应尽可能在子宫内膜异位症早期进行,腹腔镜手术作为首选,子宫内膜异位症生育指数(EFI)评分能较好地评估患者的生育能力。而药物治疗作为术后辅助治疗,并不能提高患者的生育能力,只能延缓复发,因而对有生育要求的子宫内膜异位症合并不孕患者,手术后不推荐药物治疗。当手术治疗失败或因持续性输卵管因素导致不孕时,辅助生殖技术对于提高患者的生育能力是必要的。     

Successfully developing a telemedicine system

Successfully developing telemedicine systems is primarily about effective change management. The literature suggests that certain principles are likely to increase the chances of success in developing a telemedicine system. These are: (1) telemedicine applications and sites should be selected pragmatically, rather than philosophically; (2) clinician drivers and telemedicine users must own the systems; (3) telemedicine management and support should follow best-practice business principles; (4) the technology should be as user-friendly as possible; (5) telemedicine users must be well trained and supported, both technically and professionally; (6) telemedicine applications should be evaluated and sustained in a clinically appropriate and user-friendly manner; (7) information about the development of telemedicine must be shared. If telemedicine is to realize its full potential, it must be properly evaluated and the results of any evaluations published, whether the results are positive or negative. Since telemedicine is about communication with colleagues and patients across large distances, it should be possible for those involved in it to do the same with their experiences.     

子宫内膜异位症的术后复发机制及危险因素

子宫内膜异位症（endometriosis,EMs）是育龄期女性常见疾病,手术是EMs可靠、有效的治疗手段,但术后高复发率是临床棘手的问题。目前其复发机制不明确,高危因素尚存在争议。可能与在位内膜及经血逆流有关,同时与激素依赖有关,此外,异位子宫内膜干细胞的持续存在可能在EMs术后的复发中起重要作用。影响EMs复发的因素较多,其中手术的彻底性是降低术后复发的重要保证。因此,为降低EMs术后复发率,不应过多依赖术后辅助药物治疗,而应在不损伤正常器官的前提下尽可能清除病灶,减少残留病灶及致病因子。     

Obstructive jaundice after surgery of the biliary tract, a benign stricture or not?

Obstructive jaundice occurred in 3 patients, 2 women, aged 44 and 60 years, and one man aged 62 years: 17 years after choledochojejunostomy following a complicated cholecystectomy, 8 years after hepatojejunostomy following choledochal cyst removal, and 1 year after laparoscopic cholecystectomy. Percutaneous or endoscopic stent placement was performed in all patients to relieve biliary obstruction. However, stent dysfunction repeatedly resulted in re-stenting of the obstruction. Imaging techniques, as well as endoscopic brush pathology could not distinguish between a benign or malignant stenosis. Explorative laparotomy showed a new growth in all 3 patients, of which 2 were malignant. When obstructive jaundice occurs after surgery of the biliary tract for benign disease, the most likely cause is a benign stenosis. Percutaneous or endoscopic stenting is the treatment of choice. In case of unexpected and/or repeated stent failure, when a diagnosis cannot be made due to inconclusive imaging or pathology of the stenosis exploratory surgery should be considered, as malignant stenosis may be present.     

Setting priorities in the new NHS: can purchasers use cost-utility information?

It could be argued that the success of the new NHS depends, to some extent, on the production of accurate cost-utility information. This raises questions about the quality of this information, whether it can be transferred from one study setting to another and whether such information can reasonably be used 'at the negotiating table'. The quality of some studies is open to question. Some agreement is needed on issues of principle and more work is required to make cost-utility analyses more applicable locally.     

Some Observations on Temporary Drainage of the Kidney

Temporary drainage may be necessary for the success of an operation, as, e.g., a plastic operation on a hydronephrosis. It may, however, also be used as an aid to recovery of function by a damaged kidney; its use in these cases is not a necessity but is an optional point in technique.The method of drainage should be simple to adjust at the time of the operation, easy to control during the post-operative period, and one which causes no damage to the kidney when the drainage tube is removed. The technique of such a method is described. Some difficulties in operative technique, and in post-operative management, are considered, and the normal course of drainage in these cases is outlined.An additional point in favour of the method is that it can be used both in those cases in which drainage is necessary and in the others where it is not; and the experience gained by overcoming difficulties and complications in those cases where drainage is not of vital importance is of the greatest possible use in establishing a good technique for those cases in which failure of the drainage system would imperil the success of the operation.     

The influence of diagnostic and therapeutic laparoscopy on patients presenting with an acute abdomen.

The role of laparoscopy in the management of patients presenting to one surgical firm with an acute abdomen is discussed. Sixty-seven laparoscopies have been performed over an 18 month period and it has altered the diagnosis in 19.4% of cases and the management in 13.4% of cases. At laparoscopy the diagnosis of appendicitis was made in 37 patients (81% had attempted laparoscopic appendicectomies); pelvic inflammatory disease in 15 patients; torted fimbrial cyst in two patients; and free pus in the right lower peritoneum as a result of a perforated appendix was seen in two patients. Normal laparoscopy was performed in five patients and four patients who presented with a perforated duodenal ulcer had the diagnosis confirmed at laparoscopy, in three cases the perforation was oversewn laparoscopically. Two laparoscopies were performed on trauma patients; one stabbing and one blunt trauma to the right hypochondrium. It has been demonstrated that diagnostic laparoscopy is a useful adjunct to the general surgeon's armamentarium. It is suggested that the skill of laparoscopy is passed on to junior trainee surgeons who can use this technique to help attain a diagnosis in patients presenting with an acute abdomen.     

'Drawing the line' in prenatal screening and testing: Health practitioners' discussions

As the number of fetal conditions which can potentially be screened and tested for rises, the question of whether limits should be set around prenatal screening is a timely one. There are many areas of disagreement as to whether a line can, or should be drawn, about what constitutes a 'severe' handicap, and about who should be involved in making such decisions. This paper reports on how health practitioners involved in prenatal screening discussed these questions in multidisciplinary groups facilitated by an ethicist. It explores the difficulties practitioners expressed about drawing lines on behalf of others, and then looks at who practitioners felt should be involved in drawing lines. Finally, using sex selection as an exemplar, the paper explores how practitioners discussed the possibility of selective terminations for fetal sex on social grounds. Although not impossible, it seems that reaching a public or professional agreement on prenatal screening policies will be difficult. With the current emphasis on informed choice, it is of paramount importance that there is no pressure to follow a particular line of action. This must rely in part on the provision of accurate information devised and conveyed by practitioners and people with broad, practical experience of conditions being screened for.     

The new techniques of gynaecologic laparoscopy. Gasless, open Hasson, optic trocar

BACKGROUND: New techniques of laparoscopy: gasless, open Hasson, optic trocars allow to avoid the risks of vessel and bowel injuries. The objective of this study was to evaluate the capability of a retractor system as an alternative to conventional technique without pneumoperitoneum and to assess if the system facilitates the use of conventional surgical instruments during gynaecological surgery. METHODS: DESIGN: Prospective evaluation. SETTING: University-affiliated county hospital. PATIENTS: Gasless laparoscopy surgery was performed on 49 patients between December 1995 and July 1996 with a retractor system without pneumoperitoneum consisting of an intrabdominal retractor using conventional surgical and laparoscopic instruments and to enable a simultaneous vaginal approach. RESULTS: Gasless laparoscopy was successful in 44 (90%) of cases. A simultaneous vaginal approach was used in one third of indications including vaginal myomectomy and laparoscopic assisted hysterectomy. Conversion to laparotomy was required in 5% of cases. Mean procedure duration was 90 minutes and mean hospitalisation time was 5.7 days. CONCLUSIONS: The introduction of new techniques of laparoscopy: gasless, open Hasson, optic trocars has broadened the application of operative laparoscopy. Gasless technique in lieu of conventional laparoscopy can be performed reliably and safely for most gynaecological indications. The most outstanding benefit of this method is that it can be combined with a vaginal approach which is not possible using a pneumoperitoneum due to gas leakage. The place of gasless laparoscopy will depend on continuing development by instrument manufacturers, in order to achieve an instrument providing vision as good as that seen with the pneumoperitoneum.     

Behavior improvement: a two-track program for the correction of employee problems

In the best of all possible working worlds no one would ever have to be involuntarily terminated from employment. Whether a punitive discharge for a severe violation of a word rule, or a gentle dismissal for failure to meet job standards, termination is one of the most difficult tasks a supervisor ever has to perform. However, it is the effect on the employee that should dominate the supervisor's thoughts and actions, not the personal uneasiness with which the supervisor greets the task. It is because of the impact on the employee that the supervisor has a responsibility to do everything reasonably possible to ensure the employee's success before resorting to dismissal or discharge. Adopting this sort of caring attitude toward employees is not easy; most of our management role models of past years were raised on authoritarianism. As a result there is in many supervisors a tendency to simply weed out the troublesome employee and start again with someone new. However, any supervisor can fire, but it is the exceptional supervisor who can salvage an employee and turn a source of problems into an effective producer.     

Laparoscopic treatment of bile leakage from the Luschka duct after laparoscopic cholecystectomy

The possible reasons for bile leakage following laparoscopic cholecystectomy are the injury of the common bile duct, the insufficient treatment of cystic duct (non competent or non closing, or spontaneously removing clip, stumpnecrosis due to electrocoagulation near to clipp, rupture adjacent to the clipp) or the opening of an aberrant bile duct. The latter often may occur in case of the anatomic variation described by Hubert von Luschka (1820-1875) a German anatomist as the duct named after Luschka. In a favorable case the accessory bile duct closes by itself, but occasionally developing biloma and/or biliary peritonitis need to be operated on. The authors write about the case of a 52 years old female patient, who underwent laparoscopic cholecystectomy, and 3 days later the complication was averted through the application of relaparoscopy with intracorporal suture. In connection with this case the authors acquaint the readers with the biography, the academic carrier of Hubert von Luschka, and the literature related to Luschka duct is surveyed.     

新技术、新危害与新的卫生检疫模式

目的提高对新技术所带来的新危害与卫生检疫模式的关系认识,为做好卫生检疫工作,采取积极有力的检疫措施提供参考。方法研究新技术、新危害与新的卫生检疫模式的关系。结果新技术、新危害对卫生检疫模式提出了新的要求。历经几十年运行的《国际卫生条例》已经远远不能满足保护世界人民健康安全的需要,表明必须扩大《条例》的适用范围,以适应新技术、新危害与新的卫生检疫模式的要求。加快卫生检疫模式转变的步伐,提高控制新危害的力度。结论必须加快改变传统的卫生检疫模式步伐,建立新的卫生检疫模式,采取新的对策,研究新的方法,及时解决新的问题,适应新的变化,对做好卫生检疫工作,采取积极有力的技术措施,应对新技术及新危害具有重要的现实意义。     

腹腔镜胆囊切除术中转开腹手术因素分析

目的 分析腹腔镜胆囊切除术中转开腹手术的因素.方法 取某院肝胆外科于2008年4月～2011年4月间收治的腹腔镜胆囊切除术中转开腹患者82例作为研究对象,通过观察其手术记录单分析中转开腹因素.结果 导致胆囊结石患者腹腔镜手术转为开腹手术的原因为胆囊本身因素、合并其他器官疾病、操作者的技术因素等,其中胆囊本身因素最为常见.结论 对于胆囊结石患者术前应全方面评估其病情,及时发现各项危险因素,避免一味追求小切口和快速康复而错误选择手术术式,对于危险因素较多,手术难度较大的患者,应尽早采取开腹手术,以患者的生命安全和切实的治疗效果为先,提高医疗水平.     

Common bile duct distomatosis managed by coelioscopic aproach. One case report

Biliary distomatosis is caused by a parasitis of trematode family: the fascialo hepatica. It is a rare affection in Tunisia. The diagnostic is often done in the status phase. Adult parasite stay preferentially at biliary ducts, cause obstruction and cholangitis. The authors report a case of biliary treated successfully by laparoscopic procedure.     

Peri-operative problems in laparoscopic sterilization of women]

Perioperative problems of laparoscopic sterilization of women are reported. Various techniques of sterilization are described and evaluated as to safety, reliability, and complication rates on the basis of 490 laparoscopic tubal sterilizations. The dangers of electrocoagulation with or without resection of a tubal fragment from the coagulated area are pointed out. The major complications are bleeding and burns. Therefore, it should be attempted to find a technique of laparoscopic sterilization that eliminates these risks. A promising technique may be Yoon's silicone band.