Packing for control of hepatic hemorrhage

From July 1978 to July 1985, 1,348 patients with hepatic injuries were treated. During this period, 66 patients (5.3% or 9.4 patients/year) required perihepatic packing. Penetrating wounds accounted for 77.2% of injuries requiring packing. Seventeen patients died in the operating room from massive hepatic and other intra-abdominal injuries and were excluded from further analysis. Perihepatic packing was inserted in 41 patients at a first operation and at a second or third operation in eight others. The major indications for packing were post-repair coagulopathies (85.5%) and extensive subcapsular hematomas or capsular avulsion (12.2%). Packing was removed from 28 surviving patients (28/49 = 57.1%) at an average of 3.7 days following insertion. Pack removal was accomplished by laparotomy in 24 patients (85.7%) and extraction through a hole in the body wall in four others. Ten postoperative intra-abdominal fluid collections, hematomas, or abscesses occurred in nine patients (9/49 = 18.4%) surviving the first operation. Perihepatic packing continues to be a life-saving adjunct in a highly selected group of patients with the most severe hepatic injuries and nonmechanical bleeding at the completion of repairs or extensive subcapsular hematomas.     

Surgery for oriental eyelids: Some refinements in technique

Surgery of Oriental eyelids falls into two broad groups. One method uses the conjunctival approach, and the other, the external skin approach. Technical refinements in the skin approach method which the author has developed over the last 10 years are described.     

Prostatic ultrasonography: a useful technique?

Two hundred and forty-four transrectal prostatic ultrasonograms have been reviewed and the findings compared with the final pathological or clinical diagnosis. A high degree of accuracy was achieved in diagnosing benign prostatic hyperplasia. Ultrasonography proved invaluable in staging proven prostatic carcinomas but it was disappointing as a primary diagnostic tool for cancer, with false positive and negatives rates of 12 and 31% respectively. These findings are discussed in the light of other workers' results. Further applications for prostatic ultrasonography are outlined.     

Adrenocortical carcinoma detected by retroperitoneal hemorrhage : a case report

Spontaneous massive retroperitoneal hemorrhage from an adrenal tumor is rare and is usually fatal if unrecognized. We report a case of spontaneous rupture of a primary adrenocortical carcinoma that occurred in a 79-year-old man. He visited our hospital with left abdominal pain. Computed tomography (CT) showed a left retroperitoneal hemorrhage. We could not find the origin of this hemorrhage. Two months later, CT showed the left adrenal tumor, and left adrenalectomy and nephrectomy were performed successfully. The histological diagnosis was adrenocortical carcinoma. He rejected adjuvant therapy. Local recurrence of the tumor was found, and right adrenal gland, brain, and mediastinal lymph node metastases were recognized 6 months after the operation. He died 11 months after the operation.     

Split liver technique with middle hepatic vein reconstruction on livers from transplant hepatectomies: a useful tool for surgical improvement

Livers removed during transplant hepatectomies could represent a useful anatomic ex vivo resource for surgical training, since they are intact and not altered by post-mortem changes yet. The aim of this study is to investigate the effectiveness of such kind of surgical training applied on some hepatic surgery techniques. In the present paper, we focused on split liver operation and middle hepatic vein (MHV) bipartition/reconstruction, since these procedures have a quite long learning curve. Seven native livers were submitted to split liver procedure by a senior resident assisted by a fully trained hepatic surgeon. Pre-splitting ultrasound mapping was compared to pre-operative CT scan. The whole graft was divided into two hemi-livers and the MHV into two hemi-confluents and reconstructed by venous or arterial patches obtained by deceased donor iliac homograft. Water tightness of the anastomosis was confirmed by hydro-pneumatic test and bench portal perfusion. Reduction in operating time was considered an indirect indicator of surgical skill improvement. In all cases, the US confirmed the anatomical distribution of MHV tributaries observed by pre-transplant CT scan. The “ex situ” splitting procedures and MHV bipartition and reconstruction were performed in all native livers in the usual time required for liver transplantation bench surgery (range 50–75 min). Liver grafts removed during hepatectomy could represent a useful resource of intact organs to perform surgical training and boost surgical confidence. In our initial experience, the study of venous drainage of the MHV and application of liver splitting technique and MHV reconstruction resulted technically feasible.     

Agar-embedded urinary stones: a technique useful for studying microscopic architecture

A procedure for studying urinary stones by various microscopic techniques is described. The stones are sectioned into approximately 0.2 to 1.0 mm. thick pieces using a low-speed saw. The sections are then embedded in agar and decalcified using 0.25 M ethylenediaminetetracetic acid at pH 7.2. The decalcified residue is then processed for light microscopy and scanning and transmission electron microscopy as with any other biological tissue. The results indicate that the ethylenediaminetetracetic acid-insoluble stone matrix keeps its architectural integrity and can be studied like other biological materials.     

Laparoscopy ... a useful technique for the general surgeon

A series of 227 consecutive laparoscopies performed over 3 years at a provincial hospital in the North Solomons Province is presented. There were no deaths due to the procedure and morbidity was 2.4%. Positive findings were revealed in 89% of patients, allowing rapid decisions to be made regarding patient management: a vital consideration in a busy surgical unit with limited resources. Laparoscopy provides an efficient, safe, rapid and direct approach to many abdominal problems encountered in general surgery, particularly liver disease, blunt abdominal trauma, intraperitoneal infection and neoplasia.     

A safety technique for Mitek anchor suture rupture: a useful trick

We propose that the simple method of passing an extra suture through the Mitek anchor eyelet before bony insertion provides a safety net against failure of the preloaded suture and gives extra strength to the core repair.     

Spontaneous retroperitoneal hemorrhage: unusual presentation of renal cancer

Spontaneous retroperitoneal hemorrhage as the presenting sign of renal cancer is rare. A case of spontaneous retroperitoneal hemorrhage from a renal carcinoma is described and management possibilities presented. While it is true that renal angiomyolipomas are the main cause of spontaneous retroperitoneal renal bleeding, the possibility of renal cancer should be entertained more often in the differential diagnosis.     

Laposcopic retroperitoneal lymph node dissection: evolution of a new technique

Retroperitoneal lymph node dissection is the most accurate method of detecting occult lymph node metastases in the retroperitoneum. In clinical stage II disease, a residual tumor after primary chemotherapy has to be removed surgically. For these two indications we have replaced open surgery by laparoscopy, in order to reduce morbidity. Once the learning curve had been overcome, the operative time was in the range of that of open surgery, and from the very beginning morbidity and complication rates were lower. Oncologic long-term outcome was not compromised by the laparoscopic approach. Patient satisfaction was very high.     

Direct intralumen balloon tamponade a technic for the control of massive retroperitoneal hemorrhage

Control of massive retroperitoneal hemorrhage by the direct insertion of a Fogarty catheter into the lumen of the vessel and inflation of the balloon is described. The applicability of this new technic for the control of hemorrhage from inaccessible vessels is discussed.     

Emergent middle cerebral artery embolectomy: a useful technique for cranial base surgery

Given the poor natural history of untreated symptomatic acute middle cerebral artery occlusion, we have attempted emergent reperfusion in all three cases of acute embolic middle cerebral artery occlusion seen on our cranial base service over the last 10 years. One patient developed a massive stroke requiring a life-saving "strokectomy" within 48 hours, which left him permanently hemiplegic, hemianopic, and hemihypesthetic after a failed attempt at reperfusion by superselective endovascular injection of urokinase. The other two patients, who were aphasic and densely hemiparetic, underwent successful emergent embolectomy with reperfusion established within 5 and 12 hours, respectively. One of the two is now neurologically normal, and the second is left with a subtle monoparesis but is independent in activities of daily living. Since middle cerebral artery embolism in cranial base patients usually occurs in a closely monitored hospital setting, we are presented with a unique opportunity for early successful operative intervention. Principles for optimizing outcome include: early recognition and diagnosis, maximization of medical therapy during the diagnostic workup prior to embolectomy (induced hypertension, intravascular volume expansion, and pharmacologic cerebral metabolic demand reduction), confirmation that the involved region does not have absent blood flow by xenon/computed tomography, early operative intervention, and careful surgical technique.     

Transradicular interfascicular approach for lumbar microdiscectomy: a useful technique in difficult circumstances

Nerve root retraction is a component of lumbar disc surgery. The authors describe a transdural approach for lumbar microdiscectomy through the nerve root, instead of retracting the root. This technique can be safely used in rare cases where root manipulation is considered to be difficult and dangerous.     

The gravity suit: a useful device in complicated urologic hemorrhage.

External counterpressure with a gravity suit was used to control intractable postoperative bleeding in 4 urologic patients. Two patients had coagulation defects, and 2 had been unsuccessfully reexplored prior to application of the G-suit. The bleeding was controlled with preservation and restoration of vital signs in each case. In 3 cases external counterpressure may have been lifesaving.     

Indications and long-term outcome of treatment for benign hepatic tumors: a critical appraisal

HYPOTHESIS: The natural history and clinical behavior of benign hepatic tumors during long-term follow-up may not justify primary surgical treatment. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: Two hundred eight patients diagnosed as having a benign liver tumor between January 1, 1979, and December 31, 1999. INTERVENTION: Seventy-four patients underwent hepatic surgery and 134 were managed conservatively by radiological follow-up. MAIN OUTCOME MEASURES: Symptoms and complications were assessed during management and follow-up. RESULTS: In the surgically treated population, the liver lesion was symptomatic in 47 patients (64%) and an incidental finding in 27 (36%). The operative morbidity and mortality were 27% (20 of 74 patients) and 3% (2 of 74 patients), respectively. Overall, 28 (80%) of 35 patients with complaints were asymptomatic after surgery. During observation of the tumor in the conservatively managed group, 39 (87%) of 45 patients who presented with complaints were asymptomatic during a mean follow-up of 45 months; 6 patients had mild abdominal pain considered to be unrelated to the tumor. CONCLUSIONS: Conservative management of solid benign liver lesions such as focal nodular hyperplasia and hemangioma can be performed safely, irrespective of their size. We only advise surgery for liver lesions when there is an inability to exclude malignancy or in the case of severe complaints related to the tumor. Resection is always advocated in the case of a large hepatocellular adenoma (>5 cm) to reduce the risk of rupture and malignant degeneration.