Laryngeal nerves monitoring versus non-monitoring in thyroid surgery

Thyroid surgery is the most common cause of recurrent nerve [RLN] injury. Deliberate identification of the RLN minimizes the risk of injury. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. Continuous intra-operative nerve monitoring during surgery remains a controversial issue. The basic technique involves a skin surface electrode or muscle electrode used to make electromyography [EMG] recordings, which have an audible alarm to alert the surgeon if passive [e.g.stretch during traction] or active nerve stimulation has occurred. We aim to evaluate the use of intra-operative nerve monitoring [IONM] to preserve the laryngeal nerves that may be at risk for injury during thyroid surgery and show the merits of using electrophysiologic laryngeal nerve monitoring during thyroid surgery. This study was conducted as a prospective study on 28 patients whom are thyroidectomy candidates; we elected 14 thyroidectomy candidates in whom we don't use NIM during surgery [Control group A]. These patients were chosen to be evenly matched with another 14 thyroidectomy candidates to monitor the recurrent laryngeal [RLN] and external branch of superior laryngeal [EBSLN] throughout thyroidectomy procedures [NIM group B] to compare the laryngeal nerves risk of injury with and without the use of nerve monitor. Four patients [2 patients in-group A and 2 patients in-group B] were dysphonic after operation. Laryngoscopy revealed unilateral recurrent laryngeal nerve palsy in all except one bilateral in group A. There were no significant differences in RLN paralysis, paresis, or total injury rates between both groups. The number of patients in the presented study was limited to draw a statistical conclusion for significance. The routine application of IONM cannot prevent or reduce recurrent laryngeal nerve injury. However the study signifies the trend towards the use of INOM in expectedly difficult cases and in revision surgery with distorted anatomical relationships and fibrous adhesions

Laparoscopic cholecystectomy [LC]; A retrospective study of 870 patients

Laparoscopic cholecystectomy [LC] is considered the gold standard for the treatment of cholelithiasis. Nevertheless, possible complications must not be underestimated. From July 1993 to May 1998, 870 patients with cholelithiasis underwent laparoscopic cholecystectomy. There was no operative mortality. One case died on the first postoperative day form causes not related to the procedure. In 31 patients [3.56%], the procedure was changed to laparatomy. Out of these 31 patients, three cases [0.34%] conversion was mandatory due to severe complications: bleeding in the hepatic hilar [which was controlled by ligation of the proximal end of the retracted cystic artery], injury of the common hepatic duct [C.H.D] during dissection of the cystic duct [T-tube drainage with suturing of the C.B.D.], injury of the transverse colon during introduction of the first trocar [primary repair of the transverse colon by suturing of the opening using Vicryl 3/0]. In the remaining 28 patients [3.22%] conversion was carried out selectively. In 21/28 [2.4%] due to unclear anatomy of Callot's triangle, technical difficulties or choledocholithiasis. In 3/28 patients [0.34%] had problems with anaesthesia. In 4/28 [0.46%] due to instrument or equipment malfunction. In the postoperative period there were few complications. In 12/870 [1.38%] patients. 4/12 developed postoperative jaundice [missed stones, complete or partial ligation of the C.B.D.]. In 2/12 patients had a bile leak. 3/12 developed a haemoperitoneum. The remaining 3 patients had different complications, [bilateral pneumthorax, subhepatic collection and a gastric fistula]. In this series 6/870 patients [0.69%] underwent reintervention, all by open laparotomies. This study demonstrates the safety of laparoscopic cholecystectomy. Complications are relatively rare. Conversion must not be considered a failure but a wise decision in the face of major difficulties

Laparoscopic inguinal herniorrhaphy

Remarkable success of laparoscopic cholecystectomy encourage the trials for laparscopic herniorrhaphy. Sevceral types of techniques were used. Our study followed the transabdominal pre peritoneal TAPP. A Prospective study for thirty five patients with 45 inguinal hernias under went TAPP. It was carried on from Jan. 1994 to May 1999, in Al-Zahraa University Hospital in Cairo and in Hamed G. Hospital in Doha Patients were selected without complications. Peak age incidence was between the fourth and fifth decades, with mean age 36 years. There were 6 cases direct and 39 indirect with five cases recurrent. All the patients were selected well and prepared properly preoperative. There were no operative complications, but post operative complications were infected wound and 2 recurrent cases who were treated by the open methods. Most of the patients were delivered on the same day. In conclusion TAPP is feasible and safe procedure for hernia repair with low recurrent rate and early convalescence