Direct trocar insertion technique: an alternative for creation of pneumoperitoneum.

OBJECTIVES: The direct trocar insertion technique (DTI) for the creation of pneumoperitoneum has been described as an alternative to open and Veress needle (VN) techniques. This study assesses the safety and feasibility of direct trocar insertion without a pre-existing pneumoperitoneum in patients undergoing elective laparoscopic procedures. METHODS: From November 2001 to February 2006, we retrospectively studied 196 (146 women and 50 men) consecutive patients. A single consultant laparoscopic surgeon performed all operations. The mean patient age was 57 years (range, 22 to 81). The procedures included 186 laparoscopic cholecystectomies, 3 laparoscopic appendectomies, 1 laparoscopic Nissen, 5 laparoscopic groin hernia repairs, and 1 conversion to open surgery. RESULTS: Creation of pneumoperitoneum with DTI was feasible in 99.5% of patients. No major complications were associated with the technique. Immediate minor postoperative complications included 1 (0.5%) wound infection and 3 (1.5%) hematomas. At mean follow-up of 23 months, 4 (2%) umbilical wound stitch granulomas and 1 (0.5%) incisional hernia from the umbilical port site were observed. CONCLUSION: This study shows that that when performed by an experienced laparoscopic surgeon the direct trocar insertion technique is a safe and effective alternative for creation of pneumoperitoneum.

Primary aneurysm of the basilic vein.

This is a report of a 71-year-old woman who presented with a superficial soft tissue mass in the antecubital fossa. Excision was undertaken under local anaesthesia. The lesion proved to be a primary aneurysm of the basilic vein. Reviewing the literature we found only a few previous reports of primary venous aneurysms in the upper extremities.

Wandering spleen: case report and literature review.

We report a case of a 17-year-old patient who presented with a 'wandering spleen.' Management options were influenced by her being a Jehovah's Witness.

Renal cell carcinoma metastasizing to the thyroid gland.

Renal cell carcinoma represents 3% of all adult malignancies. Metastases occur most frequently in the bone and lung. Four cases of renal cell carcinoma metastasizing to the thyroid gland are described here. A literature review is presented and guidelines for the management of this rare condition are suggested.

Prediction of risk in noncardiac operations after cardiac operations.

To determine the preoperative variables affecting the mortality rate and the development of severe complications in patients who have had myocardial revascularization or a valve replacement and who then undergo a noncardiac operation, we retrospectively studied data from 120 such patients over the 5 years from 1982 through 1986. Thirty-six percent of patients had a noncardiac operation during the first month after the cardiac operation. The mortality rate was 11%, and the morbidity rate was 56%. The statistical comparison of the predictive accuracy of postoperative complications of three simple, widely used classifications (American Society of Anesthesiologists physical status, New York Heart Association classification, Massachusetts General Hospital cardiac risk index) demonstrated the superiority of the simplified three-class cardiac risk index (Massachusetts General Hospital-cardiac risk index; predictive accuracy of 84%). In a multivariate discriminant analysis of 21 variables in this population, five variables (myocardial infarction in previous 6 months, S3 gallop or jugular vein distention, arrhythmia on last preoperative electrocardiogram, emergency operation, delay between cardiac and noncardiac operation) were identified as being the most predictive of a postoperative complication. When these variables were used in the function (DF3) obtained by linear discriminant analysis, the prediction accuracy of a postoperative complication reached 83%. Performance of the new models in a prospective validation population remained satisfactory (75% for Massachusetts General Hospital-cardiac risk index three-class index and 72% for DF3). Extensive statistical analysis of our data tested by a validation study provided simple predictive models based on clinical variables easily available even in emergency situations.

Severe bleeding from submucosal lipoma of the duodenum.

Two patients with a duodenal lipoma had severe gastrointestinal bleeding. Duodenal lipoma is relatively rare and an even rarer source of severe gastrointestinal bleeding. Endoscopy and routine radiological examination of the gastrointestinal tract may suggest the diagnosis, but computed tomography allows a definitive preoperative diagnosis. Surgery is indicated in order to avoid complications.

Esophageal dilation as an outpatient procedure.

This report describes a ten year experience with esophageal dilation done on an outpatient basis for a variety of esophageal strictures. An account is given of the two main types of dilators used, showing no particular advantage of one type compared with the other for long term results. All types of strictures have been found to be suitable for this form of therapy. The low morbidity rate and lack of general anesthesia make these interventions ideal for outpatient procedures. Attention is drawn to the possibility that malignant disease may supervene in benign strictures or be missed initially, and frequent biopsies are advocated.

Safety of central venous catheter change over guidewire for suspected catheter-related sepsis. A prospective randomized trial.

We conducted a study to determine the safety of guidewire exchange of central venous catheters suspected of causing catheter-related sepsis (CRS). Out of a total of 146 patients studied prospectively 41 (28%) suspected of having CRS, were randomly allocated to have their catheters changed over a guidewire (group I) or replaced by a new contralateral venipuncture (group II). One hundred and five patients (group III) requiring only one catheterization served as a control group. Positive semiquantitative cultures (greater than or equal to 15 colonies per plate) of the catheter tip constituted a reliable index of CRS (positive and negative predictive value of 100%). No significant difference in catheter contamination rate and CRS rate was found between group I and II (p = 0.13) and between group I and II versus group III. Nevertheless, there were fewer problems of insertion in the guidewire group (p = 0.03). We conclude that changing a central venous catheter over a guidewire is as safe and has better patient acceptability than inserting a new one, as the proven CRS rate is low (2%) despite a high (27%) suspected rate.

Surgical management of substernal goitre.

This paper presents the clinical features and problems in the management of 34 patients with substernal goitre. Complete evaluation of the mediastinum relied on computed tomography. Thyroid function tests were performed routinely and showed a clinically underestimated incidence of hyperthyroidism (44 per cent). The incidence of occult malignancy in substernal goitres was high (12 per cent). In the majority of patients (88 per cent) the substernal goitres were removed by a collar incision. Four cases of goitres located in a retrotracheal position required a combined cervical and sternotomy approach. None of the 34 patients died. Transient postoperative hypocalcaemia was found in 41 per cent of our patients. The presence of a substernal goitre is an indication for resection based on the risk of malignancy, the risk of acute respiratory distress, the high incidence of thyrotoxicity and a low surgical morbidity.

Major hepatic resection for colorectal liver metastases.

A 6 1/2 year experience in the management of hepatic colorectal metastases in a specialist unit is reviewed. During the period studied, 48 patients were referred of whom only 24 actually came to resection. There were two in-hospital deaths, at 20 and 60 days, and six patients had non-fatal complications. Although the extent of resection was greater than in most reported series (13 right hepatectomies and 6 extended right hepatectomies), the results of resection were broadly the same as those of others, with a median survival of 30 months and 2 and 3 year survivals of 50 and 44 per cent respectively. A number of factors which others have considered to be of prognostic significance were examined. Tumour clearance was the only important prognostic indicator, where a 5 mm clear margin between the tumour and cut surface produced a significant difference in survival. It is suggested that a much larger number of patients in the UK with hepatic colorectal metastases might be considered for resection.

Bile duct obstruction: radiologic evaluation of level, cause, and tumor resectability.

In a prospective study of 65 patients with bile duct obstruction, various radiologic modalities were compared for their capability to demonstrate the level and cause of obstruction and to indicate accurately tumor resectability. Ultrasound (US) was performed in 65 patients, computed tomography (CT) in 51, direct cholangiography (DC) in 57, and angiography in 35. The level of obstruction was correctly indicated by US in 95% of patients and by CT in 90%, and the cause was correctly indicated by US in 88%, by CT in 63%, and by DC in 89%. In predicting tumor resectability, US was correct in 71% of patients, compared with 42% for CT, 58% for DC, and 25% for angiography. US therefore appears to be the single most useful modality in the evaluation bile duct obstruction.

Massive traumatic hemomentocele.

A case is reported of a massive hemomentocele caused by rupture of the left gastroepiploic vessels following blunt abdominal trauma. This injury is previously unreported. Peritoneal aspiration is the simplest method of confirming that intraabdominal bleeding has occurred, but more sophisticated investigations may be needed to diagnose covert trauma.