Effects of colonoscopy on intracranial pressure: observation in a large animal model.

BACKGROUND AND STUDY AIMS: Increased intra-abdominal pressure has been associated with increased intracranial pressure. Bowel insufflation during colonoscopy may increase the intra-abdominal pressure. It was hypothesized that colonoscopy may be associated with intracranial pressure elevation subsequent to an elevation in intra-abdominal pressure. MATERIALS AND METHODS: Colonoscopy was carried out in seven anesthetized pigs, and the colonoscope was advanced up to 60 cm from the anal verge. Insufflation was used to allow safe advancement of the colonoscope and to allow visualization of the colon, in the same way as in the procedure performed in humans. Intra-abdominal pressure was measured by determining the hydrostatic pressure in the urinary bladder. A subarachnoid screw was used to monitor intracranial pressure. The mean arterial blood pressure and intra-abdominal venous pressure were directly monitored via the femoral vessel access; all parameters were recorded before and during colonoscopy. RESULTS: A statistically significant elevation in intracranial pressure was demonstrated during colonoscopy. The average increase in intracranial pressure was 3.1 mm Hg. The intra-abdominal pressure and intra-abdominal venous pressure were also significantly elevated during the procedure. CONCLUSIONS: Colonoscopy may increase intracranial pressure due to an increase in intra-abdominal pressure. This may have clinical implications when colonoscopy is conducted in patients with brain pathology associated with high intracranial pressure.

Technical considerations in laparoscopic resection of gastric neoplasms.

BACKGROUND: The purpose of this study was to determine the use of different laparoscopic approaches in the management of gastric neoplasms based on tumor type and location. METHODS: We retrospectively reviewed the records of seven patients (3 men and 4 women) with 11 gastric lesions who were referred to our facility between March 2000 and October 2001 for laparoscopic excision of gastric neoplasms. RESULTS: Two patients had gastrointestinal stromal lesions (3 lesions); two patients had hyperplastic polyps (3 lesions); one patient had carcinoid tumor (2 lesions); one patient had a carcinoma in situ and an adenoma; and one patient had an ectopic pancreas. Extraluminal laparoscopic wedge resection was used in four patients with lesions at the anterior gastric wall or along the lesser or greater curvature. Intragastric excision was used in two patients with small posterior wall lesions, and a transgastrotomy approach was used in one patient with a posterior wall lesion that could not be removed by the intragastric approach. All the lesions were completely excised with clear margins. The median hospital stay was 3 days. Complications developed in two patients. One patient presented with a perforated ulcer 2 weeks after surgery, and a second patient had postoperative pyloric edema that resolved with conservative treatment. CONCLUSIONS: The use of different laparoscopic approaches based on gastric neoplasm type and location facilitates tumor access and resection.

Laparoscopic resection of ectopic pancreas in the gastric antrum: case report and literature review.

We report a case of ectopic pancreas tissue in the gastric wall that was removed using a minimally invasive approach. The patient was a 46-year-old obese woman who presented with fatigue, weakness, abdominal discomfort, and guaiac-positive stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the gastric antrum. Intraoperative upper endoscopy clearly located the lesion at the antrum. The lesion was marked with India ink, allowing it to be identified easily at laparoscopy. A laparoscopic wedge resection of the gastric antrum was performed. The patient had an uneventful recovery. We believe that this is a valid treatment option for this benign condition.

A simple technique for decompression of distended gallbladder during laparoscopic cholecystectomy.

During laparoscopic cholecystectomy, distended gallbladder can create exposure difficulties, that precludes adequate visualization, thus rendering laparoscopic dissection impossible and even unsafe. To overcome this problems, we devised a simple technique for the decompression of distended gallbladders.

Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease.

BACKGROUND: Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia. We evaluated our experience with this surgical approach in high-risk patients. METHODS: We present the results of 29 patients with gallstones who, between 1998 and 1999, underwent laparoscopic cholecystectomy with epidural anesthesia. All but 1 patient had chronic obstructive pulmonary disease. RESULTS: All 29 surgeries were successfully completed via laparoscopy and with the patients under epidural anesthesia. No patient required endotracheal intubation during surgery or pain medication afterward. Postoperatively, 1 patient developed a wound infection and 3 patients developed urinary retention. At last follow-up (12 months postop), all patients were in good health. CONCLUSION: In this series, laparoscopic cholecystectomy was feasible under epidural anesthesia and it eliminated the need for postoperative analgesia. We believe that this approach should be considered for patients who require biliary surgery but who are not good candidates for general anesthesia due to cardiorespiratory problems.

Laparoscopy for gastric tumors.

A decade after the introduction of therapeutic laparoscopy, the use of laparoscopic gastric surgery is becoming accepted. While still evolving, currently available techniques and equipment are already sufficient for performing most ablative and reconstructive procedures. Despite feasibility, problems such as procedural complexity, long operative time, and high cost may negate the advantages of earlier and easier recovery. At present, these procedures are limited to highly trained laparoscopic surgeons, but they may become more prevalent among the next generations of surgeons, due to constant changes in surgical training and education. The question of laparoscopic curative treatment of malignant gastric tumors has not been answered. Diagnostic laparoscopy for staging is effective and widely practiced, but gastric resections are mostly limited to benign lesions. Currently, early malignant lesions are laparoscopically treated mainly in Japan, whereas more advanced lesions are laparoscopically resected in only a few centers around the world. Full endorsement of these procedures, by randomized controlled trials, although desirable, is unlikely soon, due to the technical complexity and low prevalence of these pathologies in western countries.

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND: Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS: We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS: The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION: Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

[Video-laparoscopic placement of adjustable gastric banding (lap-band) in the treatment of morbid obesity. Preliminary results after 407 interventions]. / Aplicación de la bandeleta gástrica ajustable (lap-band) por videolaparoscopia en el tratamiento de la obesidad mórbida. Resultados preliminares tras 407 intervenciones.

INTRODUCTION: Morbid obesity is the most frequent nutritional disorder in developed countries. Bariatric surgery is one option for the definitive treatment of this disorder. We present 407 patients who underwent implantation of adjustable silicone gastric banding. Ninety-four percent of the patients were satisfied with the procedure and its results. MATERIAL AND METHOD: We performed a retrospective study in the Surgery Department of the Nordwestkrankenhaus teaching hospital of the University of Frankfurt. From April 1996 to January 2000 we performed laparoscopic placement of adjustable silicone gastric banding in 407 patients, using Kuzmak's technique. Mean body mass index was 49.1 and mean weight was 139.2 kg. We describe the patient selection method and provide a detailed description of the technique and its possible problems. RESULTS: There was no operative or postoperative mortality. None of the patients required conventional surgery. Mean operating time was 62 minutes (including operating times during the learning period). Mean hospital stay was 5 days. We performed 24 (5,89%) reinterventions: 11 for displacement, 2 for erosion, 4 for infection of the reservoir, 2 due to review of the reservoir to prevent penetration and 4 due to dilatations of the pouch (changing the banding from a retrogastric to a retroesophageal position); one patient requested removal of the banding. Follow-up was performed at months 1, 6, 9 and 12. Mean weight loss was 28 kg at 6 months and 54 kg at 1 year. Mean weight loss in patients followed-up for 2 years was 58 kg. A total of 94.9% of the patients were satisfied with the procedure. CONCLUSIONS: Laparoscopic implantation of adjustable gastric banding (Lap-Band) combines the aims of conventional gastroplasty with the advantages of laparoscopic surgery in terms of postoperative morbidity and minimal invasiveness.

Laparoscopic transabdominal suspension sutures.

A limited number of access ports used in laparoscopic surgery may impair the ability of the surgeon to achieve adequate retraction and exposure, or to stabilize "moving targets" while operating on nonfixed organs. Solutions such as adding more ports or using a hand-assisted technique have the disadvantages of being more invasive, possibly creating a cumbersome situation of multiple instruments in a limited working space. We describe a useful technique for retraction and stabilization with the use of temporary sutures that pass through the abdominal wall. Although not new, this technique is not widely known or used, and laparoscopic surgeons may find it useful for a variety of applications.

Closure of laparoscopic trocar site wounds with cyanoacrylate tissue glue: a simple technical solution.

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

[Laparoscopic surgical of the liver and bile ducts]. / Laparoskopische Chirurgie der Leber und der Gallenwege.

The liver, gallbladder, bile ducts, and spleen are the least mobile organs in the upper abdomen. Thus, the laparoscopic approach is commonly used to manage a variety of pathologies related to these organs [5, 10, 60, 78]. Compared with conventional "open" surgery, minimally invasive surgery reduces postoperative pain and discomfort, lowers morbidity rates, promotes early mobilization, decreases recovery time and length of stay, and improves cosmetic results. In addition, the surgical results of laparoscopic surgery are as good as or better than those of conventional surgery [5]. This paper reviews the advances in laparoscopic surgery, and describes current patient selection practices and laparoscopic surgical techniques for benign liver cysts and tumors and biliary tract diseases.

[Laparoscopic splenectomy: new techniques and indications]. / Die laparoskopische Splenektomie: Neue Techniken und Indikationen.

Over the recent years laparoscopic splenectomy has become the preferred approach for the treatment of many conditions requiring splenic removal. At first limited to small spleens and to benign hematologic disorders, this procedure is now used for a variety of indications. Enlarged spleens are possible to be removed laparoscopically, although this is still a demanding procedure. Two factors facilitated the technique and contributed to its wide acceptance: 1) Change in the technique originally used, by positioning the patient in right lateral decubitus, and approaching the spleen from a postero-lateral direction. 2) The development of new technologies to dissect and divide tissues and vessels, including the ultrasonic shears and the laparoscopic linear stapler. In this article we review the current indications for laparoscopic splenectomy, as well as the techniques to accomplish this procedure.

A review of technical and clinical aspects of biliary laser lithotripsy.

OBJECTIVE: This paper reviews the current use of laser techniques for the treatment of biliary stones. BACKGROUND DATA: Biliary stones may pose a special problem when access to them is limited, when previous attempts of removal have failed, or when a less invasive option than surgery is needed. The availability of various laser sources and the adaptation of the technology for safe use in the biliary system make the use of laser energy for stone fragmentation possible. METHODS: Current literature is reviewed concerning the use of laser for biliary lithotripsy, including experimental data and experience with human series. Technology, indications, alternatives, and cumulative world experience are discussed. CONCLUSIONS: Recent technical advances have made the use of laser energy for fragmentation of biliary calculi possible. It is a valid option for treatment of "difficult" stones, when other methods have failed or as a primary treatment in certain situations. The technical complexity and the high cost limit its use for specialized centers.

[Temporary muco-cutaneous transversal colostomy. Technical contribution]. / Colostomia transversal muco-cutánea temporaria. Contribución técnica.

The cases of 49 patients on whom a primary temporary muco-cutaneous transversal colostomy were practiced for different pathologies, are presented and the results obtained analysed. From our point of view, certain technical aspects explain the excellent results obtained. Within these aspects we call to attention the place where the colostomy was practiced, divulsioning the rectum muscle, the total absence of colo-parietal fixation and the early removal of the glass rod-all of which as we see it, simplifies enormously the healing process of this type of ostomy, thus permitting the systematic use of local anaesthesia. This procedure allows this type of surgery to be practiced on ambulatory patients, reducing the operating costs.

Colostomia transversal muco-cutánea temporaria. Contribución técnica. / [Temporary muco-cutaneous transversal colostomy. Technical contribution]

The cases of 49 patients on whom a primary temporary muco-cutaneous transversal colostomy were practiced for different pathologies, are presented and the results obtained analysed. From our point of view, certain technical aspects explain the excellent results obtained. Within these aspects we call to attention the place where the colostomy was practiced, divulsioning the rectum muscle, the total absence of colo-parietal fixation and the early removal of the glass rod-all of which as we see it, simplifies enormously the healing process of this type of ostomy, thus permitting the systematic use of local anaesthesia. This procedure allows this type of surgery to be practiced on ambulatory patients, reducing the operating costs.