Technique and survival after laparoscopically assisted right hemicolectomy.

BACKGROUND: The role of laparoscopic colon resection in the management of colon cancer is still controversial. In this article, the surgical strategy and techniques are described, with further consideration of the oncologically relevant aspects. METHODS: Between March 1993 and July 2003, we performed laparoscopic right hemicolectomy in 56 patients with right colon carcinoma. Average age was 74.5 years (range, 17-92). We performed a standardized surgical procedure that included mobilization from the vascularized mesenteric bridges with a window technique, transection of the ileocolic lymphovascular pedicle, and lateral and proximal mobilization of the ileocecum, ascending colon, right flexure, and proximale transversum. After enlargement of one of the trocar incisions the exteriorized colon was resected and an extracorporeal anastomosis was performed in the standard manner. RESULTS: There were no conversions to open. The mean operating time was 119 +/- 38 min, the mean length of resected colon was 27.8 +/- 4.48 cm, and the average width of the clear margins was 6.8 +/- 5.3 cm. One patient died. Lymph nodes were positive in 21 patients. The 5-year survival rate in the 48 patients who were operated on with curative intent was 75%. We have had two local recurrences. The overall 5-year mortality-free fraction was 63%. Cox multivariate analysis showed that the mortality-prognostic factors were tumor stage and length of resected colon, whereas Kaplan-Meier analysis showed that the mortality-prognostic factors were positive lymph nodes and tumor stage. CONCLUSIONS: Our results show that laparoscopic right hemicolectomy for colon cancer can be performed safely. Complications and recurrence rates are comparable to those for left-sided laparoscopic and open procedures. Therefore, we recommend this procedure as the method of choice. Laparoscopically treated patients with stage II and stage III disease have almost the same cumulative rate of survival.

Traumatic false aneurysm of the subclavian artery treated by insertion of Memotherm stent.

Traumatic aneurysms of the left subclavian artery and transverse cervical artery, subsequent to penetrating gunshot wound were diagnosed by angiography in 35-year-old patient. Subclavian artery aneurysm was treated by insertion of the Memotherm bare stent, whereas the false aneurysm of the transverse cervical artery was embolized with Gianturco's coils. The follow up examinations at 6 and 12 months showed good patency of subclavian artery.

[Less invasive laparoscopic cholecystectomy: initial experience and literature review]. / Manje invazivna laparoskopska kolecistektomija: nasa pocetna iskustva i pregled literature.

Laparoscopic cholecystectomy using the 5 and 10 mm caliber instrument is still a gold standard for surgical treatment of the gallstone disease. Today it is possible to perform this operation with a less invasive manner, using the fine caliber instruments, whose diameter is under 5 mm. According to published data, less invasive laparoscopic cholecystectomy does not have a higher complication rate, and other parameters are very similar or even better, specially the cosmetic outcome. In this article with small patient number we confirmed better cosmetic outcome, described different operation techniques and warned about the shortcomings. A greater number of patients and randomized study is indispensable for better technique analysis.

A new bipolar hook for endoscopic surgery.

This article presents a new bipolar hook for endoscopic surgery. With this instrument monopolar and bipolar current can be used. The advantage of this new instrument is the possibility of using a bipolar current, which is safer than using the monopolar current. The technical details and usage instructions are discussed.

War injury to the liver. A case report.

We report a case of a war thoracoabdominal gunshot wound associated with severe injury to the liver and hemorrhagic shock. Immediately upon admission to the second Echelon Surgical Unit, the patient was operated on with two separate surgical approaches: right thoracotomy and subcostal laparotomy. The patient was transferred to rear hospital for recurrent postoperative hemorrhages. He was eventually transferred to our Department, where he underwent reoperation by the surgical approach through right thoracophrenolaparotomy. Liver lesion debridement and hepatic artery ligation were performed. The early and late postoperative course was normal, and the patient achieved satisfactory recovery on discharge. The case shows that the management of severe liver injuries requires special knowledge and experience from the surgeon.

Laparoscopic and laparotomic cholecystectomy: a randomized trial comparing postoperative respiratory function.

BACKGROUND: The fact that pulmonary complications occur in 20-60% of the patients subjected to abdominal operations clearly indicates that the lungs are the most endangered organ during the postoperative period. OBJECTIVE: The aim of this study was to demonstrate the impact of cholecystectomy on postoperative respiratory disturbances by comparing the laparotomic cholecystectomy with laparoscopic gallbladder removal. PATIENTS AND METHODS: A hundred cholecystectomized patients were included in the prospective randomized clinical trial. Half of the patients were operated on by the laparotomic procedure, whereas the other half underwent laparoscopic cholecystectomy. Spirometric parameters, arterial blood gases, and acid-base balance were determined before the operation, and at 6, 24, 72 and 144 h postoperatively. Abdominal distension was assessed by auscultating intestinal peristaltics, abdominal circumference measurement, and time interval to restitution of defecation. RESULTS: Six hours postoperatively, the values of ventilation parameters decreased on average by 40-50% from the baseline preoperative values in both groups of patients. The group of patients submitted to laparotomic cholecystectomy had significantly lower spirometric values and slower recovery of the ventilation parameters than the laparoscopic cholecystectomy group. Abdominal circumference was significantly greater and the time needed for restitution of peristaltics and defecation was significantly longer in the laparotomic cholecystectomy group compared to the group of laparoscopic cholecystectomy. CONCLUSIONS: Statistically significant impairments including hypoxia, hypocapnia and hyperventilation were observed in the patients submitted to laparotomic cholecystectomy, indicating the presence of objective respiratory risk, especially in elderly patients and patients with obstructive pulmonary diseases or cardiac insufficiency.

The problems and characteristics of hepatic war trauma management in central Dalmatia during the 1991-1995 war in Croatia.

OBJECTIVE: War injuries to the liver treated during the 1991-1995 war in central Dalmatia, Croatia, were analyzed retrospectively. METHODS: There were 713 patients with abdominal injuries, 125 (17%) of whom were operated on for liver injuries. Mobile surgical teams operated on 91 patients (73%) in rear war hospitals (echelons II and III); only 34 patients (27%) were immediately transferred to and operated on at the Split University Hospital. RESULTS: After wounds to the small and large intestine, liver injuries were the third most common abdominal injuries. Morbidity was 63%, and reoperations were required in 20% of cases. Fourteen patients (11%) died. The highest rate of complications was observed in patients with postoperative inflammatory intra-abdominal collection, disseminated intravascular coagulation, adult respiratory distress syndrome, sepsis, or ileus. The highest mortality was found in those patients requiring a right hemihepatectomy. CONCLUSIONS: The best results were achieved in patients on whom, after hepatotomy, selective hemostasis with liver debridement was carried out.

Subclavian artery stenosis caused by non-specific arteritis (Takayasu disease): treatment with Palmaz stent.

A 32-year old woman was admitted to the hospital with a sudden onset of right-sided hemiplegia and aphasia. Immediate angiographic examination revealed a severe form of type I Takayasu arteritis with occlusion of all supra-aortic vessels, with the exception of the left subclavian artery which was, however, almost completely occluded 1 cm proximal to the origin of the left vertebral artery. Since the latter provided the entire blood supply to the brain tissues, an immediate attempt was undertaken to dilate the left subclavian artery; when this was unrewarding, stenting of the lesion was successfully accomplished with excellent primary and 6-month follow-up results.

War injuries to the chest.

AIM: Presentation of our experiences in the treatment of war injuries to the chest at the Split University Hospital, Croatia, during the 1991-1995 war in Croatia and Bosnia-Hercegovina. METHODS: Retrospective analysis of clinical and surgical data on 439 (16.3%) patients with war injuries to the chest among 2693 treated battle casualties in general. The medical data from evacuation unit, transportation, emergency department and follow-up were observed and processed by basic statistical analysis. RESULTS: There were more explosive wounds than gunshot and puncture wounds (ratio 251/158/30). Penetrating injuries were found in 348 (79%) patients and nonpenetrating in 91 (21%) patients. There were 401 (91%) men and 38 (9%) women. Thoracotomy was performed in 98 (22.3%) patients, whereas conservative surgical methods (wound treatment, chest-tube drainage, appropriate fluid therapy, antimicrobial and atelectasis prophylaxis) were used in 341 (77.7%) patients. Mean time elapsed between injury and definitive surgical repair was seven hours (range, 1 to 48 hours). Recovery on discharge was recorded in 411 (93.6%) patients, 19 (4.3%) patients were referred to other institution for further treatment, and 9 (2%) severely wounded persons died. CONCLUSIONS: The treatment of respiratory insufficiency and haemorrhage shock, and prevention of infection are the basis of management of these injuries. Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the chest. Most war wound of the lung can be successfully managed by "conservative" surgical treatment. The recovery of lung function was similar in conservatively and operatively treated patients.

Can we evaluate the pressure of perihepatic packing? Results of a study on dogs.

The pressure of perihepatic packing can cause organ perfusion disturbances. The problem is to determine the pressure applied during the operative procedure. The objective of this animal study was to assess the perihepatic packing pressure and its effect on the pressure in the inferior vena cava (IVC). In order to assess the pressure in the IVC a catheter was introduced through the femoral vein. A rearranged tourniquet for blood pressure measurement was placed on the dog liver and with various perihepatic pressures the resulting pressures in the IVC were assessed. It was established, that by applying pressure of 30 mm Hg to the liver, the pressure in the IVC did not exceed 10 cm of water. Two clinical cases are reported where the method was shown to be crucial for the management. The first one is related to haemodynamic instability after successful perihepatic packing for grade V injury. In the second case, an otherwise stable patient had significantly elevated pressure in the IVC, which crucially influenced the treatment. The introduction of a catheter into the IVC to monitor the pressure in patients with liver injuries is useful.

[High frequency current in endoscopic surgery and a new bipolar hook for endoscopic surgery]. / Visokofrekventna struja u endoskopskoj kirurgiji i nova bipolarna kukica za endoskopsku kirurgiju.

High frequency current is used in surgery for cutting the tissue and stopping bleeding. Its usage is more frequent in endoscopic than open surgery. "Polarity" (monopolar and bipolar) marks the number of the electrical poles on the application place. Monopolar current has been used more often. With its usage thermal injuries are possible: coagulation outside of the laparoscopic view, direct coupling, capacitive coupling, sparking, skin combustion, activity on the heart rhythm. Because of these complications, the bipolar current is more and more in usage, which reduces the number of complications or avoids them completely. Many bipolar instruments are available today. Bipolar hook for endoscopic surgery is a new instrument which unites the good characteristics of the hook and bipolar current.

Our experience with 2693 wounded treated at the Split University Hospital during the 1991-1995 period.

The authors' personal experience of 2693 wounded treated at the Split University Hospital during the 1991-1995 period is described and compared with the results reported from other recent wars worldwide. Explosive wounds were more frequent than gunshot wounds (N=1490; 55.3% vs N=988; 36.7%), and wounds due to other factors were observed in 215 (8.0%) patients. There were 2494 (92.6%) men and 99 (7.4%) women. A total of 1815 (67.4%) patients were operated on in field war hospitals, and 878 (32.6%) at the Split University Hospital. Recovery and discharge were achieved in 1527 (56.7%) and improvement with the treatment or rehabilitation continued at other institutions in 850 (31.6%) patients. In 240 (8.9%) patients, no definite opinion can yet be given. A lethal outcome was recorded in 76 (2.8%) patients. Rapid transportation from the site of wounding to medical teams was found to be of paramount importance for successful treatment. These teams were placed in field war hospitals placed as close as possible (5-15 km) to the frontline.

War injuries to the thoracic esophagus.

OBJECTIVE: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. METHODS: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. RESULTS: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. CONCLUSION: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.