First Croatian transvaginal laparoscopically assisted cholecystectomies.

BACKGROUND/AIMS: The aim of this study was to determine the feasibility and technical aspects of a new endoluminal surgical procedure: transvaginal laparoscopically assisted endoscopic cholecystectomy. METHODOLOGY: Three female patients underwent transvaginal laparoscopically assisted endoscopic cholecystectomy (aged 40, 61 and 33 years). Pneumoperitoneum was created through a 5mm supraumbilical incision. Through the posterior fornix of the vagina the second 10mm trocar, laparoscope and 5mm laparoscopic grasper were introduced. The gallbladder was dissected using standard 5mm laparoscopic grasper, hook, electrocoagulation and harmonic shears introduced supraumbilically. The dissected gallbladder was removed in a specimen retrieval bag. RESULTS: Transvaginal laparoscopically assisted endoscopic cholecystectomy was feasible in all patients. No intraoperative or postoperative complications were observed and there was no need for extra-umbilical skin incisions. Total operative time ranged between 60 and 75 minutes. Median length of hospital stay was 1 day. CONCLUSIONS: This was the first clinical application of transvaginal laparoscopically assisted cholecystectomy in Croatia. The initial clinical application of this technique in 3 female patients was feasible, effective and safe when performed by experienced laparoscopic surgeons using standard laparoscopic instruments.

The effect of analgesics and physical therapy on respiratory function after open and laparoscopic cholecystectomy.

In this study we present prospective clinical trial included 100 patients. One half of the patients underwent open cholecystectomy, whereas laparoscopic cholecystectomy was performed in the other half Spirometric parameters, arterial blood gases, acid-base balance, were determined preoperatively, and then at 6 h, 24 h, 72 h and 144 h postoperatively. The impact of physical therapy on the respiratory parameter patterns, VAS-pain score and use of tramadol were studied after cholecystectomy. Significantly lower VAS-pain score and less tramadol use, higher values and faster recovery of ventilation parameters and PaO2 were recorded after laparoscopic cholecystectomy than after open cholecystectomy (p = 0.001 for both). Physical therapy resulted in a significant improvement in the values of respiratory parameters in the open cholecystectomy group within a short time (30 min) after therapy was performed. Physical therapy failed to produce any improvement of respiratory parameters in laparoscopic cholecystectomy, whereas in open cholecystectomy group who had a favorable although transient effect, strictly limited to the short time from its application. (p = 0.005). The patients operated on by open cholecystectomy had statistically significantly more pronounced disturbances including hypoxia, hypocapnia and hyperventilation when compared to the group submitted to laparoscopic cholecystectomy. It is recommended that physical therapy be more frequently performed during the postoperative period in patients submitted to open cholecystectomy.

Quality of life analysis after open and laparoscopic inguinal hernia repair--retrospective study.

BACKGROUND/AIMS: An inguinal hernia is a usual medical problem. The golden standard for its treatment is Lichtenstein's repair. But, there are still some dilemmas about inguinal hernia repair technique, including the role of laparoscopy. The aim of this study is to analyze patient's quality of life after Lichtenstein's or laparoscopic inguinal hernia repair. METHODOLOGY: Retrospective analysis of medical documentation of 216 operated patients during the year 2006 at the Department of digestive surgery, University hospital Split, Croatia using tension free mesh repair procedures: Lichtenstein or laparoscopy (TAPP). Among the other data, the analysis includes use of antibiotic prophylaxis and thrombosis prophylaxis. The quality of life analysis was performed using the Short form 36 questionnaire (SF-36). RESULTS: We operated 212 (98.15%) males and 4 (1.85%) females. The average age of operated patients was 60.15 +/- 13.98 years. The antibiotic prophylaxis was prescribed to 22 (10.19%) patients with some of risk factors for wound infection. We did not register any secondary wound infection. Thrombosis prophylaxis was prescribed to all patients and there were no complications. The quality of life analysis showed no statistically significant differences between Lichtenstein and laparoscopic procedure with slightly better results for laparoscopic procedure in some of the SF-36's domains. CONCLUSION: There are no differences in quality of life between the patients operated with Lichtenstein or laparoscopic procedure. Despite that, we believe that laparoscopy has its place for inguinal hernia repair especially for recurrent and bilateral hernias.

A novel algorithm for the minimal invasive treatment of choledocholithiasis.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the gold standard in choledocholithiasis treatment. Currently there is no generally accepted algorithm for choledocholithiasis treatment. A few years ago suspected or diagnosed choledocholithiasis was indication for open operation if bilious stones could not be removed with therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Today, advancements in laparoscopic equipment and operation technique render the possibility for laparoscopic treatment of choledocholithiasis. There are many different ways in which to treat choledocholithiasis, depending on the time of diagnosis. Due to the considerable variability in choledocholithiasis treatment, which depends in turn on many objective and subjective factors, we propose a unique diagnostic algorithm for the treatment of choledocholithiasis. METHODOLOGY: From January 1st until December 31st 2005, at the University Department of Surgery -Split, 131 laparoscopic cholecystectomies were performed. Thirty-three patients with suspected choledocholithiasis were treated by laparoscopic intraoperative cholangiography. After positive cholangiography, thirteen laparoscopic transcystic extractions were performed. The patients were treated in the supine position. The surgeon was positioned between the legs of the patient, the assistants on opposite sides of the patient, and the scrub nurse on the right side of the surgeon. Transcystic stone extraction was performed using a flexible choledochoscope, which was connected to the left laparoscopic monitor using Picture-in-picture system and by Nitinol tipless Dormia basket. RESULTS: The total number of operated patients includes 18 women and 15 men. The mean age of patients was 60.16 +/- 15.36. The mean length of operation was 86 +/- 21.79. Mean hospitalization length of patients with laparoscopic cholecystectomy was 2.45 +/- 1.14 days; while mean hospitalization length of patients with stone extraction was slightly longer 2.90 +/- 1.18, (p = 0.564). CONCLUSIONS: Today several different possibilities approaches exist for the treatment of choledocholithiasis and it doesn't have to be treated unconditionally using endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy before, during or after laparoscopic cholecystectomy, or by the open operation.

Effect of surgical incision on pain and respiratory function after abdominal surgery: a randomized clinical trial.

BACKGROUND/AIMS: The aim of the present study was to assess the severity of respiratory disturbances occurring after abdominal surgery and to identify surgical incisions that entail the least respiratory complications and postoperative pain. METHODOLOGY: A total of 105 patients divided into two groups were included in this randomized clinical trial. Seventy-five patients in the first group underwent upper abdominal surgery, and were operated on by use of vertical, oblique, transverse and elliptic incision. The remaining 30 patients in the second group were submitted to low abdominal surgery by use of vertical and oblique incision. Arterial blood gases and pulmonary shunt development were determined at 12 h preoperatively, and at 6 h, 72 h and 144 h postoperatively. During the postoperative course, VAS-pain score and use of tramadol were observed according to the type of surgical incision employed. RESULTS: Most severe respiratory disturbances in terms of PaO2 decrease, activating compensatory hyperventilation, pulmonary shunt increase, the highest VAS-pain score and consumption of tramadol were induced by the following upper abdominal incisions: transversal laparotomy according to Orr, elliptic periumbilical laparotomy, upper midline laparotomy, transrectal laparotomy and subcostal laparotomy. In the group of low abdominal surgery (low midline laparotomy and inguinal incision) consumption of tramadol was statistically significantly lower, but no statistically significant differences were recorded between the baseline preoperative and postoperative values of PaO2, PaCO2 and pulmonary shunt. CONCLUSIONS: All low abdominal incisions were found to entail statistically significantly less respiratory disturbances, lower VAS-pain score and lower tramadol use when compared to upper abdominal incisions. The upper abdominal incisions observed caused substantial respiratory disturbances including hypoxia, hyperventilation and pulmonary shunt increase.

Laparoscopic abdominal cysts fenestration using harmonic scalpel.

The use of ultrasonically activated scalpel for tissue cutting and coagulation is a potential replacement for electrosurgery, which can be related to different complications. Its working principle is to transform the electric power into the mechanical longitudinal movement of the working part of the instrument, by a piezoelectric transducer situated in the hand piece. Between October 2000 and June 2004, six patients with abdominal cysts were treated by laparoscopy, using the harmonic scalpel. The average age was 40.8 (ranging from 15-60) years. Laparoscopic abdominal cyst fenestration was performed in five patients, and laparoscopic cholecystectomy and abdominal cyst fenestration were done in one patient during the same operation. The average duration of the operation was 40 (ranging from 25-70) minutes and hospital stay was 2.8 (ranging from 1-5) days. Laparoscopic abdominal cyst fenestration using the harmonic scalpel is a safe and successful operation, with good results including all the advantages of the minimally invasive surgery.

Antipersonnel mine injuries in Southern Croatia.

OBJECTIVES: In this retrospective study, antipersonnel mine casualties in Southern Croatia from 1991 to 1995 are analyzed and treatment options are discussed. METHODS: Mechanism, degree of injury according to Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), as well as surgical treatment were analyzed. RESULTS: Of a 2,693 war trauma population, 422 (15.67%) patients sustained antipersonnel mine injuries, 241 (57.11%) from pressure mines and 181 (42.89%) from fragmentation mines. Military personnel were injured in 329 cases, civilians in 60 cases, and children in 33 cases. AIS was 3.01 +/- 0.56 and ISS was 17.92 +/- 6.59. Of 39 fatalities (9.24%) with a mean age of 27.98 +/- 1.70 years, 34 were soldiers, 4 were civilians, and 1 was a child. AIS was 5.35 +/- 0.39 and ISS was 54.94 +/- 2.36. CONCLUSION: Fatalities and morbidity arising from antipersonnel mines can be reduced by the provision of appropriate surgical and evacuation facilities at the actual battlefield.

[Harmonic scalpel in laparoscopic surgery]. / Primjena visokofrekventno titrajuceg rezaca u laparoskopskoj kirurgiji.

Harmonic scalpel for the tissue cutting and coagulating is a replacement for the high frequency current, which can be connected with diverse complications. The principle is transforming of the electric power into mechanical longitudinal movement of the working part of the instrument, by piezoelectrical transducer situated in the hand piece. Between October 2000 and June 2001, one hundred and three patients were operated using harmonic scalpel. The average age was 50.2 years. Laparoscopic cholecystectomy, appendectomy and abdominal cyste fenestration was performed in 86, 12 and 4 patients respectively. In one patient laparoscopic cholecystectomy and abdominal cyste fenestration were done during the same operation. The average hospital stay was 2.8 days. Laparoscopic cholecystectomy, appendectomy and cyst fenestration using the harmonic scalpel are safe and successful operations, with good results and advantages of the minimally invasive surgery.

[Education in endoscopic surgery: courses of endoscopic surgery in Split, Croatia]. / Edukacija u endoskopskoj kirurgiji: tecajevi endoskopske kirurgije u Splitu.

Education is very important in endoscopic surgery. It can be performed on endoscopic trainers, live animals, and animal organs, using tissue samples or non-natural materials. Practical work and education can also be performed during the assistance or operating under the supervision. Endoscopic training courses have the important rule, too. We organized three endoscopic courses in Split up to date. The last one lasted 5 days, covered six different topics and included operations on pigs. In comparison with the course in the year 2001, the last course had more participants and lecturers. Lectures, practice and operations took longer time. The interest for attendance was high. The participants were very satisfied, and rated the lectures, practice and operations with the average grade between 4.1 and 4.7 on the anonymous questionnaire at the end of the course. It can be concluded that indispensable education in endoscopic surgery can be performed during endoscopic courses, where participants can reach basic theoretical and practical knowledge and skills. The courses should be permanently improved and modernized, providing a good quality, with interest and engagement of the attendees.

[Catheter placement for peritoneal dialysis using videoendoscopy]. / Postavljanje katetera za peritonejsku dijalizu videoendoskopskim nacinom.

From December 1993 to December 2000 at the Department of Surgery, General Hospital "Sveti Duh", and University, Hospitals Split and Osijek the catheter for peritoneal dialysis was placed in 128 patients, in 137 cases. Videoendoscopic procedure, with the trocar made precisely for that purpose, was used. All surgical procedures, performed in the completely equipped operation room and in general anesthesia, were done without any intraoperative or postoperative complications. The procedure showed to have all advantages of endoscopic or minimally invasive surgery. The patients recovered quickly with low consumption of analgesics, got out of the bed and started with feeding sooner. There were no wound complications. It was possible to start with the dialysis 2-3 days after the procedure. Most important, the results showed that using this approach in comparison to others, there were no more dialysis solution leakages, catheter drainage problems, or more tunnel, exit site or peritoneal infections. Along with placing the catheter, other surgical procedures could be also done without increasing the complication rate. Therefore, laparoscopic cholecystectomy was done in 12 cases, adhesiolysis in 25 cases, and right adnexectomy, open hernioplasty and umbilical hernioplasty in one case. Videoendoscopic approach of placing the catheter is a simple, short and patient convenient procedure, with quick recovery and without any increase in complication rate.

[Helicobacter pylori in biopsy specimen of gastric mucosa: frequency and correlation of rapid urease test with histology]. / Helicobacter pylori u biopsijskom uzorku zelucane sluznice: ucestalost i usporedba brzog testa ureaze s histoloskim pregledom.

Between December 1999 and May 2000, general, age and sex distribution of Helicobacter pylori and rapid urease test sensitivity and specificity in correlation with histology were performed on 125 patients after gastroscopy. The average patients' age was 54.98 +/- 15.74, range 20-86 years. There were 71 (57%) of females and 54 (43%) males. Seventy seven (62%) patients were Helicobacter pylori positive on histology, and differences between the sex and age were not statistically different (p = 0.58 and p = 0.07). Sensitivity of the rapid urease test after 30 minutes, 3 and 24 hours was 23, 57 and 81% respectively, specificity was 100, 98 and 94% respectively, positive predictive values were 100, 98 and 95% respectively, and negative predictive values were 45, 59 and 75% respectively. In conclusion, it can be recommended to do biopsy of two specimens, from the antrum and body of the stomach. Distribution of Helicobacter pylori positive is higher in older patients. Rapid urease test has low sensitivity and negative predictive value with high specificity and negative predictive value. The additional advantage can be if the test is positive after 30 minutes, because the therapy can be prescribed immediatelly after the endoscopy.