A simple technique for deploying a laparoscopic bag during splenectomy: two-point anchoring to the abdominal wall.

BACKGROUND: The deployment of a retrieval bag during a laparoscopic splenectomy procedure may be time-consuming. A simple technique of holding the bag open is described in this paper. TECHNIQUE: A retrieval bag is equipped with two long, firm threads sutured to two preexisting tags on its opposite sides. The bag is introduced into the abdomen through the ports. By bringing the threads out of the abdomen through the abdominal wall and using one grasper, the surgeon can easily deploy the retrieval bag and hold it open. CONCLUSIONS: Our technique is easy to perform, and permits a rapid deployment and simple insertion of the spleen, while holding the retrieval bag wide open.

Morbidly obese patients are hemodynamically stable during laparoscopic surgery: a thoracic bioimpedance study.

PURPOSE: Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable. METHODS: In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI > or = 35 kg/m(2)) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40-50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP < or = 60 and MAP > or = 130 mmHg or HR < or = 50 and HR > or = 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI. RESULTS: Heart rate was higher in obese patients in head-up position (79 +/- 15 mmHg vs. 65 +/- 12 mmHg - P=0.011). SVR was higher in the nonobese group with head-up position (1978 +/- 665 dynes s cm(-5) vs. 1394 +/- 496 dynes s cm(-5) P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP < or = 60 and > or =130 mmHg or HR < or = 50 and > or =110 bpm in either of the groups. CONCLUSION: Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance.

BACKGROUND: Hyperphosphatemic acidosis and severe electrolyte disturbances caused by phosphate salts (PO) used for mechanical bowel preparation have been described in occasional case reports prior to bowel resection surgery. We hypothesized that PO used preoperatively for bowel preparation may cause more pronounced acid base and electrolyte changes than polyethylene glycol (PG). METHODS: Forty American Society of Anesthesiologists physical status II-III patients were randomly allocated to receive either PO or PG for bowel preparation before intra-abdominal surgery (bowel resection or other major elective intra-abdominal surgeries). Measurements of pH, base deficit, blood gases, lactate, hemoglobin, calcium, magnesium, potassium and phosphorus were undertaken before the laxative administration, intraoperatively, and postoperatively. RESULTS: Preoperative demographic, hemodynamic and laboratory data were similar in the two groups. Intraoperative calcium (8.4 [0.6] vs 9 [0.5] mg x dL(-1)) and pH (7.35 [0.04] vs 7.41 [0.03]) were lower, while lactate (1.3 [0.4] vs 0.9 [0.3] mmol x L(-1)) was higher with PO. Postoperative calcium, magnesium and potassium were lower (8 [0.5] vs 8.9 [0.2] mg x dL(-1), 1.68 [0.3] vs 1.8 [0.4] and 3.5 [0.36] vs 3.7 [0.33] mEq x L(-1) respectively) while phosphorus (4.1 [0.3] vs 3.3 [0.2] mEq x L(-1)) was higher with PO. A higher percentage of abnormal values for calcium, potassium, phosphorus and base deficit (66% vs 33%, 25% vs 10%, 19% vs 2% and 28.3% vs 5% respectively) were observed with PO. CONCLUSIONS: Calcium and magnesium changes were more pronounced in patients who received PO for bowel preparation.

Gluteal stab wound is a frequent and potentially dangerous injury.

BACKGROUND: Stab wounds to the gluteal area are a frequent injury in an urban trauma centre. These injuries may appear innocuous but is potentially life threatening. Therefore they deserve timely evaluation and management. The purpose of this study was to evaluate our experience with this type of injury and to propose a treatment protocol. METHODS: During the last 5 years 269 patients with stab injuries, were admitted to our Department of Emergency Medicine (DEM). Thirty-nine patients (14%) who had gluteal penetration were included in this study. Patients' charts were retrospectively reviewed for demographic data, type of injury and additional injuries, evaluation, management and outcome. RESULTS: Stab wound of the gluteal region was the most frequent injury after chest and abdominal injuries. Thirty patients presented with soft tissue damage only and nine were severely injured. Seven of the severely injured patients had significant bleeding; two of them were treated by embolisation. One patient suffered a rectal injury and one a small bowel perforation, both treated surgically. There was no post-operative complication or mortality. CONCLUSIONS: Penetration of the gluteal is a potentially life threatening injury. Meticulous observation and high level of suspicion ensure early treatment and can prevent mortality.

Internal jugular vein tumor thrombus associated with thyroid carcinoma.

Thyroid carcinoma usually presents as an asymptomatic thyroid nodule. Thyroid cancer may show microscopic vascular invasion; however, internal jugular vein tumor thrombus is a rare complication of thyroid cancer. A unique case of internal jugular vein tumor thrombus associated with thyroid carcinoma is presented and discussed.

Laparoscopic repair of "sportsman's hernia" in soccer players as treatment of chronic inguinal pain.

BACKGROUND: To evaluate the clinical course of soccer players affected by chronic groin pain, who were referred for laparoscopic inguinal exploration. MATERIAL/METHODS: Thirty-five professional soccer players affected by chronic groin pain and referred for laparoscopic inguinal exploration were included in this prospective, non-randomized study. Prior to surgery, patients were assessed by history, clinical examination, pelvic X-ray, bone scanning with Technetium and ultrasound of the inguinal region. The pre-peritoneal space was visualized with a laparoscope under general anesthesia. A bilateral polypropylene mesh was attached pre-peritoneally. Recorded data included demographics, history, symptoms, surgical findings and postoperative recovery. RESULTS: All patients were male. The mean age was 24.3 years. Six patients (17.1%) complained of pain affecting their normal life. A true indirect type I hernia was identified in 4 patients (11.4%). In 28 patients (80%), a wide internal ring and peritoneal dimple were found during the procedure. No clear pathology was found in three patients (8.6%). Thirty-four patients (97.1%) returned to their normal activities after surgery. CONCLUSIONS: Laparoscopic inguinal exploration and repair of "sportsman's hernias" in soccer players was associated with rapid recovery and fast return to full training and activity.

International trauma care: a comparison between Jerusalem, Israel, and Fairfax County, Virginia, USA.

BACKGROUND: Trauma is viewed by many as a global problem. The phenomenon of similar outcomes within differing healthcare delivery systems can illuminate the strengths and weaknesses of various trauma systems as well as the effects of these characteristics on patient outcome. OBJECTIVES: To compare and contrast demographic and injury characteristics as well as patient outcomes of two urban/suburban trauma centers, one in Israel and the other in the United States. METHODS: Study data were obtained from the trauma registries of two trauma centers. Demographic variables, injury characteristics and outcomes were compared statistically between registries. RESULTS: Significant differences between the registries were found in demographic variables (age), injury characteristics (Injury Severity Score and mechanism of injury), and outcome (mortality and length of stay). Age and Injury Severity Score were found to be significant predictors of outcome in both registries. The Glasgow Coma Score was found to contribute to patient outcomes more than the ISS. Differences were found in the relative impact of injury and demographic factors on outcomes between the registries. After including the influence of these factors on patient outcomes, significant differences still remained between the outcomes of the trauma centers. CONCLUSIONS: Despite possible explanations for these differences, true comparisons between centers are problematic.