Live interactive broadcast of laparoscopic surgery via the Internet.

BACKGROUND: For the first time in the history of communications, we conducted live interactive broadcasts through the Internet (on August 29, and September 3, 1996). METHODS: Successful transmissions were performed from Pontiac, Michigan, to Laguna Hills, California, and Buenos Aires, Argentina, and participants actively interacted in audio and video formats in real time. RESULTS: Video images were transmitted at a rate of 1-2 frame/s and displayed in a 320 x 240 window at the remote sites. The loss of audio packets averaged 17% with a delay of 0.5-2 s. The broadcasting computer station was also able to receive real-time video and sound from the distant computers, allowing complete interaction between both parties over the duration of each transmission session. Average broadcast time was 1. 5 h +/- 30 min, and the cost of each transmission was equal to that of a regular local phone call. CONCLUSIONS: Videoconferencing via the Internet is a viable method for transmitting information in real time allowing surgeons worldwide to work together during surgical procedures.

Laparoscopic appendectomy: a viable alternative approach.

Laparoscopic appendectomy (LA) is relatively a new technique and requires comparison to open appendectomy (OA) to determine the more favorable approach in the surgical management of acute appendicitis. We designed this study to compare the course and postoperative complications between LA and OA. We reviewed the charts of both groups of patients and followed their course in the hospital. Seventy-seven patients who underwent LA with one conversion to the open technique (1.3%) were compared to 84 patients who underwent OA. There was no difference in age and sex distribution. The mean hospital stay was shorter in the LA (32.5+/-10 vs 74.2+/-24 h, p < 0.0001). Parenteral analgesia requirement was higher in the OA group (4.7+/-1.4 vs 2.6+/-2, p < 0.0001). The total cost was higher in the OA group ($11,260+/-4000 vs 7,090+/-3500, p < 0.05). There was no significant difference in the OR time, duration of the procedure, and surgery costs between both groups. Normal appendices removed were similar in both OA and LA groups (23.8 vs 28.9%). There was no difference in the rates of postoperative complications between both groups. We conclude that LA is a viable alternative to OA. It is safe, cost effective, and less invasive than the OA with less pain and shorter hospital stay.

Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty.

A 2.8-year prospective multicenter trial was conducted to evaluate the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. A total of 441 inguinal hernias were repaired in 351 patients (326 male; 25 female). Two hundred twenty-six of the hernias were direct, 185 indirect, 4 femoral, 26 pantaloon, 90 bilateral, and 92 recurrent. Standardized data collection forms were used and submitted for centralized data analysis. For the hernioplasty, Cooper's ligament was exposed and an 8 cm x 12 cm x 1 mm GORE-TEX Soft Tissue Patch was stapled circumferentially to Cooper's ligament and the endoabdominal fascia. Patients were followed at 1 week, 6 months, 1 year, and then annually. Three-month intervals were used as needed. There was a mean follow-up of 447 days, with 21% of the total repairs followed for more than 2 years and 56% for more than a year. The overall follow-up rate was 95.5%. The operative and postoperative complication rates were 0.45% and 8%, respectively. There were 17 recurrent hernias (3.8%). The range of experience among the investigators was 13 to 168 hernioplasties. With the completion of 25 cases per investigator, the recurrence rate fell to 0.39%. Postoperative analgesia averaged a 24-hr supply of medication; 12.2% of patients required no analgesia. Convalescence averaged 5.4 days, and return to work averaged 7.7 days. This multicenter trial demonstrates that the ePTFE laparoscopic peritoneal onlay inguinal hernioplasty is a safe and dependable repair, especially after the initial learning curve is surmounted.

Flashlamp-excited dye laser therapy of idiopathic vulvodynia is safe and efficacious.

OBJECTIVE: The management of chronic vulvovaginal pain, not explicable on specific histologic grounds, presents a major problem in referral centers for lower genital tract diseases. STUDY DESIGN: This article reports on a two-step protocol in a sample of 175 medical nonresponders, drawn from a 2-year cohort of 725 women with vulvovaginal pain. The first maneuver was the use of a flashlamp-excited dye laser to selectively photocoagulate symptomatic subepithelial blood vessels in 168 women; the second was the microsurgical removal of chronically painful Bartholin's glands in 52 women not responsive or not suited to flashlamp-excited dye laser photothermolysis. RESULTS: Dye laser response rates were independent of whether patients manifested macroscopic foci of painful erythema ("vestibular adenitis") or just colposcopically apparent hyperemia-ectasia of the individual blood vessels ("pruritic papillomatosis") (56% vs 45% after a single surgical procedure; 76% vs 65% after serial retreatment; p not significant). Conversely, response rates were much lower among women in whom pressure on the Bartholin's glands produced sharp, lancinating pain (15% vs 66% after a single surgical procedure; 22% vs 93% after serial retreatment; p < 0.001). Forty-two (85%) of 50 patients with flashlamp-excited dye laser failure had deep pain; however, the impasse to progress was broken by gland removal. Final response rates were 92.5% (complete response 62%; partial response 30%) in the "surface-only" group and 80.3% in the "surface-plus-deep" group (chi 2 = 14.9; p < 0.001). The major complication was acute bacterial cellulitis, occurring in the first postoperative week. Modification of the treatment protocol to include topical antibiotics with an occlusive dressing reduced the cellulitis rate from 17.2% to 2.5%. In four women (1.8%) Koebner-like exophytic condylomas also developed within 1 month of flashlamp-excited dye laser surgery. CONCLUSION: The availability of a safe, efficacious, and relatively noninvasive treatment should reduce the need for resective surgery in most patients with idiopathic vulvodynia.

A two-person, two-handed technique for laparoscopic cholecystectomy.

This manuscript describes a technique of laparoscopic cholecystectomy which permits the surgeon to use both hands. The technique can be modified to accommodate both right- and left-handed surgeons. Advantages we have appreciated in performing over 100 procedures in this manner include a less crowded operating environment, a less costly operating team, and a resident assistant closer to the patient with two hands available so that he or she can better develop the co-ordination necessary to assume increasing responsibility for the procedure.

ICD implantation via thoracoscopy without the need for sternotomy or thoracotomy.

After development of the technique in mongrel dogs, implantable cardioverter defibrillator (ICD) patch and sensing lead implantation was attempted via thoracoscopy, without sternotomy or thoracotomy, in three patients. Two large titanium mesh defibrillator patches and two "screw-in" epicardial sensing leads were applied without difficulty in each of two patients. In a third patient, satisfactory placement of the defibrillator patches could not be achieved via thoracoscopy, necessitating thoracotomy. Defibrillation threshold (DFT), cardioversion energy requirement (CER), and rate and morphology signals in those patients with successful thoracoscopic implantation were comparable to those achieved by open technique. We conclude that ICD patch and sensing lead implantation via thoracoscopy is feasible.

Detection of breast cancer.

Routine screening has been shown to reduce the mortality from breast cancer in asymptomatic women. All women should be instructed in breast self-examination, and should begin a program of screening mammography and breast physical examination on an annual basis beginning at the age of 40. Most early breast cancers can be adequately treated without ablative surgery.

Endoscopic tonometric assessment of intestinal perfusion in a canine model.

In an anesthetized canine model tonometric balloons were colonoscopically placed into the right colon, left colon, and rectum. A femoral arterial line was established for the measurement of blood pressure and arterial bicarbonate. Laparotomy was performed and additional balloons were placed, via enterotomies, into the duodenum, jejunum, and ileum. Baseline measurements of intramural pH were obtained, and then the origin of the superior mesenteric artery was occluded. Additional measurements in all areas were made for two 1-hour intervals. Results showed rapid and marked acidosis as demonstrated by significant (p less than 0.001) pH changes in the jejunum, ileum, and right colon. There were no significant changes in the pH in the duodenum, left colon, or rectum. Systemic arterial pH remained normal. These data demonstrate that tonometric balloons endoscopically placed into the right colon will reflect superior mesenteric artery occlusion at an early stage, and that similar information is likely to be gained by endoscopic placement of these balloons into the jejunum.

Endoscopic placement of feeding tubes in the critically ill patient.

Placement of the nasojejunal feeding tube under direct visual guidance using endoscopy offers an alternative method to those currently used. We found it to be a safe method easily performed by house staff. It is less burdensome than other described endoscopic techniques and does not require patient transfer or fluoroscopic facilities.

Binding of monoclonal antibody A2B5 to gangliosides.

Monoclonal antibody A2B5 (Eisenbarth et al, Proc. Nat. Acad. Sci. (1979, 76:4913-4917), which reacts with neurons, thymic epithelium and peptide-hormone secreting cells of several species, was reported to react specifically with brain tetrasialogangliosides. We have found that A2B5 binds to gangliosides GQ1b, GD3, GD2, disialolactoneotetraosylceramide, and probably to GT1a, when assayed by an immunostaining procedure that detects binding of antibody to gangliosides on a thin-layer plate. Additional data obtained by complement fixation revealed that this antibody reacted most strongly with ganglioside GQ1b almost as well with disialogangliosides GD3, GD2 and disialolactoneotetraosylceramide, weakly with GD1b and GT1b, and very weakly with GM3 and GD1a. These data indicate that A2B5 cannot be regarded as a specific reagent for the recognition of tetrasialogangliosides.