Importance of accurate preoperative diagnosis and role of advanced laparoscopic cholecystectomy in relieving chronic acalculous cholecystitis.

Between April 1, 1989, and January 1, 1994, 38 patients with chronic acalculous cholecystitis underwent an advanced (3-puncture) laparoscopic cholecystectomy at our institution. The 30 women and 8 men had a mean age of 39 years (range, 23 to 65 years) and represented 4.5% of our overall gallbladder patient population. In each case, the disease produced typical biliary colic, but no gallstones were visualized on ultrasound examination; cholecystokinin-stimulated cholescintigraphy revealed a dysfunctional gallbladder, as evidenced by an ejection fraction of < or = 35% or nonvisualization or nonemptying of the organ. In all 38 cases, cholecystectomy resulted in the complete relief of symptoms. Although an increasing number of physicians are recommending this operation for acalculous gallbladder disease, it should not be performed on the basis of clinical history alone. Rather, objective criteria confirming the need for surgical intervention should be obtained by means of appropriate preoperative testing, including cholecystokinin-stimulated cholescintigraphy.

Laparoscopic colorectal surgery: a challenge for ET nurses.

A growing number of colorectal procedures are being performed either partially or totally by laparoscope. Because of the lack of a major incision, this approach offers numerous advantages, including reduced postoperative pain and shorter recovery time. To familiarize ET nurses with the laparoscopic technique, this article reports a case of laparoscopic abdominoperineal resection and discusses some of the special considerations involved in patient care.

Laparoscopic resection of a solitary cecal diverticulum.

Cecal diverticulitis is an uncommon disorder that, unlike sigmoid diverticular disease, usually involves a solitary true diverticulum. The resulting pain is hard to distinguish from that of appendicitis or perforating carcinoma. The typical patient is male, Asian, and in the fourth decade of life. The following case is unusual in that the patient was a 50-year-old Caucasian woman, and the diverticulum was excised laparoscopically. To the author's knowledge, this is the first case in which laparoscopy has been used for this purpose.

Music: a diversionary therapy.

1. Music is a simple, inexpensive, aesthetically pleasing means of alleviating the anxiety of surgical candidates during the immediate preoperative period. 2. When allowed to participate in decision-making regarding their care, patients can regain a partial sense of control. Preoperatively, this goal can be achieved by permitting them to choose their own music and to experience music's diversionary effect. 3. As patient advocates, nurses should take advantage of the therapeutic effect of music by incorporating it into the perioperative setting.

Giant ventral hernias: a technical challenge.

For giant hernias in which primary repair is impossible, definitive correction can be obtained by applying two layers of expanded polytetrafluoroethylene to reconstruct the fascia and reinforce the abdominal wall. This article describes the use of this technique in 18 patients, most of whom had undergone inadequate conventional repair.

Laparoscopic cholecystectomy: experience in 500 consecutive cases.

Between April 1989 and November 1991, 500 consecutive patients (393 women and 107 men, aged 17 to 87 years) underwent laparoscopic cholecystectomy at our institution. The most common indication for surgery was chronic calculous cholecystitis. Twelve (2.4%) patients underwent emergency surgery, and the rest had elective operations. The average operative time was 36 minutes. In all but 72 cases, dissection was performed with a laser. In 4 instances (0.08%), the laparoscopic procedure was converted to an open cholecystectomy because acute cholecystitis made the gallbladder hard to grasp (2 cases) or faulty insufflation equipment afforded poor visualization of the operative field (2 cases). Three patients (0.06%) underwent reoperation for posterior cystic artery bleeding, cystic duct leakage, and common-bile-duct injury (1 case each). Minor complaints during the immediate postoperative period included nausea and shoulder pain. Patients were discharged from the hospital an average of 20 hours after surgery and resumed full activity within 3 to 8 days.

Percutaneously placed inferior vena cava filter for the prevention of pulmonary emboli: a plea for early insertion.

After surgery or trauma, thrombosis of a lower-extremity vein can lead to potentially fatal pulmonary embolization. Although anticoagulation has traditionally been the preferred method of preventing emboli, this approach is often ineffective or contraindicated. In such cases, partial or complete interruption of the inferior vena cava with a specially designed filter can prevent emboli from reaching the pulmonary circulation. The author reviews the history of vena caval interruption and describes his own experience with this technique, which has the potential for becoming the treatment of choice in the prevention of pulmonary emboli.

Use of semiocclusive, transparent film dressings for surgical wound protection: experience in 3637 cases.

During an eight-year period, the author used a semiocclusive, transparent film surgical dressing as a protective cover for 3637 surgical incisions. The wet environment facilitated healing, and no patient exhibited any symptoms of wound infection. Compared with traditional methods, the semiocclusive dressing resulted in faster wound healing, decreased pain, and less scarring. It also permitted visual assessment of wound healing, as well as promoting patient mobility and hygiene.

Closure of abdominal wounds with continuous nonabsorbable sutures: experience in 1697 cases.

From September 1976 to September 1989, the author routinely used continuous nonabsorbable sutures for closing abdominal incisions in 1697 consecutive laparotomy patients, including 696 men and 1001 women. These cases did not involve any type of hernia repair. In addition to being quick and cost-efficient, the continuous technique allowed tension to be distributed evenly along the suture line. During a follow-up period of up to 13 years, six patients presented suture granulomas, and two had late incisional hernias (greater than six months postoperatively). No hematoma formation, infection, or suture-line disruption was encountered. The author concludes that continuous nonabsorbable sutures are preferable to interrupted nonabsorbable sutures for closing a wide range of abdominal incisions.

Pacemaker-lead puncture of the tricuspid valve. Successful diagnosis and treatment.

During insertion, a transvenous pacing lead pierced the tricuspid valve in a 66-year-old man, causing progressive tricuspid insufficiency and congestive heart failure. The defect remained undiagnosed for ten years and was then repaired. To our knowledge, this is the first case in which this problem has been successfully treated rather than being diagnosed at autopsy.

Endoscopic cholecystectomy with the holmium:YAG laser: preliminary report.

In the first clinical trial of its kind, the author used a pulsed holmium:YAG laser to perform endoscopic gallbladder removal in 10 patients. Compared to other endoscopic laser systems, the holmium:YAG produced relatively shallow tissue penetration. As a cutting instrument, it allowed faster dissection than other lasers. As a coagulating instrument, it provided such satisfactory hemostasis that no other hemostatic method was needed. This preliminary trial left no doubt that the holmium:YAG is a excellent laser for laparoscopic surgery, particularly removal of the gallbladder.

Endoscopic Laser Cholecystectomy: Report of 300 Cases

From April 1989 to February 1991; the author performed endoscopic laser cholecystectomy in 300 patients (236 women and 64 men; who ranged from 19 to 86 years of age). The operation was undertaken with the neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in 275 cases; the argon laser in 13 cases; the potassium titanyl phosphate (KTP) laser in 1 case; and the holmium:YAG laser in 11 cases. The average operative time was 34 minutes. Four endoscopic procedures (1.3) were converted to open cholecystectomies because of poor visualization of the operative field. Reoperation was necessary for bile leakage in 1 case and for haemorrhage in another case; both patients recovered satisfactorily. Postoperative discomfort was controlled with an average of 235 mg of demerol. Twenty-six patients were discharged from the hospital on the day of surgery; and 248 remained in the hospital only overnight; the other patients were treated early in the series and had slightly longer hospitalization times. Unrestricted activity was resumed within 3 to 8 days

Complete jejunoileal necrosis due to torsion of the superior mesenteric artery.

We have reported a case of small-bowel volvulus in which complete jejunoileal necrosis resulted from torsion of the superior mesenteric artery. This case was unusual not only because of the extent of necrosis but also because primary small-bowel volvulus is rare in adults. Despite nearly total small-bowel resection, the patient continues to do well 6 months postoperatively.

Use of adhesive tape for primary closure of surgical skin wounds.

Although, during the last half century, there has been plenty of evidence that the healing of skin wounds is hindered by suture closure and fostered by the use of surgical tapes, the latter technique has not been widely practiced, because the adhesiveness of surgical tapes has been deemed too unreliable. When used at all, tapes have generally been applied only over subcuticular and subcutaneous sutures. The author describes his experience in using a new transparent adhesive tape for primary wound closure of 37 surgical incisions without underlying sutures. The series involved a wide range of surgical wounds, in various portions of the body. In all cases, the results were excellent; neither major nor minor complications were observed. Compared with suture closure, this method was associated with a reduced potential for infection, faster renewal of tensile strength, greater cost effectiveness, and better cosmetic effects.