Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery.

BACKGROUND: Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used. METHODS: A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases. RESULTS: The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma). CONCLUSIONS: The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.

Pectus excavatum in adults: destructive surgery or simple correction of an aesthetic defect?

Pectus excavatum, a congenital depressive malformation of the sternum, is described since 1594 by Johannes Schenk and has successively been the subject of many studies because of its various inherent problems. The repercussions on the respiratory and cardiac dynamics caused by the compression on the mediastinal structures and by the reduction of the respiratory volume have only recently been valuated completely with the application of the latest techniques to diagnosis, cardiology and radiology. The aesthetic defect, often the first aspect to attract the attention of patient and doctor, has serious psychological implications, especially for what concerns the affective life and relationships in general. The surgical therapy consists in radical interventions with large sternocostal resections and repositioning of the sternum (turnover), or in interventions with a less invasive technique to correct only the aesthetic defect. In this study have been examined 7 cases of patients affected by pectus excavatum who were operated at the Institute of General Surgery IV and the Department of Plastic surgery of the University of Rome "La Sapienza" between 1983 and 1993. The patients were divided in two groups: a first group of 4 patients who underwent a sternal turnover, and a second group of 3 patients who were operated with conservative methods to correct the aesthetic defect. In both groups the results were good without any post-operatory complications. The experience gained during these years consents us to propose radical interventions for patients who have a severe malformation with evident physiopathological implications; this intervention is especially indicated if the patient is young, to prevent further disabling complications. Less invasive methods, on the other hand, should be applied to all other cases, considering the higher degree of tolerance of the intervention, the absence of postoperatory complications and the minor cost, thanks to a shorter hospital stay.