Diagnostic accuracy of ultrasonography and surgical decision-making in patients referred for suspicion of appendicitis.

Two groups of patients referred for suspicion of acute appendicitis were compared to evaluate the accuracy of preoperative ultrasonography (US) and surgical decision-making. In one retrospective study, US was performed by trainees using a 3.5 MHz probe (219 patients). In the second prospective study, US was performed by a resident radiologist using a 5 MHz probe (144 patients). US accuracy rose from 65% to 90%, especially due to an improved negative predictive value (from 52% to 92%). The positive predictive value of US was 89%. The sonographically adjusted clinical decision to operate was correct in 85%. Thus, all patients with positive US should be operated. In contrast, clinical judgment must prevail in case of negative US findings in order to prevent surgical delay in about 11%. The negative laparotomy rate decreased by 5% only. This is probably due to the limited influence of negative US findings on surgical decision. US is to be recommended in all patients suspected for acute appendicitis when performed with an appropriate probe by an experienced ultrasonographist. However, it may not, on it self, reduce the rate of unnecessary operative procedures.

Totally preperitoneal laparoscopic approach combined with minianterior dissection in the treatment of indirect inguinal hernias.

Totally preperitoneal laparoscopic hernioplasty has become more popular recently and will possibly replace the transabdominal preperitoneal procedure. This procedure, however, is more demanding for the surgeon, especially in large indirect hernias. We describe an alternative technique derived from Darzi's anterior endoscopic approach. To date, it has been used in 15 patients, all with good success. The technique results in a shorter operative time and is easier for the surgeon.

Balloon dissection in extended retroperitoneoscopy.

The anatomy of the retroperitoneum, including the high retroperitoneum, was studied as it appears with balloon dissecting techniques. We used fresh cadavers in this study. A relatively unknown fascia that is located between the lateral aspect of the perirenal fascia and the posterior parietal peritoneum, called the paraconal fascia, was a constant finding. This structure is important because it protects delicate retroperitoneal organs: the duodenum, pancreas, celiac axis, and superior mesenteric artery. Locating this fascia is an important step in the dissection of the high retroperitoneum, which is of interest in advanced videoendoscopic procedures involving retroperitoneal organs.

Operative strategy in laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy was attempted in 17 consecutive patients and was successful in 15. STUDY DESIGN: This study is a critical analysis of the operative strategy in laparoscopic splenectomy, as reviewed in the operative video recordings and operative summaries of the 17 patients discussed. RESULTS: The 15 successful laparoscopic splenectomies were all conducted according to the same strategy: mobilization of both the upper and lower pole of the spleen, division of the short gastric vessels close to the spleen, and dissection and separate ligation of the main trunk of the splenic artery and vein. An erroneous strategy that diverged from the one proposed, resulted in parenchymatous hemorrhage and open conversion in two patients. CONCLUSIONS: In this series of 15 successful laparoscopic splenectomies, the most important technical aspect seems to be full mobilization of the spleen before the hilum is dissected.