Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients.

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Mumps outbreak in a highly vaccinated school population. Evidence for large-scale vaccination failure.

OBJECTIVES: To describe an outbreak and to identify risk factors for mumps occurring in a highly vaccinated high school population. (Note: Highly vaccinated means a population in which more than 95% have been vaccinated.) DESIGN AND PARTICIPANTS: Survey and cohort study of 307 (97%) of 318 students. OUTCOME MEASURES: Mumps was defined as an illness with 2 or more days of parotid swelling. Serologic confirmation of infection was obtained in eight cases, seven of which were evaluated for presence of IgM antibody using immunofluorescent antibodies. Vaccination records were verified for 297 (97%) students. RESULTS: Between October 3 and November 23, 1990, clinical mumps developed in 54 students (attack rate, 18%), 53 of whom had been vaccinated. Most cases (40 [77%] of 52) occurred 12 to 20 days after a school-wide pep rally. Immunofluorescent antibody testing of all seven specimens demonstrated IgM antibody to mumps. Risk factors for clinical mumps identified in multivariate analyses included female gender (odds ratio, 3.0; 95% confidence interval, 1.6 to 5.7) and source of vaccination other than the local public health clinic (students vaccinated by private providers [odds ratio, 3.0; 95% confidence interval, 1.3 to 5.2] or in other districts [odds ratio, 2.4; 95% confidence interval, 1.1 to 5.3]). CONCLUSIONS: The overall attack rate is the highest reported to date (and to our knowledge) for a population demonstrating virtually complete mumps vaccine coverage. Even verified documentation of vaccination may not be an accurate indicator of an individual's protection against mumps. Vaccination failure may play an important role in contemporary mumps outbreaks. We found no evidence to indicate that waning immunity (secondary vaccine failure) contributed significantly to this outbreak. A second dose of mumps vaccine, as recommended using measles-mumps-rubella vaccine, could potentially prevent similar outbreaks in secondary school populations in the future.

[Seat belt syndrome: a new abdominal pathology]. / Le syndrome de la ceinture de sécurité: une pathologie abdominale nouvelle.

Between January 1976 and December 1980, 43 patients involved in automobile accidents while wearing passive restraints were treated at l'Hôpital du Sacré-Coeur in Montreal. Thirty-seven showed signs of abdominal trauma and were operated upon. There was a strikingly high incidence of gastrointestinal injury. Thirty-two of the 37 had injury to the bowel or its mesentery. This spectrum of injury is most likely related to the rapid deceleration caused by the restraint with the three-point harness.

Changing trends with abdominal injury in seatbelt wearers.

Seatbelts were incorporated as standard equipment for automobiles constructed in North America in 1964. The first seatbelt law was made mandatory in Canada as of 1 January 1971. Between January 1976 and January 1980 38 patients involved in automobile accidents while wearing passive restraints were treated at l'Hôpital du Sacré-Coeur: 32 of these 38 patients had signs and symptoms of abdominal injury. These patients wearing passive restraints had an unusually high incidence of gastrointestinal injury in comparison to previously reported patients not wearing restraints. Twenty-seven of the 32 patients had injury to the bowel or the bowel mesentery. This different spectrum of injuries is most likely related to the altered physics of rapid deceleration caused by restraint with the lap belt and shoulder harness.

Importance of the serum amylase level in patients with blunt abdominal trauma.

Possible intra-abdominal injuries were sought in 101 patients admitted with blunt abdominal trauma. The serum amylase level was measured in the first 12 hours after the accident. Twenty-five patients had hyperamylasemia; 18 underwent laparotomy and 7 were treated conservatively. At laparotomy all 18 patients exhibited at least one serious intra-abdominal lesion, and there was a total of 28 lesions in the who group (including only four pancreatic injuries). The mean value of the serum amylase for those who had laparotomy was 1190 IU, while it was only 363 IU for those not operated upon. The authors conclude that hyperamylasemia in blunt abdominal trauma is not specific to pancreatic injury, but may suggest the presence of a serious intra-abdominal lesion.

Resection and primary anastomosis for diverticulitis with perforation and peritonitis.

Primary resection is the treatment of choice for diverticulitis of the colon with perforation and generalized peritonitis. Although there has been controversy concerning the management of the bowel ends after resection, for the last 20 years immediate anastomosis has been gaining increasing support. Between 1970 and 1981, at the Hôpital du Sacré-Coeur in Montreal, 15 patients having diverticulitis with perforation and diffuse spreading peritonitis who fulfilled specific criteria were treated by primary resection of the perforated segment of bowel and immediate anastomosis. The criteria for operation were : (a) the bowel must not be distended; (b) the bowel should be empty of feces; (c) edema of bowel wall at the resection site must be minimal; (d) the distal segment of colon should be above the peritoneal reflection; (e) there should be no fecal contamination; (f) the patient's general condition should be reasonably good. If these criteria were met, the procedure was safe and gave satisfactory results. In the authors' series, postoperative hospital stay was reduced considerably (it averaged 11 days). There was one anastomotic pulmonary edema.

Primary adenoid cystic carcinoma of the esophagus.

Primary adenoid cystic carcinoma or cylindroma of the esophagus is rare, only 22 cases having been reported previously. The histogenesis of this tumour is disputed, but it is believed to arise from the submucosal glands. A 75-year-old man with a cylindroma of the esophagus underwent radical excision of the tumour and has been clinically disease-free and asymptomatic since his operation in February 1979. Despite the poor results of surgery in the small number of patients reported in the literature, this unusual type of adenocarcinoma of the esophagus should be treated like epidermoid carcinoma--by radical excision.