Entry technique for laparoscopy.

The present trend in laparoscopic surgery is to make use of the Veress needle as an instrument for palpation of the abdominal cavity to secure "safe" blind introduction of the first trocar. The oxymoron is witness to the many mishaps experienced by the most daring surgeons who approach blindly each and every abdomen, irrespective of previous surgery. The "bayonet technique" heralded by the gynecological school oflaparoscopy has never been accepted by us, due to its inherent characteristic risk of injuries to the pelvic or retroperitoneal organs. Whenever the patient has had previous abdomino-pelvic surgery, the open laparoscopy technique is preferred with the Hasson's trocar either at the navel or at any other location, as deemed appropriate by the site of old incisions. Experience and laparoscopic findings have led us to enforce the principle that open laparoscopy should be instituted if any scar, even from previous Iaparoscopy, is present over the anterior abdominal wall. A variation in the technique for introduction of the Veress needle and safe execution of the pneumoperitoneum was devised to be used when the peritoneal cavity has not been violated surgically.

Complications of Trocar Wounds and their Prophylaxis.

Laparotomy is vision of the abdominal content by direct eyesight through an abdominal incision. Laparoscopy achieves the same or better result with an optic device placed into the abdomen through special introducers. Exploration, part or complete procedures, can be performed with much less postoperative morbidity; thishas instilled a new sense of optimism in both the community and surgical ranks. Suddenly it appeared that the old "sacred" rules of traditional surgery had been buried under a thick layer of dust.

Cystosarcoma phylloides of the breast: a new therapeutic proposal.

An analysis of forty cases of cystosarcoma phylloides of the breast was undertaken to clarify the relationship between histology, surgical treatment and prognosis of this fibroepithelial tumor. Thirty-eight female patients 12 to 85 years of age, treated for this diagnosis over a 17-year period, were studied retrospectively. Histologically malignant lesions were diagnosed in 17 cases: six were treated by local excision, one by subcutaneous mastectomy with prosthetic implant, four by simple mastectomy, three by modified, two by radical mastectomy, and one by biopsy only. Of the 23 histologically benign tumors, 18 were treated by local excision, three had simple mastectomy, and one had subcutaneous mastectomy with prosthetic implant. Three recurrences, observed (7.5%) among patients with benign tumors, were locally excised. Wide local reexcision has controlled the disease to date after average follow-up of 32 months. In the malignant group, metastases developed in four patients (10%). Three of these patients are dead of disease and one is being treated by chemotherapy. Malignant histology seemed to correlate directly to the presence of pain (46.6%), size of the tumor (average 7 cm in diameter), and older age (average 52 years), but there was no correlation with prognosis. Recent reports on the subject advocate wide local excision for small benign lesions and simple mastectomy for larger or malignant ones. Our data indicates that the histologic appearance does not correlate with the clinical behavior of this neoplasm, and the choice of the procedure does not alter the long-term result, provided that the tumor is completely excised. More radical procedures than wide local excision are not justified for cystosarcoma phylloides which behaves more like a soft tissue sarcoma than a breast gland tumor.

Focal dermal hypoplasia (Goltz's syndrome) manifesting as condyloma acuminatum: report of a case and review of the literature.

A new case of Goltz's syndrome, focal dermal hypoplasia, is documented. The literature is reviewed. The composite individuality warrants considering Golt'z syndrome a separate syndrome in the ectodermal dysplasias. Caution against diagnosing "condyloma-like" lesions occurring in ectodermally dysplastic patients as condyloma acuminatum is urged. Neoplastic transformation and the tendency to recurrence after surgical exicision of the cutaneous angiofibromas pose a difficult problem in surgical management.