A new device for the detection and recognition of blood vessels in laparoscopic surgery.

BACKGROUND: The recognition and localization of blood vessels to prevent their intraoperative perforation poses a major problem in laparoscopic surgery. The endoscopic pulse detector is a new device that has been specially developed for the detection and recognition of blood vessels in laparoscopic surgery. The instrument uses an accelerometer to detect a pulse, and it is inexpensive and simple to use. The aim of this study was to investigate the performance and possibilities of the new instrument. METHODS: The instrument's performance and features were tested in laboratory conditions by use of simulated circulation. We assessed the dependence of the signal amplitude recorded by the instrument over a given blood vessel on the blood pump frequency change (36-130/min), circulating systolic pressure change (40-180 mm Hg), and adjacent blood vessel pulsations. Clinically, the instrument was tested in a randomized study in 40 elective noncomplicated laparoscopic cholecystectomies, where we assessed the time needed for the preparation of Calot's triangle and positioning of the cystic artery. RESULTS: The results of laboratory testing showed that the instrument operated throughout the frequency range of 36-130/min and a circulating systolic pressure range of 40-180 mmHg, while the signal amplitude rose with pressure increase. The results of clinical testing showed that use of the pulse detector in laparoscopic cholecystectomy significantly reduced the time needed to prepare Calot's triangle (t = 3.91; df = 38; p <0.001) and also made the positioning of the cystic artery more reliable. CONCLUSION: The study showed the new instrument to be very simple to use and potentially valuable in laparoscopic surgery, primarily for the differentiation of blood vessels of similar structures.

Treatment of acute cholecystitis. A comparison of open vs laparoscopic cholecystectomy.

BACKGROUND: In this study, the clinical results and cost-effectiveness of open vs laparoscopic cholecystectomy in the treatment of acute cholecystitis were compared. METHODS: Over a 5-year period (1994-98), 894 cholecystectomies were performed, 545 (60.96%) of them laparoscopically and 349 (39.04%) by the open method. The study included 209 patients with a clinical diagnosis of acute cholecystitis; 115 (55.02%) of them were operated on by the open method and 94 (44.98%) by the laparoscopic method. RESULTS: A comparison analysis revealed that the mean postoperative treatment period was 8.40 days after open and 4.38 days after laparoscopic cholecystectomy. In the group operated on by the open method, 106 patients received an antibiotic, a mean of 5.09 ampules and 3.2 tablets or suppositories of an analgesic, and 2.91 dressings per patient; whereas in the group submitted to the laparoscopic method, the comparable figures were 43, 3.13, 2.1, and 1.47, respectively. In 31 (26.96%) employed patients operated on by the open method, the mean absenteeism from work was 42 days; whereas in 31 (32.98%) of those operated on by the laparoscopic method, it was 17 days. The mean operating times for the procedures were 89 and 115 min for the open and laparoscopic methods, respectively. Two patients submitted to open cholecystectomy died within 30 days postoperatively. Wound infection was recorded in 10 (8.7%), prolonged biliary secretion in two, and cicatricial hernia in five (4.35%) patients. In the group submitted to laparoscopic cholecystectomy, there were no deaths; nine (9.57%) conversions were required; four patients had to be reoperated on, two of them for bile lobe hemorrhage and two for massive biliary secretion from the open cystic duct; herniation at the site of supraumbilical incision developed in three patients, and infection developed at the same site in two (2.13%) patients. The hospital cost was significantly higher in laparoscopic patients ($1181 vs $873) USD), as was the total cost of treatment for acute cholecystitis ($1430 vs $1316). However, the cost for sick leave and rehabilitation was significantly lower in laparoscopically treated patients ($486 vs $1199). CONCLUSIONS: Our comparison analysis of the results and cost-effectiveness of the surgical treatment of acute cholecystitis clearly pointed to the advantages of laparoscopic over open cholecystectomy-i.e., better clinical outcome and a more rapid resumption of daily activities. Hospital and total costs of treatment were on average higher in laparoscopic patients, except for the employed ones, where the lower sick leave cost translated into a significant reduction in total costs.

Intradural disc herniation at the T1-T2 level.

Intradural disc herniations comprise 0.26-0.30% of all herniated discs. Five percent are found in the thoracic, 3% in the cervical, and 92% in the lumbar region. Although intradural disc herniation may be suspected on preoperatively made CT scans, myelograms, and MRI scans, establishing the diagnosis prior to the surgery is difficult. We present a case of the patient with severe neurological deficits, caused by intradural thoracic disc herniation at T1-T2 interspace, which required surgical treatment. The symptoms were relieved immediately after surgery. This is the first description of an intradural disc herniation at that level.

[Anastomosis of the colon using the Valtrac biofragmentable ring]. / Anastomoze na debelom crijevu biofragmentarnim prstenom Valtrac.

Since January 1995, Valtrac biofragmentary ring for compressive anastomosis of the colon has been employed in Croatia. This study comprises experience in four Croatian hospitals in which 244 anastomoses of the colon with Valtrac biofragmentary ring were performed in the four-year period (1995-1998). The average age of the patients was 64.7 years. One hundred and eighty-seven of them (76.64%) were operated for colon cancer, 15 (6.1%) for Crohn's disease, eight (3.3%) for rectal cancer, and 34 for other diseases. One hundred and nineteen anastomoses were made between small intestine and colon, and 125 end-to-end of the colon. Valtrac BAR 28 mm in diameter was most frequently used (41.8%), and 34 mm in diameter least often (8.6%). Sixteen patients had complications related to anastomosis. One had obstruction which required repeated surgery, and 15 (6.15%) dehiscence of the anastomosis, of which 12 were reoperated. In the postoperative course six patients (2.46%) died due to the sequelae of dehiscence. Compressive anastomoses with Valtrac biofragmentary ring should be considered equal to manual and stapler methods when choosing the technique of colon anastomosis.

The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome.

The authors retrospectively analysed two groups of consecutive patients who were similarly matched for brain injury severity. From a total of 39 severe head injury patients, 23 were treated according to the Guidelines for the Management of Severe Head Injury with intracranial pressure (ICP) monitoring ("Guidelines group"). Such an approach allowed the maintenance of ICP within normal values, especially in patients with intraventricular ICP monitoring allowing the release of cerebrospinal fluid (CSF) from the ventricular system. In the Guidelines group only two patients were administered barbiturates, after all other means of ICP lowering had been exhausted. The second group consisted of 16 patients who were not monitored for ICP ("non-Guidelines group"). In this group, management consisted of the prophylactic administration of barbiturates, high dose osmotic diuretics and hyperventilation usually at levels below 25 mm Hg. In the Guidelines group the mortality rate was 30% compared to 44% in the non-Guidelines group. Almost twice as many patients achieved a "favourable" (good recovery and moderate disability) outcome (49%) compared to the non-Guidelines treated patients (25%). Furthermore, there was a 32% decrease in severe neurological disabilities in those patients in the Guidelines group. It seems that the implementation of "Guidelines" in the treatment of severe head injury, based on the result of our clinical study, reduces death and disability rates in patients with severe head injury. The administration of therapy based on the "Guidelines principles" and monitoring of ICP, can minimise the application of those therapeutic modalities (barbiturate coma and prolonged hyperventilation) which, in addition to favourable effects, may also have harmful effects on patients with severe head injury.

[Initial results of privatization of primary health services in the area of Pozega]. / Prvi rezultati privatizacije primarne zdravstvene zastite na primjeru Pozege.

Privatization of the primary health care in the Pozega region has been going on gradually since 1992, when 30 general practice teams and 27 dentist teams provided care for 71,745 inhabitants. Up to 1998, 17 general practices with the contract with the Croatian Institute of Health Insurance (HZZO) for 36,714 insured, 15 dentist offices with the contract with the HZZO for 39,715 insured, one orthodontist office, and one for home care, underwent privatization. Another three dentist offices, one gynecological, and one ophthalmological practice were privatized without the contract with the HZZO. As it turned out, the successful privatization requires good knowledge of the project devised by the Ministry of Health, positive attitude of the county authorities and the administration of health care centres, as well as flexibility during the implementation of the project. On the basis of the conducted poll and other objective indices, it is concluded that the initial positive results of the privatization of the primary care are numerous and encouraging. However, there are also some negative ones which should be eliminated.

[60 years' of the modern hospital in Pozega]. / 60 godina moderne bolnice u Pozegi.

The development of the hospital in Pozega, from medieval poor houses to the establishment of a modern hospital in 1936, is presented. In the late 19th and early 20th century, surgery departments were founded in many hospitals in Slavonia. The old town hospital built in 1836 did not meet the demands of medical work, and in the period from 1930 to 1936 a new hospital building was constructed. Since then, the hospital has played a major role in health education and promotion, prevention and treatment of disease, and training of medical staff. After 1961 new departments were established (pediatrics, gynecology, otorhinolaryngology), and in 1981 a new surgery was built with seven operation rooms, as well as a modern intensive care unit, delivery rooms etc. These developments contributed to good hospital functioning during the war in 1991-1992. The hospital reconstruction with equipment renewal is now under way. Education of medical staff and scientific activities are continuing tasks which must accompany advances in medicine.

War-related transformation and work of surgery service of the Pozega Medical Center, East-Croatian Hospital unaffected by direct war activities.

The work of the Pozega Medical Center Surgical Unit during the two war years (from July 16, 1991, to October 1, 1993) in Croatia is described. Since the war operations did not affect the town directly, the work was mostly characterized by treatment of wounds inflicted by explosive devices (51.2%) and localized mostly on the extremities (62.9%). Apart from these wounds, there were 0.7% burns, 26.6% gunshot wounds, and 19.6% injuries caused by blunt and hard objects. Of the total of 959 treated wounded persons, only 18 (1.9%) died, illustrating the success of the therapy administered according to the war surgery doctrine criteria.