Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center.

BACKGROUND: Port placement injuries are a potentially devastating complication of laparoscopic surgery. Ultrasound assessment for visceral slide has the ability to preoperatively determine adhesion-free areas. The utility of this technique has not been studied when performed by surgeons. METHODS: Surgeons without expertise in ultrasound were taught the visceral slide technique. Patients with a history of abdominal surgery were then assessed for adhesion-free areas on the abdominal wall. Ultrasound assessments were validated against intraoperative visualization. RESULTS: Nine surgeons using the visceral slide technique assessed 145 patients for the presence of adhesions immediately before surgery. Surgeon who performed ultrasound demonstrated a sensitivity of 69.6%, specificity of 98.7%, and positive predictive value of 99.5% for detection of areas free from critical adhesions. The median time to perform the examination was 2 minutes. CONCLUSION: The visceral slide technique was easily learned, was rapid to perform, and reliably identified adhesion-free areas of the abdominal wall.

Surgical fixation vs nonoperative management of flail chest: a meta-analysis.

BACKGROUND: Flail chest is a life-threatening injury typically treated with supportive ventilation and analgesia. Several small studies have suggested large improvements in critical care outcomes after surgical fixation of multiple rib fractures. The purpose of this study was to compare the results of surgical fixation and nonoperative management for flail chest injuries. STUDY DESIGN: A systematic review of previously published comparative studies using operative and nonoperative management of flail chest was performed. Medline, Embase, and the Cochrane databases were searched for relevant studies with no language or date restrictions. Quantitative pooling was performed using a random effects model for relevant critical care outcomes. Sensitivity analysis was performed for all outcomes. RESULTS: Eleven manuscripts with 753 patients met inclusion criteria. Only 2 studies were randomized controlled designs. Surgical fixation resulted in better outcomes for all pooled analyses including substantial decreases in ventilator days (mean 8 days, 95% CI 5 to 10 days) and the odds of developing pneumonia (odds ratio [OR] 0.2, 95% CI 0.11 to 0.32). Additional benefits included decreased ICU days (mean 5 days, 95% CI 2 to 8 days), mortality (OR 0.31, 95% CI 0.20 to 0.48), septicemia (OR 0.36, 95% CI 0.19 to 0.71), tracheostomy (OR 0.06, 95% CI 0.02 to 0.20), and chest deformity (OR 0.11, 95% CI 0.02 to 0.60). All results were stable to basic sensitivity analysis. CONCLUSIONS: The results of this meta-analysis suggest surgical fixation of flail chest injuries may have substantial critical care benefits; however, the analyses are based on the pooling of primarily small retrospective studies. Additional prospective randomized trials are still necessary.