Safe Veress Needle Intraperitoneal Placement and Safer Laparoscopic Entry.

STUDY OBJECTIVE: Fifty percent of laparoscopic bowel and vascular injuries occur at the time of entry. These serious complications can lead to significant morbidity and even mortality. This video demonstrates 3 techniques that have been developed to minimize the risk of these injuries during entry. DESIGN: Step-by-step description of 3 techniques that can be used as a highly reliable and safe method of obtaining intraperitoneal entry during laparoscopy. MEASUREMENTS AND MAIN RESULTS: Caudal displacement of the umbilicus before insertion of the veress needle allows for a median displacement of 6 cm between the site of entry and the common iliac vessels. An entry pressure of less than 9 mm Hg is suggestive of successful intraperitoneal entry. The left upper quadrant should be used in specific cases instead of the umbilicus as the point of entry for the veress needle. The use of a visualized trocarless cannula instead of a conventional primary trocar for entry after insufflation allows for real-time recognition of injury and converts linear penetrating force to radial torque. CONCLUSION: These 3 techniques can help decrease the risk and improve intraoperative recognition of serious bowel and vascular injuries during laparoscopy.

Management of ingested magnets in children.

We describe a comprehensive algorithm for the management of ingested rare-earth magnets in children. These newer and smaller neodymium magnets sold as adult toys are much stronger than the traditional magnets, and can attract each other with formidable forces. If >1 magnet is swallowed at the same time, or a magnet is co-ingested with another metallic object, the loops of intestine can be squeezed between them resulting in bowel damage including perforations. An algorithm that uses the number of magnets ingested, location of magnets, and the timing of ingestion before intervention helps to delineate the roles of the pediatric gastroenterologists and surgeons in the management of these cases.

Management of intestinal injury in deployed UK hospitals.

INTRODUCTION: Definitive laparotomy (DL), with completion of all surgical tasks at first laparotomy has traditionally been the basis of surgical care of severe abdominal trauma. Damage control surgery (DCS) with a goal of physiological normalisation achieved with termination of operation before completion of anatomical reconstruction, has recently found favour in management of civilian trauma. This study aims to characterise the contemporary UK military surgeon's approach to abdominal injury. PATIENTS AND METHODS: A retrospective analysis was performed on British service personnel who underwent a laparotomy for intestinal injury at UK forward hospitals from November 2003 to March 2008 as identified from the Joint Theatre Trauma Registry. Patient demographics, mechanism and pattern of injury and clinical outcomes were recorded. Surgical procedures at first and subsequent laparotomy were evaluated by an expert panel. RESULTS: 22 patients with intestinal injury underwent laparotomy and survived to be repatriated; all patients subsequently survived to hospital discharge. Mechanism of injury was GSW in seven and blast in 13. At primary laparotomy, as defined by the operating surgeon, 15/22 underwent DL and 7/22 underwent DCS. Mean Injury Severity Score (ISS) was 19 for DL patients compared to 29 for DCS patients (p = 0.021). Of the 15 patients undergoing DL nine had primary repair (suture or resection/ anastomosis), one of which subsequently leaked. Unplanned re-look was required in 4/15 of the DL cases. CONCLUSION: This review examines the activity of British military surgeons over a time period where damage control laparotomy has been introduced into regular practice. It is performed at a ratio of approximately 1:2 to DL and appears to be reserved, in accordance with military surgical doctrine, for the more severely injured patients. There is a high rate of unplanned relook procedures for DL suggesting DCS may still be underused by military surgeons. Optimal methods of selection and implementation of DCS after battle injury to the abdomen remain unclear.

Difficult caesarean section: A literature review.

BACKGROUND: Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications. METHODS: We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English. FINDINGS: The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation. CONCLUSIONS: Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies.

Fatores de risco para lesões periestomais em estomas de eliminação: um protocolo de revisão sistemática e metassíntese / Risk factors for peristomal skin complications in elimination stomas: a systematic review and meta-synthesis protocol

OBJETIVO: Analisar os fatores de risco para complicações de lesão periestomal em estomas de eliminação. MÉTODO: Uma revisão sistemática e um protocolo de meta-síntese serão conduzidos de acordo com o checklist Principais Itens para Relatar Revisões Sistemáticas e Metanálises (PRISMA) e as diretrizes e recomendações metodológicas do Joanna Briggs Institute (JBI). Dois pesquisadores independentes realizarão buscas nas seguintes bases de dados: Web of Science, Scopus, Embase, PubMed via CAPES e LILACS. Os estudos elegíveis incluirão estudos observacionais, estudos experimentais e estudos quase-experimentais publicados em inglês, espanhol e português, com foco em fatores de risco para complicações da pele periestomal em estomas de eliminação. Será utilizado o software Rayyan Intelligent para auxiliar no processo de seleção dos estudos. O risco de viés será apresentado usando gráficos de barras ponderadas e gráficos de semáforos para exibir os resultados para cada domínio avaliado em cada estudo incluído. A metassíntese será realizada em software de análise qualitativa, empregando análise de similaridade textual.

OBJECTIVE: To analyze risk factors for peristomal skin complications in elimination stomas. METHOD: A systematic review and meta-synthesis protocol will be conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the methodological guidelines and recommendations of the Joanna Briggs Institute (JBI). Two independent researchers will search the following databases: Web of Science, Scopus, Embase, PubMed via CAPES, and LILACS. Eligible studies will include observational, experimental, and quasi-experimental studies published in English, Spanish, and Portuguese, focusing on risk factors for peristomal skin complications in elimination stomas. A software will be used to aid in the study selection process. The risk of bias will be presented using weighted bar graphs and traffic light plots to display the results for each assessed domain in each included study. The meta-synthesis will be conducted using qualitative analysis software, employing textual similarity analysis.

Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery.

Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.

Index Use of Smoflipid in a Tertiary Intestinal Rehabilitation and Transplantation Program.

Long-term parenteral nutrition (PN) may be complicated by PN-associated liver disease (PNALD), and some studies suggest an association between the use of soy-based fat emulsions and PNALD development. Patients' liver function typically improves and PNALD resolves after reducing or stopping a soy-based fat emulsion, and thus lipid minimization has been the primary strategy for managing PNALD in many intestinal rehabilitation programs. However, fat emulsions often cannot be stopped entirely, leading some patients to develop PNALD even after lipid reduction strategies have been implemented. Smoflipid emulsion (Kabi-Fresenius, Bad Homburg, Germany), a balanced mixture of soybean oil, medium-chain triglycerides (MCTs), olive oil, and fish oil, was recently approved by the Food and Drug Administration for use in the United States as an equivalent alternative to Intralipid (Baxter Healthcare Corporation, Deerfield, IL). In several pediatric studies, patients who received Smoflipid had significantly lower serum bilirubin levels than those who received Intralipid. In this case report, we present a patient who developed severe PNALD with subsequent resolution after 20 weeks on Smoflipid.

Bowel complications in endometriosis surgery.

Endometriosis surgery by laparoscopy or laparotomy can be associated with various types of intestinal complications that may occur in the immediate postoperative period or later. They include bowel anastomotic dehiscence, rectovaginal fistula, anastomotic bleeding, intra-abdominal infections, wound infections, bowel stricture, intestinal obstruction, chronic constipation, and diarrhea. There is growing evidence that bowel injuries can be repaired by primary closure in two layers even without previous bowel preparation. Surgical treatments of deep bowel endometriosis include conservative surgery (including shaving technique or discoid resection) or a more radical approach such as bowel resection that is associated with increased complications. Good perfusion and no tension at the anastomosis site are essential when segmental resection is performed. Early recognition of bowel complications during surgery or in the immediate postoperative period is fundamental to decreased morbidity and mortality. This chapter will deal with the prevention of bowel complication in minimally invasive surgery for endometriosis.

Injuries produced by shattering annealed glass.

Attention is drawn to the significant number of accidents related to plate (annealed) glass, and the relative paucity of information available on the subject. Four cases of life-threatening injuries secondary to accidents involving annealed glass are described and illustrated. It is suggested that the use of one of the types of safety glass already available should be made mandatory universally, but particularly in those locations defined as 'risk areas' by the British Standards Code of Practice (CP 152) on glazing in the construction industry.

A novel approach to the treatment of gunshot injuries to the sacrum.

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5-9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.

Changing patterns in civilian arterial injuries.

A critical review of 185 patients with 211 arterial injuries over an eleven year period was performed to recognize the changing patterns in clinical findings, management and results. A ten fold increase in multiple arterial injuries as well as higher incidence of associated venous and visceral injuries occurred during the last five years. Despite this, the incidence of hypotension on arrival at hospital was reduced by half due to rapid transportation and resuscitation during transit. Shock in patients with only extremity injuries heralded dual injuries (arterial and venous). Lateral repair of both arterial and venous injuries has given way to end to end anastomoses, vein grafts and patch grafts. A greater tendency to repair all major arteries, most minor arteries, more liberal use of heparin, fasciotomy, intraluminal shunts, repair of venous injuries and extra-anatomic bypass has been noted. Rapid patient retrieval, early resuscitation, improved recognition and management of arterial injuries has not lead to better limb salvage or survival. The apparent lack of benefit in limb salvage is probably due to the higher incidence of multiple arterial injuries and associated venous injuries as well as the willingness to attempt repair all major arterial injuries and reluctance to advise primary amputation. Early patient retrieval, rapid transportation and resuscitation during transit has increased the number of potentially unsalvageable patients (who would otherwise be declared dead on arrival) resulting in an unchanging mortality.

Laparoscopically assisted vaginal hysterectomy as definitive therapy for stage III and IV endometriosis.

Operative laparoscopy combined with vaginal hysterectomy and salpingo-oophorectomy was used to treat advanced endometriosis in 40 of 46 patients. This treatment plan was abandoned in favor of laparotomy in six patients. Of the 40 patients successfully treated by laparoscopically assisted vaginal hysterectomy, 39 are completely free of symptoms. Major complications, including blood loss requiring transfusion and injury to the ureter or bowel, were sustained at acceptable rates. No serious infections occurred. The mean operating time was 191 minutes. Laparoscopically assisted vaginal hysterectomy and removal of all ovarian tissue combined with excision of all endometriosis may be used as definitive therapy for advanced endometriosis. The major complications associated with surgical therapy for high-stage endometriosis are encountered; therefore, laparoscopic treatment requires advanced laparoscopic surgical skills.

Double laparoscopy: an alternative two-stage procedure to minimize bowel and blood vessel surgery.

We present double laparoscopy as an alternative technique especially useful with the scarred abdomen postlaparotomy or when open laparoscopy has failed. This is a two-stage abdominal endoscopic procedure. Stage 1. This is the establishment of a pneumoperitoneum with insertion of a Verres needle through the left upper quadrant of the abdominal wall lateral to the rectus muscle, two fingers beneath the inferior costal margin. A sharp 5 mm trocar and sleeve is inserted through a small skin incision at the needle puncture site, and a small endoscope is then inserted. The hysteroscope or a 5 mm OD diagnostic laparoscope is an excellent instrument for upper abdominal laparoscopy in the adult and for general laparoscopy in infants and children. The abdominal cavity is surveyed, especially viewing the periumbilical area. Stage 2. When an adhesion-free and bowel-free area is identified, a standard 10 mm sharp trocar and sleeve is inserted under direct vision, and a standard laparoscope is introduced. We present a small sampling (24 cases) of our combined experience of 5000 laparoscopies, where this technique proved useful. Although we have used this technique over the years without any complications, the procedure has never been published.

Protective effects of ulinastatin on intestinal injury during the perioperative period of acute superior mesenteric artery ischemia.

OBJECTIVE: This work aims to explore the protective effects of ulinastatin on intestinal injury during the perioperative period of acute superior mesenteric artery ischemia (ASMAI). PATIENTS AND METHODS: 28 patients undergoing revascularization were divided into 2 groups, with 14 cases each. The cases in the observation group (OG) were treated with ulinastatin 300,000 U intravenously 30 min before the operation, and continuously treated with 300,000 U every 4 hr thereafter until 24 hr of the operation, while those in the control group (CG) were not given the intervention of ulinastatin. Patients' circular intestinal fatty acid binding protein (I-FABP) levels were measured at the following time points to reflect the intestinal injury: 30 min before the operation, before revascularization, then 1, 12 and 24 hr after the operation. The white blood cell counting (WBC), serum alanine aminotransferase (ALT), serum creatinine (Cr), D-dimer, and serum endotoxin (ET) were also measured simultaneously for the analysis of the significance of their values with the intestinal injury. RESULTS: There were no significant differences (p > 0.05) in ischemia duration, length of the affected intestinal segments, WBC, ALT and Cr levels at the above time points between the 2 groups, and all the indicators of the 2 groups, including the mean circular I-FABP levels before the operation and the revascularization, showed no significant difference (p > 0.05). After the blood supply was restored, the I-FABP levels in OG dropped significantly as compared with those in CG. The pattern of circular ET levels appeared the similar manner as the circular I-FABP levels did. CONCLUSIONS: Our study showed a protective effects of ulinastatin on intestinal injury during the perioperative period of ASMAI, as revealed by the circular I-FABP levels which mainly happened after the blood supply was restored.

Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care.

INTRODUCTION: Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. METHODS: The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. FINDINGS: A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.

Electrosurgical injuries during laparoscopy: prevention and management.

Despite the fact that electrophysics and its application to surgery, in particular endoscopic surgery, is a discreet science, there is little attention paid to the applied principles of the physics involved when surgeons receive their formal training in the technical aspects of surgery. Most training programs consider the discipline of electrosurgery as a skill that is left to the 'hands on' exposure of the student, and that the skills and knowledge of the average professor have been awarded through a 'grandfather' process of credentials. As a result, many myths have been perpetuated over the past decades since William Bovie introduced the first electrosurgical diathermy machine using high frequency radio waves instead of heated instruments (cautery) to destroy human tissue. Electrogenerators, today, have become finely tuned instruments that offer many versatile variables for the contemporary surgeon to harness and deliver, in either a discreet or broad manner, to tissue to obtain a desired effect and outcome.

Avoidance of complications of laparoscopic hysterectomy.

The laparoscopic approach to hysterectomy offers the patient very considerable advantages over the open surgical approach. Claims that operations can 'always be done vaginally' are false. Such claims are based on inappropriate patient selection. Comparisons between vaginal hysterectomy and the laparoscopic approach betray illogical thinking: they are two different operations for very different patients. For safe practice, the surgeon must be properly trained and experienced before attempting advanced laparoscopic surgery, including hysterectomy, and patients must be carefully selected for their suitability to undergo such operations. There are a number of specific precautions and manoeuvres detailed here which may greatly enhance the safety of laparoscopic hysterectomy and reduce complications to an absolute minimum in the hands of the trained laparoscopic surgeon.