Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures.

BACKGROUND: The use of the Veress needle in laparoscopy to create the pneumoperitoneum has inherent risks; it may cause vascular and visceral injuries. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming. One alternative is to enter the abdomen using an optical trocar under direct view. Our aim was to determine whether the optical access trocar can be used to effect a safe and rapid entry in various laparoscopic procedures. METHODS: Over a 4-year period, the Optiview trocar was used for initial entry in 650 laparoscopic procedures. The procedures included cholecystectomy (n = 282), transabdominal inguinal hernia repair (n = 76), radiofrequency ablation of liver tumors (n = 73), adrenalectomy (n = 54), appendectomy (n = 41), colorectal surgery (n = 39), and various other procedures (n = 85). The following parameters were analyzed: presence of previous abdominal operations, site and duration of entry, and complications. RESULTS: Of the 650 patients, 156 (24%) had had previous abdominal operations. In 25 cases, previous trocar sites were reused for optical access. The optical trocar was inserted at the umbilicus in 495 patients (76%), in the right upper quadrant in 77 (12%), in the left upper quadrant in 26 (4%), in the upper midline in eight (1%), in the right lower quadrant in six (0.9%), and in the left lower quadrant in three (0.5%). In 35 patients undergoing posterior adrenalectomy, optical trocars were used to enter Gerota's space. Mean (SD) entry times were 92 (45) sec at the umbilical site, 114 (30) sec at the back, and 77 (35) sec at the remaining sites. Complications (0.3%) included one injury to the bowel and one injury to the gallbladder; however, they were recognized and repaired immediately. CONCLUSIONS: To our knowledge, this report comprises the largest series in which the optical access trocar was used for laparoscopic surgery. This device provides the basis for a safe and fast technique for initial trocar placement: it also has the potential to reduce costs. Thanks to our favorable experience, the optical trocar method has become the standard technique for abdominal access in our laparoscopic practice since 1995.

Isolated intra-abdominal esophageal cyst. Case report and review of the literature.

We describe the first case of an isolated intra-abdominal esophageal cyst. The cyst was unilocular, smooth-surfaced, and attached to the superior border of the pancreas, and it contained clear mucoid material. The gross and in situ features most closely resemble four previously reported cases of isolated intra-abdominal bronchogenic cyst. Histologically, the cyst contained a simple and pseudostratified, ciliated, mucus-secreting, columnar epithelium and a wall composed of two distinct layers of smooth muscle. Both bronchogenic cysts and esophageal cysts may have ciliated epithelium; however, the presence of two smooth-muscle layers, along with the absence of cartilage or respiratory glands, allows for a definitive diagnosis of esophageal cyst.

Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination.

The resuscitation of patients with cardiopulmonary arrest from a penetrating injury of the heart requires emergency thoracotomy and control of hemorrhage. Suture control may be technically difficult in patients with large or multiple lacerations. Emergency cardiac suturing techniques expose the surgeon to the risk of a contaminated needle stick. After we determined that rapid control of hemorrhage from cardiac lacerations could be achieved in anesthetized sheep with the use of a standard skin stapler, the technique was applied in the clinical setting. Twenty-eight patients underwent emergency stapling of 33 cardiac lacerations at our institution from September 1987 to December 1991. Seventy-nine percent (22) of the patients sustained stab wounds, and 21% (6) were injured by gunshots. Fifty-eight percent (19) of the injuries involved the right ventricle, 27% (9) involved the left ventricle, 9% (3) involved the right atrium, and 6% (2) involved the left atrium. In 93% (26) of the patients, control of hemorrhage was achieved within 2 minutes of exposure of the injuries. Both patients in whom control could not be achieved had sustained large-caliber gunshot injuries. Fifteen (54%) of the patients survived, including one patient with two cardiac lacerations and another with three lacerations. Of the surviving patients, two had mild neurologic deficits. No personal contamination occurred related to the use of the stapler. We conclude (1) cardiac stapling is highly effective in the management of hemorrhage from penetrating injury, particularly in the setting of multiple cardiac lacerations; (2) the technique may not be effective with certain types of gunshot wounds; and (3) the use of the stapler for emergency cardiorrhaphy eliminates the risk of personal contamination from a needle stick.

General surgery in the patient with AIDS.

In 1993, it is estimated that 2 million Americans are infected with the human Immunodeficiency Virus (HIV). The Acquired Immune Deficiency Syndrome (AIDS) represents the most severe manifestation of infection with the virus. In the patient with AIDS, helper T lymphocytes are depleted resulting in a defect in cell mediated immunity. The resulting state of profound immunosuppression leads to susceptibility to rare infections and tumors. Although opportunistic infections have been seen in patients on immunosuppressive therapy, those associated with AIDS are much more severe and extensive. Many patients present with symptoms that mimic acute surgical emergencies. In other cases, the presentation has been one of a more chronic disease state. Some of the diseases associated with AIDS are directly attributable to the effects of the HIV virus. In all of these categories, there are some patients who will benefit from surgical therapy. In many cases medical therapy will be more appropriate. The evaluation of these patients can represent a major diagnostic challenge to the surgeon. A familiarity with these disease processes is essential for timely diagnosis and appropriate treatment.

Appendicitis in acquired immunodeficiency syndrome.

Reports in the surgical literature are few regarding common intra-abdominal disease processes, such as gallstone disease or appendicitis, in patients with AIDS and instead have focused on AIDS-related intra-abdominal diseases that infrequently require surgical intervention unless complicated by bleeding, obstruction, or perforation. A literature review for appendicitis in AIDS patients revealed only 30 well-documented cases drawn from 13 studies, with a 40% perforation rate and frequent delays and errors in diagnosis. A 7-year experience with 28 patients with appendicitis and AIDS from 4 urban San Francisco hospitals is reviewed. There were no perioperative deaths and an 18% postoperative complication rate. Five patients (18%) were found to have normal appendices with other intra-abdominal pathology, and an AIDS-related etiology for appendicitis was discovered in 7 of 23 patients with appendicitis (30%). With the exception of diffuse versus localized abdominal pain, no preoperative symptom or sign was useful in differentiating AIDS-related and non-AIDS-related disease. Aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended.

Surgical care of HIV-infected patients.

An increasing number of HIV-infected patients will require surgical therapy. The methods of diagnosis and therapeutic planning for HIV-infected patients are the same as for all other patients. Surgery should be advised if an operation is likely to have a positive effect on the patient's life. Most patients with AIDS with diseases for which surgical therapy is advantageous benefit from carefully chosen operations designed to solve specific problems.

Emergency thoracotomy: survival correlates with physiologic status.

Emergency thoracotomy is a standard procedure in the management of cardiac arrest in patients sustaining severe trauma. We examined the records of 463 moribund trauma patients treated at our institution from 1980 to 1990 to refine indications for emergency thoracotomy. Patients underwent thoracotomy either in the emergency department (ED) (n = 424) or in the operating room (OR) (n = 39) as a component of continuing resuscitation after hospital arrival. The survival rate was 13% (61 of 463) overall, 2% (3 of 193) for blunt, 22% (58 of 269) for all penetrating, 8% (10 of 131) for gunshot, 34% (48 of 141) for stab-wound patients, and 54% (21 of 39) for patients who underwent emergency thoracotomy in the OR. Survival correlated with the physiologic status of patients both on initial evaluation in the field by paramedics and on arrival at the ED. Patients with penetrating trauma and in profound shock (BP less than 60 mm Hg) or mild shock (BP 60-90 mm Hg) with subsequent cardiac arrest had survival rates of 64% (27 of 42) and 56% (30 of 54), respectively. None of the patients with absent signs of life, defined as full cardiopulmonary arrest with absent reflexes (n = 215), on initial assessment by paramedics in the field, survived. We conclude that (1) no emergency thoracotomy should be performed if no signs of life are present on the initial prehospital field assessment; (2) emergency thoracotomy is an indicated procedure in most patients sustaining penetrating trauma; (3) blunt traumatic cardiac arrest is a relative contraindication to emergency thoracotomy.

Wound healing after anorectal surgery in human immunodeficiency virus-infected patients.

Medical records of 52 human immunodeficiency virus (HIV)-infected patients who underwent a total of 80 anorectal operations from January 1985 to January 1990 were retrospectively reviewed to determined whether anorectal surgical wounds healed in HIV-infected patients and the mean survival time of these patients after surgery. Twenty-four operations were performed in asymptomatic HIV-infected patients, 19 in HIV-infected patients with persistent lymphadenopathy, and 37 in patients with acquired immunodeficiency syndrome. Wounds healed in 49 patients (94%). The mortality rate 30 days after surgery was 2%. There were no major complications. The mean survival time of HIV-infected patients after surgery was 15 months. We conclude that anorectal surgical wounds heal in most HIV-infected patients and that the survival time after surgery of HIV-infected patients with anorectal disease justifies appropriate surgical treatment.

Rational approach to the management of multiple systems organ failure.

MSOF is a complicated disorder that can involve every organ system in the body. Whatever causes or perpetuates the syndrome, its management involves the prevention and treatment of infection, the maintenance of tissue oxygenation, nutritional and metabolic support, and the support of individual organ systems. Unfortunately, this therapy often is nonspecific and of little proven efficacy. It also is potentially harmful in that measures used to benefit some organ systems may be detrimental to others. Further research is needed both to understand MSOF and to improve its management.

Gastrointestinal surgery in the AIDS patient.

The acquired immunodeficiency syndrome is associated with opportunistic infections and unusual malignancies that may affect the gastrointestinal tract. The number of patients affected by this condition is large and will continue to increase. The manifestations of the disease may mimic acute surgical conditions. In addition, standard surgical problems may occur in the AIDS patient. Diagnosis may be confounded by pre-existing symptoms and atypical presentations. An awareness and understanding of the disease processes distinctive to AIDS patients is essential for surgeons so that they may provide appropriate care to their patients and, at the same time, protect themselves and their fellow health care team members.

Management of sepsis following injury.

Sepsis is a significant cause of late morbidity and mortality in the severely injured patient. In addition to the risk factors of shock, multiple transfusions, and contamination, the trauma patient may have the additional factor of severe immunologic depression. The prevention of sepsis should be an early consideration. Invasive diagnostic and therapeutic maneuvers should be limited to those that are absolutely necessary, since the incidence of nosocomial infection is high. Prophylactic antibiotics should not be misused, as these may increase the risk of serious, resistant infections. Frequent examination of sputum smears may allow the early diagnosis of pneumonia. Nutritional supplementation can improve host defenses, and should be instituted early. The patient in septic shock should be resuscitated and stabilized in the intensive care unit. Monitoring should include determination of cardiac index and systemic oxygen consumption. Computed tomography has emerged as the primary modality for the diagnosis of intra-abdominal sepsis. When combined with percutaneous drainage of abscesses, it represents a rapid and safe approach to the diagnosis and treatment of the critically ill septic patient. In certain cases, such as bowel perforation or necrosis, anastomotic breakdown, or acalculous cholecystitis, laparotomy is the procedure of choice. Opportunistic infections may become significant in patients who have required a prolonged course of treatment. In the patient with multiple organ-system failure who is not responding to therapy and in whom no clear source of sepsis has been identified, exploratory laparotomy should be considered. Antibiotics should be used with caution and should not started in every patient with a fever. Their use should be directed by appropriate cultures and sensitivities.(ABSTRACT TRUNCATED AT 250 WORDS)