Chief resident experience with laparoscopic cholecystectomy.

Resident competence in both open and laparoscopic cholecystectomy (LC) has been a concern among general surgeons. Laparoscopic surgery was late in coming at many surgical residency programs in the United States, and many residents have graduated with limited experience in LC. We are chief residents who were fortunate enough to start our training when LC was first introduced at our institution in 1990. This report summarizes our experience with LC in our chief year, during which we performed LC on 147 patients. The average operating time was 37 minutes (range, 12-82 minutes). Six patients (4%) required conversion to an open procedure. There were three complications (2 postoperative cystic duct leaks and 1 intraoperative common bile duct injury) for an overall complication rate of 2%. There was no mortality. It is our conclusion that graduating chief residents with 5 years' exposure to LC may perform the procedure with a complication rate comparable to that reported in the current literature. Insuring that graduating chief residents have adequate training in open cholecystectomy may become a more pressing issue in the near future.

Hernia repair during endoscopic extraperitoneal lymph node dissection.

The objective of this study was to determine whether extraperitoneal lymph node dissection for the staging of prostate cancer and extraperitoneal herniorrhaphy could be performed concomitantly with acceptable operative time and morbidity. Sixty patients underwent endoscopic extraperitoneal lymph node dissection (EEPLND) between 1991 and 1996. Eleven of these had 14 hernias repaired with polypropylene mesh. Endoscopic hernia repair added an average of 15 to 20 minutes to the EEPLND, resulting in an average operative time of 127 minutes (range 90 to 182 minutes). There was no difference in postoperative pain between patients undergoing combined operations and those undergoing EEPLND alone. The mean hospital stay after either procedure was 48 hours. There were no complications in the group undergoing herniorrhaphy. We conclude that extraperitoneal endoscopic hernia repair can be safely performed with EEPLND when necessary.

Effect of inorganic ions on the solar detoxification of water polluted with pesticides.

The effect of eleven inorganic ions (Cl(-), NO(3)(-), SO(4)(2-); PO(4)(3-), Na(+); NH(4)(+), Ca(2+), Mg(2+), Zn(2+), Cu(2+) and Al(3+)) on the photo-Fenton elimination of pesticides has been investigated. Phosphate and chloride have been demonstrated to have an inhibitory role; on the other hand, the reaction was accelerated in the presence of Cu(2+), most probably due to a copper-driven Fenton-like process. The solar photo-Fenton treatment of a mixture of four commercial pesticides was studied at pilot plant scale in the presence of chlorides. Samples with coincident dissolved organic carbon (DOC) showed similar chemical composition, which resulted in a comparable biocompatibility, however longer irradiation periods were needed to reach the desired mineralization when Cl(-) was present. It was demonstrated that the chemical process was able to improve significantly the biocompatibility of the effluent, as shown by the inhibition of respiration of activated sludge, BOD/COD ratio and Zahn-Wellens test.

Major vascular injuries during laparoscopic cholecystectomy. An institutional review of experience with 2589 procedures and literature review.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. METHODS: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. RESULTS: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. CONCLUSIONS: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.

Laparoscopic transabdominal lumboperitoneal shunt.

Communicating hydrocephalus can be handled either by the ventriculoperitoneal or, occasionally, the ventriculoatrial shunt. The lumboperitoneal shunt is another option. It does not require a transcranial approach; therefore, it is safer for the patient. We describe a technique that can be performed easily by a skilled laparoscopic surgeon through an anterior approach transabdominally. The lumboperitoneal (LP) shunt is placed laparoscopically under direct videoscopic vision, with the catheter inserted transabdominally through the L3 disc space into the thecal sac. In our patient, the lumboperitoneal shunt was placed at the L3 disc space for communicating hydrocephalus. There were no intraoperative or postoperative complications. The LP shunt can be easily placed by a skilled laparoscopic surgeon. The incidence of infection and complications is lower, and the patency rate is higher. This should be the initial choice for communicating hydrocephalus.

Laparoscopic splenectomy in a Jehovah's Witness with profound anemia.

Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion.

Pneumothorax as a complication of laparoscopic inguinal hernia repair.

Pneumothorax was identified as a complication of endoscopic hernia repair in two patients with insufflation pressures of 15 mmHg and operating times exceeding 2 h. These patients also showed intraoperative perturbations in both oxygen saturation and end-tidal CO2 production. A prospective study was undertaken to determine whether similar complications would arise if preperitoneal insufflation pressures were limited to 10 mmHg. Postoperative chest x-rays were obtained on all patients to check for pneumothoraces, even clinically occult ones. Fifty patients were studied, with average operating times of 67 min. No patient demonstrated any hemodynamic or ventilatory changes, and none had any evidence of pneumothorax on x-ray. We conclude that these complications were not present when insufflation pressure was maintained at 10 mmHg and that routine x-ray is not warranted. Larger randomized trials of insufflation pressures are needed.