Lifting of the umbilicus for the installation of pneumoperitoneum with the Veress needle increases the distance to the retroperitoneal and intraperitoneal structures.

BACKGROUND: In laparoscopy, 50% of all complications occur during establishment of the pneumoperitoneum. Elevation of the fascia is recommended for the Veress needle approach, although the benefit has not been proved to date. This study aimed to evaluate the intraabdominal changes during lifting of the fascia with regard to the distance from the fascia to the retroperitoneal vessels and the intestine for access in laparoscopy. METHODS: For 10 patients scheduled to undergo laparoscopic cholecystectomy, the operation started with the computed tomography (CT) scan. After orotracheal intubation, a CT scan of the umbilical region was performed. After a supraumbilical incision, the fascia was freed and elevated with stay sutures. During maximal elevation, a second CT scan was performed. Distances to the intestinal (small bowel) and retroperitoneal structures (iliac artery, vena cava) were measured. Intraabdominal pressure was measured with a transcystic balloon manometer before (a) and after (b) elevation of the fascia, after insertion of the Veress needle (c), and after completion of the insufflations (d). RESULTS: Lifting of the fascia increased the distance between the fascia and the intestinal structures in the patients with no prior abdominal surgery (mean distance, 1.92 cm; range, 0.87-2.67 cm) and the distance between the fascia and the retroperitoneal vessels (mean distance, 7.83 cm; range, 3-11 cm). The median intraabdominal pressures in terms of cm H(2)O were 5.4 for a, 1.1 for b, 1.1 for c, and 12. 5 for d. CONCLUSION: Elevation of the fascia before the first entrance to the abdominal cavity for laparoscopy may increase safety due to a significant enlargement of distance between the fascia and the retroperitoneal structures.

Long-term follow-up in patients with lost coronary stents during interventional procedures.

The aim of this retrospective study was to determine the incidence of stent loss during interventional procedures and to identify the associated immediate and long-term consequences of such loss. We evaluated 36 cases in which the stents were prematurely displaced from the stent delivery device. Five stents were completely removed from the vascular system successfully. Five stents could not be retrieved from the coronary circulation and led to significant adverse events in 3 patients, in whom the lost stents were not excluded by the placement of another stent. In 26 patients, peripheral embolism below the renal arteries occurred after successful stent retrieval from the coronary arteries. Of these 26 patients, 1 patient died during hospital stay, unrelated to the peripheral stent loss. Additional follow-up examinations were performed for 20 of the remaining 25 patients. Clinical patient status and the ankle-brachial index were evaluated 59 +/- 30 months after stent loss. All patients were free of any stent-related peripheral ischemic symptoms. We also attempted to determine the exact physical locations of the lost stents using computed tomography during follow-up. In 15 patients, we were able to detect the stent in the peripheral arteries using computed tomography. In conclusion, if stents cannot be retrieved from the coronary system, severe problems may occur. Stent loss with peripheral embolization is asymptomatic in long-term follow-up.