Sclerotic thickening of the peritoneal membrane in maintenance peritoneal dialysis patients.

Five patients receiving maintenance peritoneal dialysis (duration, three months to four years) required surgical exploration of the abdomen for various reasons. Four had a prior history of bacterial peritonitis, and four of aseptic peritonitis. At laparotomy, the peritoneal membrane was found to be markedly thickened and sclerotic in all patients, and loops of bowel were bound together in a dense, opaque casing. On microscopic examination, an increase in fibroconnective tissue in the peritoneum was observed.

Total and active T cell dynamics in renal allograft recipients.

Serial determinations of human thymus-dependent (T) and bone marrow-dependent (B) peripheral blood lymphocytes were performed to detect changes in activity of these rosette-forming cells in five groups of patients: controls; chronic renal failure (CRF) patients; dialysis patients receiving pretransplant splenectomy; 5 days before transplant immunosuppression; and following 17 patient renal allograft implantations. Five cadaver recipients received ATG for 14 days. Patient follow-up was 27 to 215 days (M = 101) during which time four cadaver grafts were lost to rejection. Twenty clinical acute rejection (AR) episodes occurred. CRF patients had suppressed total T cells when compared to control patients (63.2 to 44.7 percent, P less than 0.01) without change in active T cells. Similarly, total T cells decreased in CRF patients following splenectomy (56.7 to 35.5 percent, P greater than 0.01), during prednisone-azathioprine immunosuppression (65.6 to 46.7 percent, P greater than 0.01), with no change in active T cells. Both active and total T cells declined profoundly during ATG administration, following allograft implantation, and during AR. Active and total T cells increased when ATG was discontinued, when AR subsided, and following transplant nephrectomy. B cell populations were suppressed in only the ATG group. These studies delineate that total T cells are influenced by many interventions and active T cells specifically reflect cellular-immune kinetics in renal allograft recipients.

Laparoscopic herniorrhaphy: results and technical aspects in 450 consecutive procedures.

BACKGROUND: The effectiveness of laparoscopic herniorrhaphy, the patient outcome, and technical aspects have been controversial. We have performed 450 consecutive laparoscopic inguinal herniorrhaphies and have reviewed the rationale, technical aspects, and the outcomes. METHODS: Four hundred and fifty consecutive laparoscopic herniorrhaphies were performed using synthetic mesh for tensionless repair and adhering to surgical principles of preperitoneal herniorrhaphy. Patients were 16 to 83 years of age, 74% men, 26% women. Mesh was transfixed to anatomic landmarks with suture or staples. The peritoneum was closed, separating mesh from abdominal contents. RESULTS: Ninety percent of patients were discharged from perioperative care; 10% were in the hospital 23 hours as a result of urinary retention, cardiac disease, etc. No adhesive or mesh complications occurred. Three hernias recurred at 2 to 4 months after operation. Two were repaired laparoscopically. CONCLUSIONS: Laparoscopic inguinal herniorrhaphy is a safe and effective procedure. It compares favorably with other classic methods of hernia repair (especially use of a tensionless repair with mesh). Patients exhibit minimum morbidity and ambulate soon with minimal discomfort. This repair should be considered preferential in many subsets of patients.

The fate of unruptured intrahepatic hematomas.

In 4 year's experience, we admitted 283 patients suffering from severe blunt torso trauma. Sixty-five had serious hepatic injury. Of these, 49 (75.4%) had explosive hemorrhagic hepatic injuries and underwent surgery immediately. The remaining 16 (24.6%) had intrahepatic hematomas (IHHs); three were receiving anticoagulants. Fourteen IHHs were diagnosed by liver-spleen scan within 1 to 3 days after injury, one was diagnosed at autopsy and one during surgery. Nine (56.3%) were successfully treated nonoperatively. Six (37.5%) were initially treated nonoperatively, but required emergency surgery later because of life-threatening complications. The onset of complications occurred from 1 to 28 days after injury. Indications for delayed operative intervention were hepatic abscess with sepsis (four patients) and expanding hematoma and blood loss (two patients). We conclude from this experience that: (1) Patients admitted with blunt torso trauma should undergo liver-spleen scan examinations; (2) IHHs should be treated initially nonoperatively; (3) the observation period for nonoperative management should be at least 28 days; (4) serious sequela of IHHS occur approximately 1 to 28 days after injury; (5) the combination of anticoagulation and IHH is highly lethal and must be treated aggressively; and (6) patient with progressive findings--worsening sepsis, increasing peritoneal findings, evidence of progressive blood loss, or expansion of IHHs--should be treated by urgent surgical intervention.

Prognostic significance of the active thymus derived rosette forming cells in renal allograft survival: a preliminary report.

The prognostic significance of hemodialysis, blood transfusions, total T (T-T) and active T (A-T) lymphocytes, as they relate to renal allograft survival, were evaluated in 36 renal transplant recipients. The A-T cell is thought to be a surveillance cell responsible for cellular immunity and the only prognostic factor for graft survival observed in this study. An 83% graft survival rate occurred in patients having a lower percentage of A-Ts (fewer surveillance cells) prior to renal transplantation, as compared to 50% graft survival in patients with a higher percentage of A-T cells. Evaluation of pretransplant T-T cells, phytohemagglutinin (PHA) response, and number of transfusions was not prognostic for graft survival. Similarly, there was no difference in graft survival rates in patients hemodialyzed for more vs less than 1 year. Patients hemodialyzed for more than a year received twice as many blood transfusions. There were no differences in the number of T-T or A-T lymphocytes in either group. However, lymphocytes from patients hemodialyzed less than a year were more responsive to PHA stimulation. These data suggest that pretransplant determination of A-T cell values may be prognostic for graft survival and may delineate patients, by an immunological parameter, who may be at high risk for allograft rejection.

Vascular access: long-term results, new techniques.

Effective approaches to unique problems of vascular access in renal failure have evolved from a five-year experience with 840 angioaccess procedures. Standard techniques plus innovations have required only 0.62 operations per year per patient with an average access life of 1.6 years. Classical forearm external arteriovenous (AV) cannulas and internal AV fistulas provided vascular access in 392 patients, while 61 required more complex procedures due to failure of primary cannulas and fistulas, inherently small forearm vessels, and iatrogenic vessel loss. Secondary techniques include reverse fistula, vascular graft AV fistulas using expanded polytetrafluoroethylene (E-PTFE), and arterioarterial (AA) jump graft. Presently, the new renal failure patient receives a forearm radiocephalic AV fistula; the cannula is restricted to emergency or short-term hemodialysis and may later be converted to a subcutaneous fistula. The reverse fistula is attempted before using E-PTFE grafts. Upper extremity AV and AA loops can then be constructed de novo or from the reverse fistula.

Sequential psychomotor skills development in laparoscopic colon surgery.

OBJECTIVES: To quantify the complexity of each of three skills used in laparoscopic colon surgery and to quantify the relative complexity of seven laparoscopic colon procedures on a graduated complexity scale. DESIGN: Five surgeons used a scale of 1 through 6 to measure the relative complexity of three laparoscopic skills (intracorporeal mobilization, intracorporeal devascularization, and intracorporeal anastomosis) to assess the relative difficulty of seven laparoscopic procedures (right colon resection, sigmoid colon resection, low anterior resection, Hartmann's procedure, left colon resection, abdominoperineal resection, and transverse colon resection) using detailed evaluation of their first 100 laparoscopic colon resections. SETTING: Three private community hospitals. MAIN OUTCOME MEASURES: The complexities of intracorporeal mobilization, intracorporeal devascularization, and intracoporeal anastomosis were recorded for seven laparoscopic colon procedures. RESULTS: The least complex procedure was right colon resection, followed in increasing complexity by sigmoid colon, Hartmann's procedure, low anterior resection, abdominoperineal resection, left colon resection, and transverse colon resection. The addition of each laparoscopic skill increased the complexity during each procedure. All three skills were not required for every procedure. CONCLUSIONS: Since all procedures do not require all three skills, skills can be learned sequentially if patients are chosen judiciously. A sequence of laparoscopic procedures performed by surgeons is recommended. The relative complexities for each procedure suggest an outline (map) for surgeons to use during laparoscopic colon surgery.

Surgery, nutritional support, and survival in patients with end-stage renal disease.

In 216 patients with end-stage renal disease (ESRD) undergoing 406 major operations, surgery was elective in 143 cases (mortality, 1.4%) and nonelective in 263 (mortality, 11.1%). Of 82 patients who received 105 pretransplant operations to prevent posttransplant complications, eg, gastrointestinal hemorrhage, urinary tract sepsis, and azathioprine intolerance, surgical mortality was 1.9%, with 80 patients becoming active candidates for transplantation. Sepsis requiring surgical care occurred in 54 patients, in 36 of these in the posttransplant period. Parenteral and enteral hyperalimentation was used as a therapeutic adjunct in 40 of these patients. Overall mortality in those with septic complications was 35.2%, 22.5% in the nutritional support group and 71.4% in the group not receiving hyperalimentation. Improved survival rates can be achieved for surgical emergencies in ESRD, particularly in the posttransplant immunosuppressed patient, if both definitive surgical intervention and nutritional support are actively applied.

Pseudolymphoma in renal allograft recipients.

Five renal transplant recipients exhibited giant systemic lymphadenopathy shortly after transplantation. Biopsy specimens did not show Hodgkin's lymphoma. Immunosuppression was continued in all patients. In contrast to the rapidly fatal course of malignant lymphoma in transplant recipients, adenopathy in these five patients has uniformly resolved. Patients have been observed for 6 to 15 months with no evidence of residual disease. Interval biopsy specimens are not malignant. Each patient received antithymocyte globulin from a single lot for 10 to 21 days after transplantation. During administration, T cell lymphocytes were suppressed to 5% of control values. When lymphadenopathy occurred, T cell values rebounded to 371% of control values. Toxoplasmosis titers as well as viral cultures of lymph node biopsy specimens were negative. These data indicate a benign course of this histologically malignant disease and suggest a lymphoblastic rebound phenomenon to antithymocyte globulin.

Technical considerations in elderly renal allograft recipients.

Atherosclerosis in renal allograft recipients necessitated modification of vascular anastomoses in 62 per cent of patients older than forty years in contrast with 10 per cent in younger patients. Three forms of vascular disease occurred: atherosclerotic occlusion, tortuosity of vessels, and disruption of plaques by vascular clamps. Successful modifications of the procedure and avoidance of ischemic graft injury are described including relocation of the transplanted ureter.

Hepatic complications.

Hepatic dysfunction is one of the most common complications following major surgical intervention, and it presents a wide spectrum of clinical manifestations as discussed. Recent progress in hepatology has provided better knowledge in etiology and pathophysiology of hepatic dysfunction and its sequelae. In addition, modern medical technology has made the diagnosis of liver disease easier and more precise. Underlying liver disease should be disclosed precisely prior to surgery and surgical complication minimized for patients with hepatic impairment. If hepatic complications occur following surgical intervention, the most logical etiology and pathophysiologic explanation should be found, utilizing all the clinical and laboratory data and diagnostic procedures in order to institute proper treatment. Specific complications in hepatic surgery are also discussed. A good understanding of pathophysiologic alterations following hepatic surgery is mandatory together with detailed anatomic knowledge and surgical skill in order to prevent and to treat serious complications.

Major thoracic surgery in octogenarians: the video-assisted thoracic surgery (VATS) approach.

BACKGROUND: Thoracic surgery is associated with a high morbidity and mortality rate in the elderly patient population. Appropriate management of thoracic diseases is often avoided because of the inherent risks associated with the access thoracotomy. The purpose of this study was to evaluate the perioperative outcomes of octogenarians who underwent video-assisted thoracic surgery (VATS) for a variety of thoracic conditions. METHODS: A retrospective chart review was done on all patients who were between 80 and 90 years of age and underwent elective VATS between January 1995 and August 2001. RESULTS: A total of 162 consecutive VATS procedures were performed in 157 patients. Comorbid conditions consistent with their advanced age included chronic obstructive pulmonary disease, hypertension, coronary artery disease, and diabetes. The procedures included 96 lung resections (53 lobectomies, 42 wedge/segment resections), 46 pleurectomies, 8 decortications, 8 mediastinal biopsies, 3 pericardial windows, and 1 drainage of hemothorax. The pathology included 76 primary lung cancers, 35 metastatic diseases, 37 benign conditions, 9 nesotheliomas, and 3 carcinoid tumors. The average operative time and length of hospital stay after surgery were 51 min and 2.6 days, respectively. There were 3 (1.9%) mortalities, 2 from cardiac complications and 1 from pneumonia. Two (1.2%) patients required reexploration for bleeding. Four (2.5%) cases were converted to open thoracotomy thirteen (8.0%) cases had an air leak, of which 11 were managed on an outpatient basis with a Heimlich valve. They were discharged from the hospital an average of 3.3 days postoperatively. CONCLUSION: With VATS, surgical therapy can be offered to octogenarians with a low morbidity and mortality rate, as well as a short hospital stay.

Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK.

STUDY DESIGN: Eighteen patients with lumbar instability from fractures, postlaminectomy syndrome, or infection were treated prospectively with minimally invasive retroperitoneal lumbar fusions. OBJECTIVES: To determine if interbody Bagby and Kuslich fusion cages and femoral allograft bone dowels can be inserted in a transverse direction via a lateral endoscopic retroperitoneal approach to achieve spinal stability. SUMMARY OF BACKGROUND DATA: Endoscopic spinal approaches have been used to achieve lower lumbar fusion when instrumentation is placed through a laparoscopic, transperitoneal route. However, complications of using this approach include postoperative intra-abdominal adhesions, retrograde ejaculation, great vessel injury, and implant migration. This study is the first clinical series investigating the use of the lateral retroperitoneal minimally invasive approach for lumbar fusions from L1 to L5. METHODS: Eighteen patients underwent anterior interbody decompression and/or stabilization via endoscopic retroperitoneal approaches. In most cases, three 12-mm portals were used. Two parallel transverse interbody cages restored the neuroforaminal height and the desired amount of lumbar lordosis was achieved by inserting a larger anterior cage, distraction plug, or bone dowel. RESULTS: The overall morbidity of the procedure was lower than that associated with traditional "open" retroperitoneal or laparotomy techniques, with a mean length of hospital stay of 2.9 days (range, outpatient procedure to 5 days). The mean estimated intraoperative blood loss was 205 cc (range, 25-1000 cc). There were no cases of implant migration, significant subsidence, or pseudoarthrosis at mean follow-up examination of 24.3 months (range, 12-40 months) after surgery. CONCLUSIONS: This preliminary study of 18 patients illustrates that endoscopic techniques can be applied effectively through a retroperitoneal approach with the patient in the lateral position. Unlike the patients who had undergone transperitoneal procedures described in previous reports, in these preliminary 18 patients, there were no cases of retrograde ejaculation, injury to the great vessels, or implant migration.

The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases.

STUDY DESIGN: A prospective multicenter study on 100 consecutive surgical procedures. OBJECTIVES: A prospective multicenter study was performed to evaluate the early perioperative complications in 100 endoscopic spinal procedures--78 video-assisted thoracic surgical procedures and 22 laparoscopic lumbar instrumentation and fusion procedures. SUMMARY OF BACKGROUND DATA: Endoscopic procedures have been widely applied in general surgery for appendectomy, cholecystectomy, liver resection, Nissen fundoplication, colon resection, and hernia repairs. Video-assisted thoracic surgery is widely used for pleural biopsy, lung resection, and sympathectomy. This is the first large series to date investigating the safety and potential complications using endoscopic surgery for anterior decompression or fusion of the thoracolumbar spine. METHODS: Video-assisted thoracic surgical procedures included multilevel anterior thoracic releases for deformity, 27 patients; anterior thoracic discectomies with spinal canal decompression, 41 patients; pyogenic vertebral osteomyelitis decompression, 2 patients; and vertebral corpectomy for neurologic decompression, 8 patients. Mean operative time was 2 hours, 34 minutes (range, 45 minutes to 6 hours), and mean length of stay was 4.97 days (range, 2-21 days). Anterior laparoscopic interbody stabilization and fusion at L4-5 or L5-S1 was performed in 22 patients. The mean operative time was 4 hours, 17 minutes (range, 2 hours, 40 minutes to 9 hours), and the mean length of stay was 5.6 days (range, 1-23 days). RESULTS: The most common video-assisted thoracic surgical complications were transient intercostal neuralgia (six patients) and atelectasis (five patients). The most common laparoscopic complication was bone graft donor site infection (two patients). There were two endoscopic cases that were converted to open procedures, one for extensive pleural adhesions and one for a common iliac vein laceration. CONCLUSIONS: The endoscopic spinal approaches proved to be safe operative procedures in 100 consecutive cases. There were no permanent iatrogenic neurologic injuries and no deep spinal infections.

Laparoscopic bilateral inguinal herniorrhaphies: use of a single giant preperitoneal mesh patch.

Recent reports support excellent results following laparoscopic inguinal herniorrhaphy. Similarly, nonlaparoscopic preperitoneal bilateral inguinal herniorrhaphy has been performed with a giant anterior abdominal mesh with excellent results. In order to maximize patient benefit, we have used the laparoscopic approach to repair bilateral inguinal hernias using a large single patch of mesh in the preperitoneal space for the past 12 months. Twenty-nine patients with an age range of 26 to 83 have undergone this procedure. Technical details included creation of preperitoneal flaps to cover the preperitoneal retropubic space and inguinal and femoral canals bilaterally; use of "keyhole" technique to surround cord structures with mesh (transfixing mesh to important anatomic landmarks); and closure of peritoneum. Ninety-four per cent of patients were discharged on the operative day with minimal pain. One-third required pain medication; patients returned to work five to nine days post-operatively. There have been no recurrences, no morbidity requiring hospitalization, and no complications related to mesh or the laparoscopic approach. This procedure combines the benefits of two successful approaches to bilateral inguinal herniorrhaphy, is associated with excellent short-term results, and should be considered as a potential "best option" in patients with bilateral inguinal hernias.

Minimally invasive surgical techniques to treat spine infections.

Minimally invasive techniques including closed laparoscopy and thoracoscopy as well as video-assisted procedures using limited open incisions provide an excellent alternative for treating vertebral osteomyelitis and tuberculous infections in the thoracic and lumbar spine. The traditional principles of surgical debridement and a stable interbody fusion are unchanged when applying endoscopic techniques. In the future, the spinal endoscopist will have available a larger selection of endoscopic instruments, more sophisticated video technology, and the development of anterior instrumentation systems to allow for rigid internal fixation. These advances, along with the surgeon's endoscopic experience and refined techniques, will further establish minimally invasive surgical techniques in the field of spinal surgery.

Laparoscopic pyloroplasty in idiopathic hypertrophic pyloric stenosis in an adult.

BACKGROUND AND OBJECTIVES: Idiopathic hypertrophic pyloric stenosis, in adults, is a rare disease. Partial gastrectomy, gastroenterostomy, pyloromyotomy, pyloroplasty and endoscopic dilatation have all been recommended with variable results. A 54-year-old white female is presented with the onset of symptoms of idiopathic hypertrophic pyloric stenosis one year prior to operation. Two endoscopic pyloric sphincter balloon dilatations provided only temporary relief. METHOD: A laparoscopic pyloroplasty was performed. RESULT: The patient tolerated a solid diet on postoperative day three. The patient was symptom-free at a 13 month follow-up. CONCLUSIONS: Idiopathic hypertrophic pyloric stenosis in adults can be treated with laparoscopic pyloroplasty, offering a minimally invasive alternative to open repair.

Visual clues in minimally invasive surgery: use of 2-D versus 6-D enhanced performance of complex minimally invasive complex skills.

UNLABELLED: In the recent past, we used two 2-D videoscopes to obtain both a close detailed view and simultaneously a panoramic view to improve the efficient and safe access for instruments into the microscopic working field by way of the benefits of the panoramic view. This bi-modal visual set of clues allows for (1) insertion of suture, (2) cutting of suture with scissors (3) retraction of tissue, and (4) removal of suture and needle. During these experiences, we observed the benefits accrued to the surgeon by allowing the focusing of his/her attention on the work (technical skills) without diffusing energy to other activities. Similarly, when training surgeons to perform micro-anastomoses, and while working to improve performance in micro-anastomoses, we hypothesize that two or more videoscopic views of the 3-dimensional working space would provided added visual information to the surgeon during the microscopic work. To examine this hypothesis, we have used a non-animate model, in the performance of complex skills in videoscopic surgery. METHODS: Inanimate videoscopic models for suturing and tying (24 studies) were used in this study. The technical skill studied was the sophisticated skill of suturing. The speed and accuracy of Free-Handed suturing and tying was determined in these studies. They were compared using a single 2-D system verses three videoscopic views reconstructing a 3-D effect. RESULTS: In each of these models, the delineation of multiple views allowed greater detailed 3-dimensional information for the surgeon. The sutures were placed faster, more accurately, and with fewer false motions. These data allow us to conclude the use of multiple high-resolution 2-D views will improve accuracy and efficiency in the performance of delicate and precise skills in videoscopic surgery.

Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgical procedures.

Resource allocation, including manpower and other expenses, have limited the evolution of minimally invasive surgical procedures to provide humanism and to improve surgical care for patients. Robotic enhancement has been proposed as a mechanism to improve the cost-benefit relationship for patients. To this end, we have used the robotic arm enhancement to minimize resource and personnel utilization during minimally invasive procedures. Phase I of our study has included the use of the robotic arm in 24 laparoscopic hernia repairs, cholecystectomies, and nissen fundoplications with the surgeon as a solo surgeon, i.e., the primary surgeon is the only participant in the operative sterile field. The scrub nurse did not participate in the procedures. During this study, there were no technical mishaps, no complications related to the solo surgeon-robotic arm concept, and the operative times were statistically similar to equivalent procedures utilizing multiple personnel. The hernia repair is least complex and most amenable to solo surgery due to the use of only three access ports; cholecystectomy occasionally requires four access ports increasing its complexity to a measurable degree. Nissen fundoplication, however, requires five access ports and proved to be the most complex of the procedures to adapt successfully to solo surgery utilizing robotic arm enhancement. Phase II of our study has involved the use of a combination of technologically complex and sophisticated technology to improve outcomes in complex laparoscopic procedures. The head-mounted display, the robotic arm, and the harmonic scalpel have been used in 140 complex minimally invasive procedures; the procedures were laparoscopic spine surgery (24 cases), laparoscopic gastric surgery (28 cases), and laparoscopic colon resection (88 cases). The use of these sophisticated technologies added safety, improved versatility, and did not increase the length of the operative procedures. The use of multiple technologies had an additive effect on the benefits. There were no experiences in which the technologies contributed to a technical complication or an adverse result for the patients. However, the successful use of these technologies requires an in depth educational experience for the surgeon and for the operating room team. In a further effort to improve efficiency and control of the visual fields during minimally invasive surgery, we have implemented a prototype voice activation, head-directed control, and instrument tracking by robotic arm enhancement in order to control the visual field through computer programming. Prototype voice activation and deactivation also allows instruments to be used in the visual field for the surgical procedure while not being used for tracking of the visual field. Tracking with the instrument utilizing a color-coded tracking system, and the head-directed control system have both been 100% effective in our hands, have not induced errors in technical performance of procedures, and have shortened the time required for performance of specific procedural tasks. Further, this process improves versatility for the surgeon, increases concentration, reduces fatigue and does not interfere with the position of the surgeon. Areas for improvement which have been observed utilizing these techniques are (1) the use of appropriate and consistent voice activation terminology, (2) the proper positioning of the instrument tracking unit in the most appropriate locations on the video screen and on the instrument within the visual field, and (3) the appropriate use of head-directed control of the robotic arm. We have concluded from these experiences that the robotic technology will continue to reduce costs and minimize risk for patients undergoing minimally invasive surgical procedures; moreover, safety, versatility, and diminished use of resources will accrue utilizing the additive benefit of sequential sophisticated technologies requiring a simultaneous educational