Alternative operative techniques in laparoscopic Roux-en-Y gastric bypass for morbid obesity.

The only effective treatment for patients with morbid obesity is surgery. Laparoscopic bariatric surgery has become quite popular in attempts to decrease the morbidity associated with laparotomy. In this article, we describe the technical details of laparoscopic Roux-en-Y gastric bypass with three different techniques for creating the 15-cc gastric pouch. These techniques avoid upper endoscopy for the transoral introduction of the 21-mm circular stapler anvil down to the gastric pouch.

Gas extravasation complicating laparoscopic extraperitoneal inguinal hernia repair.

Carbon dioxide can extravasate from the abdominal cavity during insufflation and result in pneumomediastinum, pneumothorax, and subcutaneous emphysema. We report a case of unilateral pneumothorax with pneumomediastinum and subcutaneous emphysema after laparoscopic extraperitoneal bilateral inguinal hernia repair. Additionally, we discuss the pathophysiology, diagnostic work-up, and management of this malady. Because of the natural resolution of CO2 pneumothoraces, observation for asymptomatic patients is appropriate, whereas tube thoracostomy should be reserved for symptomatic patients. It is utmost importance to determine the etiology of gas extravastion and consider other complications such as airway or esophageal injury or pulmonary barotrauma.

The history of thoracic surgical instruments and instrumentation.

Thoracic surgical practice has evolved from the innovations of its pioneers. Beginning with the stethoscope discovered by Laënnec with his system of auscultation, to the tools we use in the dissection and control of the hilum of the lung for resection, our practice of thoracic surgery has been entwined with the development of instruments and instrumentation. The development of strategies to prevent death from the open pneumothorax began with manual control of the mediastinum and progressed through differential pressure to, finally, the technique of intubation and the methods of positive-pressure and insufflation anesthesia. The instruments we place in our hands are not enough to define our art. Entry into the chest would not be possible without the use of rib retractors, rib shears, and even periosteal elevators. Finally, to the present day of minimally invasive techniques and the application of thoracoscopy for therapeutic purposes, we find the efforts of our predecessors well developed. For the progression from the fear of the open pneumothorax to the present-day state of the ease of thoracotomy for lung resection we are indebted to those who gave so much of their time and, for some, their lives to death from tuberculosis, to allow the advancement of our practice of surgery. These great people should be remembered not only for their acceptance of novel ideas but also, more importantly, for their lack of fear of testing them.

Pancreatic pseudocyst treated by laparoscopic Roux-en-Y cystojejunostomy. Report of a case and review of the literature.

Advances in laparoscopic surgical technique and instrumentation have furthered our ability to perform more complex laparoscopic procedures. We report the case of a 45-year-old man in whom a giant pancreatic pseudocyst developed after biliary pancreatitis. He underwent laparoscopic internal drainage by a Roux-en-Y cyst-jejunal anastomosis after unsuccessful percutaneous drainage. The surgical technique and a review of the current literature is presented. We conclude that although laparoscopic internal drainage technically is feasible in selected cases, additional data are required to define the role of this surgical approach in the treatment of pancreatic pseudocysts.

["Mini-invasive" surgery of the abdomen in 1996]. / La chirurgie "mini-invasive" de l'abdomen en 1996.

Intracavitary abdominal and thoracic operations as well as endoluminal procedures, guided or assisted by videoendoscopic techniques through minimal access sites have the following goals: Diagnosis, excision only of an organ, excision followed by reconstruction, repair only. The indications are well established for diagnostic procedures and organ excisions only. They are being defined for excisions and repair or repair only by present, widespread clinical activities and participation in prospective randomized clinical trials. The author presents recommendations for a variety of operations in each one of the four groups.

Bricker-Johnston sigmoid colon graft for repair of postradiation rectovaginal fistula and stricture performed with mechanical sutures.

In patients with postradiation rectovaginal fistula who are otherwise healthy and cured of their cancer, repair of the fistula with return to a normal lifestyle is indicated if this repair can be achieved with minimal morbidity, no mortality, and a good prospect for a functionally satisfactory result. The Bricker-Johnston vascular sigmoid colon graft fulfills these conditions by respecting the tissular equilibrium of the radiated rectum and supplying the area with a sound, vascular sigmoid pedicle graft. While this improves tissue vitality locally, it restores rectal function to a near-normal preradiation level and preserves the previously intact sphincter muscles. The concept of this repair is very sound, and its implementation is greatly facilitated technically by the use of mechanical suture instruments. In this presentation, we describe and show the use of stapling instruments in achieving a three-stage repair of a rectovaginal fistula with Bricker and Johnston's technique.

Penetrating cardiac injuries: twenty-year experience.

Analysis of 228 patients who sustained penetrating cardiac injuries (1963-1983) reveals that among patients who arrived with vital signs, survival was 73 per cent as opposed to 29 per cent of patients who arrived in extremis; and delay in thoracotomy contributed to an increased mortality among patients in profound shock who failed to respond promptly to volume expansion and agonal patients who were transported to the operating room for thoracotomy. An increasing incidence of gunshot wounds and a greater frequency of patients presenting in extremis was noted in the latter years of the study as compared with the earlier period. Our data indicate that there is an increasing need for emergency room thoracotomy in the management of cardiac injuries. Urban trauma centers should be equipped for major procedures in the emergency room and, ideally, should have operating rooms in this area.

The modified Duhamel operation for Hirschsprung's disease performed entirely with mechanical sutures.

The Duhamel operation of retrorectal transanal pull-through is a widely used technique in the treatment of Hirschsprung's disease. Modifications of the technique have been made with the introduction of stapling instruments. The construction of a side-to-side colorectal anastomosis has been facilitated with the introduction of the GIA linear anastomosing instrument. The advent of the EEA stapling device has allowed us to perform a modified Duhamel operation in a 9-month-old boy with Hirschsprung's disease using mechanical sutures entirely. The technique for the procedure is described.

[Development of the mechanical suture and comparison with the manual suture in surgery]. / Entwicklung der Maschinennaht und Vergleich mit der manuellen Naht in der Chirurgie.

Mechanical sutures in surgery were first used in 1908 by Hültl. Since then they have found a large field of application in thoracic and abdominal surgery because of their ease in handling and consequent reduction of duration of operation, as well as reduction of contamination from hollow organs. Safety, diminished tissue trauma and early function of anastomotic continuity are other advantages that recommend the use of staplers over hand sutures.

Abdominal approach to the Collis gastroplasty and Nissen fundoplication.

A technique to perform the Collis-Nissen operation through an abdominal approach has been described. This method is especially indicated in patients with severe reflux esophagitis and dilatable esophageal strictures, where existing cardiac and pulmonary disease would make a thoracic approach a greater liability to the patient.

Contemporary stapling instruments and basic mechanical suture techniques.

This article provides a description and demonstration of the basic linear staple closures and anastomoses, as well as of circular anastomoses. Depending on the technique used, bowel may be closed in a mucosa-to-mucosa or serosa-to-serosa fashion, and comparable results with either modality are demonstrated.

Varieties of stapled anastomoses of the esophagus.

The rationale for esophageal replacement or bypass is described, and based on the substitute organ chosen, various anastomoses and reconstruction of gastrointestinal continuity are demonstrated.

Emergency room thoracotomy for penetrating cardiac injuries.

The results of emergency room thoracotomy (ERT) and cardiorrhaphy for 91 patients with penetrating cardiac injuries admitted in extremis to Lincoln Medical and Mental Health Center from 1963 to 1981 are reviewed to determine criteria for selection of patients for this procedure. Four groups were defined based on the severity of the effects of their injuries. The survival rates were 32.1 and 33.3%, respectively, for Group I ('fatal') and Group II ('agonal') patients. There were no survivors in Group IV ('D.O.A.') patients for whom ERT is a fruitless procedure. Survival in Group III ('profound shock') patients was only 40%, which might have been improved if ERT had been performed without delay. We conclude that ERT is essential for patients with 'fatal' and 'agonal' wounds and advise prompt ERT for patients in 'profound shock' who do not respond immediately to rapid volume infusion.