Laparoscopic hernia repair and bladder injury.

BACKGROUND: Bladder injury is a complication of laparoscopic surgery with a reported incidence in the general surgery literature of 0.5% and in the gynecology literature of 2%. We describe how to recognize and treat the injury and how to avoid the problem. CASE REPORTS: We report two cases of bladder injury repaired with a General Surgical Interventions (GSI) trocar and a balloon device used for laparoscopic extraperitoneal inguinal hernia repair. One patient had a prior appendectomy; the other had a prior midline incision from a suprapubic prostatectomy. We repaired the bladder injury, and the patients made a good recovery. CONCLUSION: When using the obturator and balloon device, it is important to stay anterior to the preperitoneal space and bladder. Prior lower abdominal surgery can be considered a relative contraindication to extraperitoneal laparoscopic hernia repair. Signs of gas in the Foley bag or hematuria should alert the surgeon to a bladder injury. A one- or two-layer repair of the bladder injury can be performed either laparoscopically or openly and is recommended for a visible injury. Mesh repair of the hernia can be completed provided no evidence exists of urinary tract infection. A Foley catheter is placed until healing occurs.

Effect of mammography outreach in women veterans.

We undertook this study to test whether progressive intervention would increase the use of mammography. In 1995, we randomly assigned into 2 groups 717 underserved women veterans in the Veterans Affairs Palo Alto (California) Health Care System (VAPAHCS) who earned less than $22,000 a year. The women were sent an informational letter and brochure explaining why mammography is needed and how often. The letter further requested that if the woman was due for a screening mammogram or if a lump or other recent change in her breast had occurred, that she call for scheduling of a free mammogram and a visit to the breast clinic. Women in group I (n = 351) received no further intervention. Women in group II (n = 366) received a follow-up phone call by a breast care nurse if they had not responded within 45 days of the informational mailing. The nurse talked to each woman about her particular needs, explained to her that the screening mammogram would be provided free of charge, and discussed transportation arrangements to the mammography facility. A total of 17 women in group I had mammograms versus 100 in group II during the same time period. We conclude that the additional intervention of a phone call by a breast care nurse increased use by more than 5-fold, which reached significance (P < .01).

Surgery, drugs, lifestyle, and hyperlipidemia.

Heart disease is the number-one cause of death in the United States, and more money is spent on its treatment each year than for any other condition. Both epidemiologic and experimental data clearly show that elevated plasma cholesterol levels increase the risk of death from coronary heart disease. Genetic insufficiencies can cause high blood cholesterol, but most people with high cholesterol do not have genetic abnormalities; rather, they have lifestyles that include high-fat diets and little exercise. Cholesterol can be managed aggressively with coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, partial ileal bypass, and even liver transplant. Antihyperlipidemic drugs include bile-acid-binding resins, nicotinic acid, fibric acid derivatives, hydroxymethyglutaryl coenzyme A-reductase inhibitors, and the antioxidant probucol. Strict programs of low-fat diets and exercise are also effective for reducing cholesterol, lowering blood pressure, and preventing heart disease without the side effects associated with surgery and drug therapy. Such lifestyle changes are critical to reducing the incidence of heart disease in this country.

Elastin degradation in the aorta of Watanabe hereditary hyperlipidemic rabbits.

The Watanabe hereditary hyperlipidemic (WHHL) rabbit is an animal model that resembles humans with familial hyperlipidemia. In the thoracic aortae, there is also morphologic evidence of marked destruction of medial lamellar elastin fibers. Herein is provided the chemical evidence of elastolytic degradation. The levels of lysyl oxidase (L.Ox.), soluble elastin (SE) and insoluble elastin (IE) were estimated in thoracic aortae samples from New Zealand white (NZW) and WHHL rabbits at 6 months of age or 5 WHHL rabbits at 2.5 years of age. Enzyme-linked immunosorption assays (ELISA) were used in the L.Ox. and SE measurements. IE was measured following alkali extraction of aortae. There was a decrease in IE in thoracic aortae from Watanabe rabbits compared to NZW controls at 6 months of age (P < 0.1), and a further loss of IE in aortae from 2.5-year-old WHHL rabbits relative to the values at 6 months (P < 0.05). Average values for IE were: 130 mg/g for 6-month-old NZW, 100 mg/g for 6-month-old WHHL, and 60 mg/g for 2.5-year-old WHHL rabbits. Moreover, SE was only observed in aorta extracts from the older WHHL rabbits, a sign of elastolytic damage. There was also a five- to sixfold decrease in L.Ox. in the older vs. younger rabbits.

Watanabe hyperlipidemic rabbit as a model of aortic degeneration of the medial lamellar elastin unit.

At age 3 years, WHHL rabbits are near the end of their lifespan, frequently dying from the progression of their hyperlipidemic disease from events such as myocardial infarction. Out of a colony of 20 three-year-old WHHL rabbits raised as part of a NIH breeding project, 2 rabbits actually died of a ruptured thoracic aortic aneurysm. The need for a model to study abdominal aortic aneurysm formation led us to explore further the abdominal aortic pathology in aged WHHL rabbits. Six rabbit abdominal aortas from 3-year-old WHHL rabbits were preserved in formalin, sectioned, and stained for elastin. These were compared to the same sections of six normolipidemic age matched New Zealand white (NZW) rabbits. There was significant (P less than or equal to .001) destruction of the medial lamellar elastin unit in the aorta of the WHHL rabbits compared with the control NZW rabbits. Severe cholesterol deposits appeared to destroy the medial lamellae from the inside out. No definite aneurysm formation was seen in the abdominal aorta despite the significant changes in the medial lamellar elastin units. Thus, this model could be used to study the elastin degeneration of the media, but not necessarily abdominal aortic aneurysm formation.

No change in alpha 1 adrenoceptors in canine femoral arteries after lumbar sympathectomy.

In the dog, alpha 1 adrenoceptors have been identified in the aorta, femoral mesenteric, and renal arteries. The concentration of alpha receptors may be regulated by hormones such as estrogen and progesterone and by drugs such as epinephrine. To assess whether sympathetic denervation, which is known to decrease norepinephrine output, might change the population of alpha 1 receptors in vascular smooth muscle, the femoral artery alpha 1 receptor population was examined 2 weeks after unilateral lumbar sympathectomy. [3H]Prazosin radioligand receptor assay analysis was used to measure the alpha 1 receptor populations. No statistical difference for dissociation constant and receptor density values between sympathectomy and nonsympathectomy femoral artery samples could be detected.

Aortic compliance in hypercholesterolemic Watanabe rabbits compared to normal New Zealand controls.

This study was designed to test the hypothesis that severe atherosclerosis changes aortic compliance. Compliance of a vessel is defined as change in volume per unit change in pressure and is a measure of the stiffness or distensibility of the vascular wall. Part of the energy delivered by the left ventricle in systole is used to propel the blood forward into the aorta and part of it to distend the aorta and major vessels. During diastole, the arterial walls recoil and provide energy for propulsion of blood, thereby making blood flow continuous. It is known that Watanabe hereditary hyperlipidemic rabbits develop severe atherosclerosis beginning at 6 months of age. Compliance of the ascending thoracic aorta was studied angiographically in eight Watanabe hereditary hyperlipidemic rabbits of ages greater than 6 months and six normal lipidemic New Zealand white rabbits of ages greater than 6 months, used as controls. The normal New Zealand white rabbits had an average blood cholesterol of 27.4 mg/dL, SD = 13.8, and a regional compliance in the ascending aorta of 0.004 mL/mm Hg, SD = 0.002, compared to the Watanabe hereditary hyperlipidemic rabbits with a cholesterol of 583.1 mg/dL, SD = 162.7, and a compliance of 0.0022 mL/mm Hg, SD = 0.0015. These are significant differences (p less than .05). In addition, the histopathology of the aorta of the Watanabe hyperlipidemic rabbit compared to that of the controls showed a significant decrease in the number of medial lamellar elastin units, an indicator of the decreased elasticity of the blood vessel wall.

Health for all: a surgical model in Haiti.

The need for health services, healthpower, and university participation is evident in Haiti, West Indies. The Hospital Albert Schweitzer in Haiti has a reputation for quality health care and a large volume of tropical disease that is worth experiencing. Health volunteers and university personnel are treated well and receive room and board in pleasant houses on the hospital complex. One becomes involved quite quickly in the active practice of medicine at the hospital and the necessity to read is facilitated by an excellent library. Reaching out to others and helping them achieve healthier lives is a direct form of hope for the future of the world. One can see that this makes a difference in one's own lifetime. To promote health for all it is important to promote changes in university training and research objectives that include interest in and concern for the scientific and educational problems associated with health for all. The Hospital Albert Schweitzer has always had these concerns and universities such as Yale have sent their surgical residents for one- to three-month rotations as part of their surgical training program. The residents are supervised by a board-certified general surgeon. Medical universities that participate in the global strategy of health for all could be allocated a greater number of residency training positions. To inquire further about the Hospital Albert Schweitzer write to Dr. Michel Jean-Baptiste, Medical Director, Hospital Albert Schweitzer, P.O.B. 1744, Port-Au-Prince, Haiti, West Indies.

Superior mesenteric artery vasoactivity in hyperlipidemic Watanabe rabbits versus normal lipidemic New Zealand controls.

Recent in vitro studies on isolated coronary and mesenteric arteries have shown that hyperlipidemia appears to hypersensitize the vascular arterial smooth muscle to drugs such as ergonovine and that this increased contractility seems to be mediated by a serotinergic mechanism. This results in vasospasm with exposure to certain vasoactive drugs such as serotonin or norepinephrine. However, in vivo quantification of this observed phenomenon has not been done. In the present study we used Watanabe hereditary hyperlipidemic (WHHL) rabbits (cholesterol level 459 +/- 216 mg/dL) and the normal lipidemic New Zealand white (NZW) rabbit (cholesterol level 35 +/- 19) as a control in the study of hyperlipidemia and blood flow changes in response to various vasoactive drugs. Blood flow measurements were made by the video dilution technique (VDT) following catheterization of the superior mesenteric artery. The serotinergic vasoactive drug ergonovine maleate was injected into the superior mesenteric artery at low dose (0.002) mg/kg) and high dose (0.004 mg/kg). A significant decrease (p less than .05) in blood flow was observed in response to high-dose ergonovine maleate in WHHL rabbits compared to the NZW rabbits. This in vivo experiment confirms the in vitro studies showing that hyperlipidemia sensitizes mesenteric arteries in the presence of serotinergic stimuli. The vasodilators verapamil hydrochloride and calcitonin gene-related peptide (CGRP) injected into the superior mesenteric artery caused a marked increase in flow in both the WHHL and the normal lipidemic NZW rabbits. This model can be used in the assessment of superior mesenteric artery ischemia and its reversal.

The effect of lumbar sympathectomy on postsynaptic vascular smooth muscle response in the lower limb in dogs.

The intent of this experiment was to study the postsynaptic vasoactive response to tolazoline hydrochloride and sodium-meglumine diatrizoate (Renografin-76) after a unilateral lumbar sympathectomy in a dog model. Both lower extremities were examined using the video dilution technique before and 1-2 weeks after unilateral lumbar sympathectomy (SE). Results showed (1) resting blood flow in the femoral artery as a percentage of cardiac output did not change after sympathectomy (mean and SD before and after SE: 7.0% +/- 2.3 and 6.0% +/- 2.9 respectively n = 13); (2) the reactive hyperemia in the femoral artery caused by sodium-meglumine diatrizoate (Renografin-76) was unchanged after sympathectomy; (3) the vasodilator effect of tolazoline hydrochloride decreased significantly after sympathectomy (p less than 0.05).

Vasoactivity of verapamil in the canine hindlimb and sympathetic nervous system interaction.

Since enhanced sensitivity to verapamil in essential hypertension has been noted, a relationship between verapamil and the sympathetic nervous system has been suggested. It has also been noted that both verapamil and lumbar sympathectomy appear to decrease the vasospasm seen in Raynaud's phenomenon. To further investigate the possible interrelationship between verapamil and the sympathetic nervous system, a unilateral lumbar sympathectomy was performed on eight dogs. Two weeks later the femoral artery blood flow response to intra-arterial verapamil was compared on the sympathectomy limb side and the non-sympathectomy limb side. Blood flow measurements were done without surgical trauma by video dilution technique. Although baseline femoral artery blood flow was unchanged and equal on both sides following sympathectomy (4.6% of cardiac output), there was a significant rise, p less than 0.05, in the blood flow response to verapamil on the side of sympathectomy. Therefore, sympathectomy appears to enhance the calcium channel blocking properties of verapamil.

Axillary-femoral graft compression by prosthetic belt.

In severe peripheral vascular disease, a patient may need not only an amputation but an axillary-femoral bypass. In order to prevent the potential problem of axillary-femoral graft compression by a prosthetic belt, the importance of amputation length is stressed in this case report discussion.

Effect of lumbar sympathectomy in distal arterial obstruction.

We developed a model that simulates distal arterial occlusive disease to determine the effects of sympathectomy on certain hemodynamic changes. Two groups of seven dogs each received unilateral distal popliteal artery ligation. Intra-arterial BPs, angiography, pulse volume recordings (PVRs), and photoplethysmograms were taken of the distal hind limb throughout the experiment. After ligation, PVR and distal hind limb pressures were lowered to less than half of the preligation values. Four days after unilateral distal popliteal artery ligation, group 2 dogs received lumbar sympathectomy on the same side as the ligation. One week after sympathectomy, the PVR amplitudes and pressures showed a transient significant rise. Two weeks after sympathectomy, the PVR pressures and amplitudes returned to the previous, diminished postligation values.