Laparoscopic repair of post-traumatic diaphragmatic hernia: a case report.

In a large number of cases, post-traumatic diaphragmatic hernias (PTDH) are a consequence of occult diaphragmatic injuries associated with penetrating abdominal trauma. We present a case of a 26-year-old male patient who, 2 months prior to the current admission, sustained a non-penetrating stab wound to the left anterior chest below the nipple. Upon presentation the patient complained of epigastric pain radiated to the left shoulder, and nausea and vomiting. The chest X-ray, and abdominal and thoracic CT scan were inconclusive. The patient was sutured and discharged. The laparoscopic approach was selected as a diagnostic and minimally invasive therapeutic method. The suspected diagnosis of PTDH was confirmed. The herniated organs (transverse colon, small bowel loops, and greater omentum) were reduced, and the diaphragmatic defect was sutured by placing 3 non-resorbable 2.0 knots. The suture was reinforced with a composite mesh affixed with resorbable clips. Postoperative period was uneventful, and the patient was discharged 4 days later.

[Postoperative early enteral nutrition in a patient with polytrauma and late duodenal perforation]. / Nutritie enterala postoperatorie precoce la un politraumatism cu perforatie duodenala tardiva.

We present the case of a 51 years old multiple injured female patient who was transferred from another hospital. She suffered a car accident and at admission, the diagnosis was anterior flail chest with fractured sternum, blunt abdominal trauma with IIIrd grade kidney laceration, multiple extremities fractures, ISS = 50. We performed emergency nephrectomy, surgical fixation of the flail chest and bilateral pleurostomy. Postoperatively the evolution was difficult, she was intubated and mechanically ventilated. We started early enteral nutrition (EEN), at 24 hours with 20 ml/hour Fresubin (Fresenius-Kabi, Bad Hamburg, Germany) and then with 40 ml/hour. In the fourth postoperative day, CT scan identified no supplementary lesions. In the seventh postoperative day, jaundice became apparent and the CT exam identified gas in the retroperitoneum. At surgery, we identified a IInd degree D2 rupture. We practiced duodenal suture, pyloric exclusion, latero-lateral gastro-entero-anastomosis. We passed a naso-gastro-entero-duodenal tube into D2 for active suction and we performed a fine needle catheter jejunostomy. Difficult postoperative evolution, intubated, febrile, with hemodynamic instability. EEN on the jejunostomy at 20-40-60 ml/hour. 10 days after the reoperation, the general condition ameliorated. Enteral nutrition was continued for 22 days after reoperation. The patient was discharged after 44 days. The particularities of this case are the complexity of the traumatic lesions: anterior costal flail chest, left kidney rupture, late duodenal perforation, multiple extremities fractures (APACHE II score = 34). The treatment involved internal pneumatic stabilization and surgical fixation of the flail chest, duodenal suture with pyloric exclusion and fine needle catheter jejunostomy, left nephrectomy. We consider that the use of EEN was of real help in this case and we recommend it in all polytraumatised patients and in all the cases where it can be used.

[Multimodal analgesia in elective laparoscopic cholecystectomy. A double-blind randomized controlled trial]. / Analgezia multimodal in colecistectomia laparoscopica elective. Studiu prospectiv randomizat dublu-orb.

BACKGROUND: The aim of this study was to test the effects of preincisional parietal and intraperitoneal infiltration with ropivacaine (R) on postoperative pain after elective laparoscopic cholecystectomy. METHODS: 60 patients scheduled for laparoscopic cholecystectomy performed by the same surgeon were enrolled in a randomized, controlled double-blind trial. All patients received the same general anesthesia protocol and Ig i.v. paracetamol was infused after induction of anesthesia for postoperative analgesia, repeated postoperatively each 6 hours, up to 4 g/ 24 h. After induction of anesthesia, the patients were randomized in 4 groups (15 patients each): group A received preincisional parietal infiltration of 20 ml normal saline (NS) solution and 20 ml R0, 25% intraperitoneal instillation; group B, 20 ml R0, 0.25% preincisional parietal and 20 ml NS intraperitoneal; group C, 20 ml R0, 25% preincisional parietal and 20 ml R0, 25% intraperitoneal; group D (control), 20 ml NS preincisional local and 20 ml NS intraperitoneal. Tramadol was used as a rescue analgesic Primary end points: were postoperative pain at Oh, 2h, 6h, 12h, 24h on visual analogue scale (VAS 0-100 mm) score and rescue analgesic requirements. RESULTS: We found no differences in demographics, length of surgery time and hospital stay (total 3.38 +/- 0.22 days). VAS was significantly lower at all intervals in groups C versus D and at Oh, 6h and 12 h in group C versus group A and B (p < 0.05). We found no influence on shoulder pain. Tramadol doses required were significantly lower in group C vs. D (0,73 +/- 1.10 vs 1,93 +/- 1.03, p = 0.017). CONCLUSION: Ropivacaine shows significant favorable effects on postoperative pain after laparoscopic cholecystectomy when using both parietal and intraperitoneal instillation in combination with perioperative i.v. paracetamol.

Laparoscopic suture repair of perforated duodenal peptic ulcer for patients without risk factors.

BACKGROUND: Suture repair became the standard treatment for perforated duodenal ulcer (PDU) due to the efficacy of modern anti-ulcer therapy. This study compared short-term outcomes of open versus laparoscopic suture repair of PDU in patients without risk factors. METHOD: Patients with perforated duodenal ulcer were selected for open or laparoscopic suture repair. Patients with either one or more of the following risk factors were excluded: age > 50 years, interval between perforation and operation > or = 12 hours, presence of major comorbidities (American Society of Anesthesiologists [ASA] III-IV), and previous abdominal surgery. RESULTS: 174 patients underwent open surgery (OSG) and 85 underwent laparoscopic surgery (LSG). The two groups were similar in regard to age, sex, ulcer disease history, time between onset of surgery, ASA score, and presence of free air on X-ray. There were statistical differences between OSG and LSG in the duration of operating time (55 vs 85 min), analgesic doses (16 vs 9) and hospital stay (7.8 vs 6.1 days). During the night (10:00 PM - 06:00 AM), 129 patients were operated: 107/174 in OSG and 22/85 in LSG. In LSG we performed suture repair in 37 patients and suture repair with omental patch in 41 patients. In OSG, 7 patients had a wrong preoperative diagnosis of acute appendicitis. Five patients (5.8%) in LSG group and 15 patients (8.6%) in OSG had postoperative complications and 2 respectively 1 patient needed reoperation. The two reoperated patients in LSG presented suture repair leak and a right subphrenic abscess. Both had only suture repair. There were no mortalities. CONCLUSION: We believe that suture repair with omental patch associated with anti-ulcer medical therapy is the standard therapeutic solution in PDU for young patients without risk factors.

[Progress of surgical treatment in the last 10 years. Comparative study of surgical interventions performed between 1993-1995 versus between 2003-2005]. / Evolutia terapiei chirurgicale în ultima decada. Studiu comparativ al interventiilor 1993-1995 vs. 2003-2005.

In the last decade of the past century, as laparoscopy was introduced in our clinic in 1993, minimal access therapy (MAT--endoscopy, angiography, interventional imagery) had a positive and constant evolution. Our paper retrospectively evaluates the interventions performed between 2003-2005 (group A) compared to those performed between 1993-1995 (group B). We observed a 17.08% (7056 vs 6026 interventions/year) raise in the total number of interventions in group A, with a significant 66% decrease (195 vs. 588 interventions/year) of interventions for gastro-duodenal ulcer and a 18% decrease (1211 vs 1490 interventions/year) of appendectomies, but a 63% increase (1560 vs. 955 interventions/year) of cholecystectomies, 53% increase (1186 vs. 773 interventions/year) of interventions for parietal defects and a 62% (626 vs. 325 interventions/year) increase of oncological interventions. The most frequent interventions were, in the order of frequencies: cholecystectomies (79.8% laparoscopically), appendectomies, interventions for hernia and eventrations, oncological operations and trauma surgery. The incidence of laparoscopic interventions was greater in group A, counting for 19% of the total number of interventions. In group A were performed 2334 endoscopies, 149 diagnostic and therapeutic angiographies. Postoperative mortality dropped with 29.64% and hospital stay dropped to 4.7 days. We believe that the incidence of MAT should rise, by performing more laparoscopic interventions and this change should lead to a revision of the surgical residents training program.