Laparoscopic management of acute small bowel obstruction.

BACKGROUND: As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO). METHODS: From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point. RESULTS: Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days. CONCLUSIONS: Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.

Laparoscopically guided distal ventriculoperitoneal shunt placement.

In standard techniques for performing ventriculoperitoneal shunts, the peritoneal catheter is threaded more or less blindly into the peritoneal cavity. Using laparoscopic techniques allows accurate peritoneal placement, without a large incision, even in replacement procedures and in patients with previous abdominal operations. We performed 28 laparoscopically guided ventriculoperitoneal shunt placements and shunt revisions in 24 patients with hydrocephalus (aged 6-80 years). Sixteen of 24 patients (67%) had previous abdominal surgery. Laparoscopic shunt placement was successful in all patients. Mean operative time was 63 +/- 34.9 minutes (range 15-150 minutes). In 2 patients, broken and disconnected distal parts of previously inserted shunts were removed from the abdomen. One shunt was removed following infection and other one was revised due to shunt malfunction. Three patients required revision of the cranial part of the shunt. Laparoscopically guided distal ventriculoperitoneal shunt placement provides definite patient benefits: it allows shunt placement under direct vision, associated with reduced trauma to the abdominal wall, and avoids a consequent risk of intra-abdominal adhesions.

The use of laparoscopy in abdominal emergencies.

BACKGROUND: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. METHODS: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). RESULTS: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. CONCLUSIONS: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

Endoluminal methods of treating gastroesophageal reflux disease.

Several endoluminal methods of treating gastroesophageal reflux disease (GERD) have either been approved, or are under investigation and development. This review outlines the two approved methods (Bard's endoluminal sewing machine and Curon's Stretta radiofrequency treatment), and describes the available data on new methods under investigation. The various methods can be divided into three broad categories: methods that create a controlled stricture, methods that bulk the gastroesophageal junction, and methods that attempt to create a fundoplication. The pros and cons of each method are discussed. Unlike medical treatment, these methods attack the reflux itself, not just the symptoms. This is a promising approach. However, the controlled stricture and bulking methods do not approach the success rate of a standard fundoplication.

Predictors of amputation for popliteal artery injuries.

BACKGROUND: Popliteal artery injuries continue to result in limb loss. This study identifies risk factors that predict amputation. METHODS: Over a 5-year period, a retrospective chart review was conducted of 80 consecutive patients with 81 popliteal artery injuries. RESULTS: The overall amputation rate was 16.5%. Blunt trauma carried a higher rate of amputation (47%) than penetrating injuries (6.2%); P < 0.0001). Associated fractures had a higher amputation rate, regardless of mechanism (odds ratio +2.7, 95% confidence limits 1.2 to 6.2). Fasciotomy at the time of operation was associated with reduced amputation rate. CONCLUSIONS: Blunt injuries and associated fractures carry an increased risk for amputation. Compartmental pressures should be appropriately monitored postoperatively. Fasciotomy at the time of vascular repair may be considered even without evidence of compartment syndrome.

Sternal fractures: a red flag or a red herring?

We reviewed the records of 28 patients with sternal fractures. Seat belts were used by 79% of the patients. Pain and tenderness were the most common complaints. Forty-six percent of patients had associated injuries, which were all evident in the emergency room. Seven patients had rib fractures, six had myocardial contusion, and five had pulmonary contusions. The associated injuries determined the outcome: 2 patients died, 2 required rehabilitation, the rest recovered uneventfully. Mean length of stay (LOS) was 8.17 +/- 1.78 days, but the median LOS was 4 days, and 75% stayed a week or less. The sternal fracture was treated with rest and analgesics. We conclude that sternal fractures are benign and do not require special treatment or an expensive work-up. It is possible that the seat belt and the sternal fracture absorb a substantial part of the energy transfer, and prevent greater damage.

Transient quadriceps paresis following local inguinal block for postoperative pain control.

Two patients were observed who had transient quadriceps paresis following local inguinal block for postoperative pain control following inguinal herniorrhaphy.