Variability in the anterior extralaryngeal branch of the recurrent laryngeal nerve: clinical implications.

BACKGROUND: This study aimed to identify the anterior and posterior extralaryngeal branches (AELB, PELB) of the recurrent laryngeal nerve (RLN), measure these branches when present, and determine relationships between gender, sidedness and neck length. MATERIALS AND METHODS: Dissection was completed to level of the thyroid on 45 cadavers. The course of the RLN was then traced superiorly from its entry into the neck. Careful reflection of the thyroid and dissection of the lateral thyroid ligament permitted visualisation of the full course of the nerve. If extralaryngeal branching (ELB) was present, measurements were taken from the point of bifurcation of the RLN to the point of laryngeal entry through the cricothyroid membrane. Neck measurements, from the spinous process of C7 to the superior nuchal line, were taken. Gender of the specimen was noted. Data was analysed in SPSS. RESULTS: Extralaryngeal branching was found in 77.78% of our sample, 77.14% on the left and 54.29% on the right. A significant difference was found between AELB length on the left and right, indicating that the left branch will be longer than the right when present. A significant difference in neck length between those with and without ELB was also found, indicating that people with longer necks more often display ELB. Neither neck length and AELB length, nor gender and AELB length were strongly correlated in this sample. CONCLUSIONS: Extralaryngeal branching can occur in all populations, but there are definite trends in its incidence and length. Surgeons should be aware of these trends before operating on patients.

Examination of the recommended safe and unsafe zone for placement of surgical instruments in thoracentesis and video-assisted thoracic surgery: a cadaveric study.

BACKGROUND: Thoracentesis and video-assisted thoracic surgery procedures can result in haemorrhage as a consequence of severing the collateral branches of the posterior intercostal artery. These branches have been shown to be most common in the 5th intercostal space (ICS). Tortuosity has been shown to be especially prevalent nearer to midline. A group of investigators have recommended the 4th and 7th ICS, 120 mm lateral to midline as a safe zone, least likely to hit branches when cutting into the ICS. The present study aimed to investigate that safe zone as a better entry points for procedures. In addition, investigation of the least safe 5th ICS was also performed. MATERIALS AND METHODS: A total of 56 embalmed human cadavers were selected for the study. With the cadavers laid prone, 2 cm incisions were made at the 4th, 5th and 7th ICS, 120 mm lateral to midline bilaterally. The cadavers were then placed supine and the incisions were dissected. Careful attention was paid to identify if any collateral branches were cut. RESULTS: After thorough dissection of the 4th, 5th and 7th ICS incision sites, it was shown that damage to the 5th intercostal was seen most frequently. CONCLUSIONS: Based on this cadaveric study, a 2 cm incision at the 4th, 5th and 7th ICS 120 mm lateral from midline resulted in the most damage at the level of the 5th ICS. The 4th ICS had the least damage seen. Therefore, it is recommended that insertion should be placed at the level of the 4th ICS bilaterally.

Quantification of the distal radial artery for improved vascular access.

BACKGROUND: There is no consensus in the literature as to which point of the radial artery (RA) is the safest to attempt vascular access. The purpose of this study was to measure the diameter, tortuosity and branching patterns of the distal RA. MATERIALS AND METHODS: 140 cadaveric RAs (66 male, 74 female) were dissected and measured. The external diameter of the RA was measured at 2 cm increments starting at the radial styloid process (SP), moving proximally. The location and degree of 2-dimensional arterial tortuosity were recorded if > 35 degrees. Branches of the RA were recorded with respect to their distance from the SP. RESULTS: We observed that the right RA significantly increased in diameter at distances beyond 4 cm proximal from the radial SP, regardless of the sex of the individual. This increase in size was not noted on the left RA's. Muscular artery branches of the distal RA were noted on average 1.82 cm proximal from the SP. Clinically significant tortuosity was present on average 3.47 cm proximal from the radial SP. The left RA did not significantly change in size along its course, but its statistically similar diameter when compared to the right RA allows us to make a recommendation this is applicable bilaterally. CONCLUSIONS: Our data suggests that regardless of gender, vascular access of the RA could be safely performed at distances greater than 4 cm from the SP to yield a vessel with a larger diameter, less tortuosity, and fewer branches.

Posterior intercostal artery tortuosity and collateral branch points: a cadaveric study.

Publications report observing tortuosity in the posterior intercostal arteries of elderly patients. Studies also describe the size and course of the collateral intercostal arteries. This information is clinically significant when performing thoracentesis and video-assisted thorascopic surgery. To the best of our knowledge, no studies have examined arterial tortuosity or described collateral artery origins relative to bony landmarks. The purpose of this study was to define a safe surgical zone for thoracic access using palpable external bony landmarks. A total of 348 intercostal spaces (3rd-8th) of 29 male and female embalmed cadavers were dissected from the vertebral body to the mid-axillary line to observe the posterior intercostal artery and its collateral branch. The origins of the collateral intercostal arteries relative to the midline of thoracic spinous processes were measured. Mild to moderate tortuosity (arterial curves covering 25- -50% of the intercostal space) was observed in at least one posterior intercostal artery in the majority of cadavers. The origins of the collateral intercostal arteries were variable relative to the midline. Additional collateral intercostal arteries distal to the primary collateral branch were observed, most commonly in the 5th intercostal space, which is used in video-assisted thorascopic surgery and thoracentesis. Tortuosity is common in the 3rd to the 8th posterior intercostal arteries, especially in individuals over the age of 60 years. Given the findings of this study, we recommend that any procedure involving placement of a surgical instrument into these intercostal spaces does so at least 120 mm lateral to the midline of the spinous processes. We also recommend pre-procedure ultrasound (intercostal scan) of the posterior and collateral intercostal arteries when performing non-emergent thoracentesis and video-assisted thorascopic surgery, particularly in patients over 60 years of age.

[Correlation of retinal thickness with the extent of Purtscher's retinopathy]. / Korrelation der Netzhautdicke mit dem Verlauf der Purtscher-Retinopathie.

BACKGROUND: The course of Purtscher's retinopathy (PR) or Purtscher-like retinopathy (P-lR) is dependent on time, length, and expression of confluent cotton-wool spots. To correlate the course of the disease with findings of optical coherence tomography (OCT), we present two extreme courses of PR and P-lR. METHODS: Complete ophthalmological examination plus electroretinography (ERG) and OCT were performed. In the first case the follow-up was carried out until complete resorption of the edema and in the second case 8 years after the occurrence of P-lR. RESULTS: An increase of the central retinal thickness (308-430 microm was observed during the acute phase of PR. Normalization of visual acuity and central retinal thickness to 210-273 microm with an ERG within normal limits (35 ms) was achieved after 8 weeks. In the course of P-lR the marked edema was visible even after 6 months and a markedly reduced neuroretina (112-120 microm) was measured after 8 years. CONCLUSIONS: Retinal thickness analysis correlates well with organic functions in the cases of PR or P-lR. Fast reduction of the edema was associated with a good prognosis for visual acuity.

Up-regulation of GABA(B) receptor mRNA and protein in the hippocampus of cocaine- and lidocaine-kindled rats.

To evaluate the effect of GABA(B) receptor in drug-kindled seizures, the gene expression of GABA(B) receptor in cocaine- and lidocaine-kindled rats was examined in this study. Rats were injected (i.p.) daily with cocaine (55 mg/kg) or lidocaine (65 mg/kg) until they experienced a motor seizure (kindling). After kindling, rats received a 1-day, 10-day, or 30-day drug washout period. The rats in the 1-day washout group were killed after the washout. Those in the 10-day and 30-day groups were challenged either with drug or saline, and killed 24 h later. Control rats were injected and challenged with saline. GABA(B)R1a, 1b and R2 mRNAs in discrete regions of brain were detected by in situ hybridization; GABA(B)R1a protein level was measured by Western blotting. Ninety percent of the cocaine-treated rats and 100% of the lidocaine-treated rats were kindled by day 12. Those rats responded to the challenge cocaine or lidocaine with a motor seizure after the 10-day and 30-day washout. GABA(B) receptor mRNA and protein levels in the hippocampus were significantly increased after the 1-day and 10-day washout, but not the 30-day washout. In addition, the levels in drug-treated and drug-challenged rats were significantly greater than those in drug-treated and saline-challenged rats after the 10-day washout. Those data suggest that changes of GABA(B) receptor gene expression could be a factor underlying the development of drug-kindled seizure, but not a necessary component for the maintenance of this phenomenon.

[Laparoscopic 2-level fusion of the lumbar spine with Bagby and Kuslich implants]. / Laparoskopische 2-Etagenfusion der lumbalen Wirbelsäule mit Bagby-and-Kuslich(BAK)-Implantaten.

In a 50-year-old female patient, presenting with permanent low lumbar back pain and intermittent neurological alterations due to degenerative disc disease L4-5 and L5-/S1 we demonstrate that two-level anterior interbody fusion can be performed via laparoscopic transabdominal instrumentation using BAK interbody implants. Intervertebral disc space L5-/S1 was stabilized approaching the spine caudally of the aortic bifurcation, while disc space L4-L5 required an approach from the left lateral aspect, mobilizing the aorta and vena cava to the right. The postoperative course was without complications and allowed discharge from the hospital on day 8. X-ray control 4 months later demonstrated restoration of adequate disc space at L4-L5 and L5-/S1 and appropriate positioning of the implants.

[Results of replantation in thumb amputations. New examination methods for evaluation of sensation]. / Replantationsergebnisse von Daumenamputationen. Neue Untersuchungsmethoden zur Sensibilitätsprüfung.

Of 91 thumb amputation injuries which were treated over a five-year period at the Department of Traumatology, University School of Surgery Homburg/Saar, 56% could be subjected to a critical follow-up evaluation. The evaluation scheme of Millesi "Evaluation and Registration of Hand Function" programmed for electronic data processing forms the basis for the study. Besides the specified criteria for sensitivity testing, a further method for objective testing is presented. The principle of this method is point stimulation of pressure and mechanoreceptors after eliciting a threshold perceptible vibration stimulus of an 80 Hz sinusoidal oscillation the intensity of which can be directly measured as a yardstick for the stimulus response. Electronic processing of all results of the patients investigated shows that the injured hand can be used to almost 100% in 38%. In 16 patients (31%), there is a reduction by 5 to 20%. In ten cases (20%), the reduction was rated as over 20% compared to a healthy hand and in 11% (six patients), the overall result is to be designated as poor with more than 40% reduction of use.

[Purtscher's syndrome. An example of a rare occurrence of ocular complication after thoracic compression trauma]. / Das Purtscher-Syndrom. Fallbeispiel einer seltenen okulären Komplikation nach Thoraxkompressionstrauma.

Purtscher's retinopathy is a traumatic angiopathy, most commonly caused by head and chest trauma. Retinal signs include white ischemic infarcts (cotton-wool spots or Purtscher flecken) and hemorrhages (dot and blot, preretinal, or flame). The prognosis for patients with decreased vision is unpredictable. We report one case of this disease developing 3 days after a motorcycle accident.

Staged major limb replantation: a concept to minimize the risk in replantation of the lower extremity.

The replantation of large limb segments presents two major problems: first, a general danger to survival because of major accompanying injuries and additional ischemia-reperfusion injury; second, local soft-tissue damage at the amputation site. Successful replantation can be compromised by infection, vessel thrombosis, and disturbed bone healing. Possible risk reduction may be accomplished by the concept of a two-staged replantation. A brief primary emergency procedure involving bone resection, osteosynthesis, and revascularization (with the goal of limb survival) is followed by a second procedure within 72 hr after trauma, for final debridement, completing the osteosynthesis, nerve and tendon suturing, and soft-tissue coverage by free flaps. The advantages of the double procedure are demonstrated in 27 patients by comparison of two treatment groups. Group I comprised 15 patients with definitive primary care. In Group 2 (n = 12), the two-stage operation was performed. The second group showed a shorter duration of overall treatment, reduction of blood loss, and fewer infections.

[Blunt trauma in soccer. The initial manifestation of synovial sarcoma]. / Stumpfes Trauma beim Fussballspiel. Erstmanifestation eines Synovialsarkoms.

Report on a young man, who was operated upon after adequate trauma following the diagnosis "organizing haematoma of the adductorial compartment". Surprisingly we found intraoperatively tumor suggilations. According to the definition of Enneking the surgical procedure was finished as "marginal excision" and the patient was referred to an oncological center. After multimodal therapy the patient is meanwhile tumor and recurrence free for 5 years. In case of such an unexpected diagnosis the importance of paying attention to the criterias of an "incisional biopsy" is emphasized. The concept of a "conceived biopsy" is explained in preoperatively malignant looking tumors. The outstanding responsibility of the surgeon for prognosis (local recurrence) and patients quality of life (amputation versus limb salvaging) is elaborated.

First experience with laparoscopic spine fusion in an experimental model in the pig.

BACKGROUND: We elucidated whether anterior lumbar spine fusion with interbody implants (BAK) can be performed in an experimental model in the pig using a transperitoneal laporoscopic approach. METHODS: In seven animals, a pneumoperitoneum with an intraabdominal pressure of 12 mmHg was induced, and five trocars were placed in the middle, as well as in the left and right lateral aspect of the abdomen. With the use of specially designed instruments, the bifurcations of the aorta and vena cava were prepared. The sacral artery, overlying the anterior aspect of the L5/S1 disc space, was retracted, allowing the exposure of the disc space. A working trocar was then fixed to the spine bodies above (L6) and below (S1) the disc, and instrumentation was completed by destruction of the disc, insertion of distraction plug, and implantation of the BAK cage. X-ray control allowed exact positioning of the cage. RESULTS: There were no major complications during the operative procedure, in particular no bleeding from major blood vessels and no injury to intraperitoneal organs. Cages were implanted in all animals in correct position, as indicated by postoperative X-ray control. CONCLUSIONS: We conclude from our experiments that in the pig model implants for anterior interbody lumbar spine fusion can be inserted successfully using the laparoscopic approach. We propose that the pig model represents an ideal tool for training before applying this operative procedure in men.

Cardiopulmonary dysfunction during minimally invasive thoraco-lumboendoscopic spine surgery.

UNLABELLED: The endoscopic retroperitoneal approach to thoracolumbar anterior spine fusion is associated with CO2 insufflation into the thoracic space. We studied the cardiopulmonary effects of this CO2 thoraco-retroperitoneal insufflation compared with the conventional open surgical procedure using thoraco-phreno-lumbotomy in 12 pigs under balanced anesthesia, paralysis, and mechanical ventilation. During open surgery of the thoracolumbar spine, animals exhibited unchanged systemic and pulmonary hemodynamics, as well as ventilation and oxygenation variables. Animals retroperitoneally insufflated with CO2 (12 mm Hg) exhibited a significant increase of PaCO2 and a moderate decrease of PaO2, SaO2, and pH, with insignificant changes of central venous filling pressures and systemic hemodynamics. Endoscopic phrenotomy with thoracic CO2 insufflation instantaneously and drastically affected hemodynamic status and pulmonary gas exchange with marked hypoxia, hypercapnia, systemic hypotension, tachycardia, and pulmonary hypertension within minutes. An increase of minute ventilation, inspiratory oxygen fraction, and positive end-expiratory pressure promptly reversed these cardiopulmonary effects. CO2 evacuation allowed the animals to completely recover and regain almost baseline cardiopulmonary status, except for a reduced arterial blood pressure. Appropriate monitoring and immediate CO2 desufflation may be beneficial in cases of therapy-resistant hemodynamic, oxygenation, and ventilation difficulties. IMPLICATIONS: For endoscopic thoraco-lumbar spine fusion, CO2 thoraco-retroperitoneum-induced cardiopulmonary dysfunction must be of concern, especially in patients with cardiopulmonary compromise. Appropriate monitoring and immediate CO2 desufflation may be beneficial in cases of therapy-resistant hemodynamic, oxygenation, and ventilation difficulties.

First clinical experience with an endoscopic retroperitoneal approach for anterior fusion of lumbar spine fractures from levels T12 to L5.

BACKGROUND: Recent experience indicates that unstable spine fractures should be stabilized dorsoventrally. To avoid the high morbidity associated with the common anterior approach-i.e., thoraco-phreno-lumbotomy-we developed a technique that allows the anterior fusion of lumbar spine fractures using an endoscopic retroperitoneal (lumboscopic) approach. METHODS: Lumboscopic anterior fusion was performed a few days after the initial dorsal stabilization. The retroperitoneal space was accessed endoscopically via a suprailic incision and enlarged using a balloon spacer and CO(2) insufflation. The peritoneum and the kidney were gently pushed ventrally. Mobilization of the psoas muscle dorsally then allowed exposure of the fractured spine bodies. Via two additional trocars placed opposite the fractured level, the damaged disc and bone were removed, and anterior spondylodesis was performed with an iliac crest bone block and a titanium plate. RESULTS: The technique was applied successfully in 12 patients with fractures of L1 (n = 6), L2 (n = 4), L3 (n = 1), and L4 (n = 1) as a mono- or bisegmental fusion, requiring instrumentation from T12 to L5. No major complications (including neurological problems) were encountered. Blood loss was minimal. None of the patients required conversion to open surgery. Patients were mobilized early, starting regularly at the second postoperative day. CONCLUSIONS: Lumboscopic instrumentation of the lumbar spine is a safe, minimally invasive method for the treatment of spine fractures. The patients benefit from reduced pain, low morbidity, and excellent cosmetic results.

Reliable noninvasive parameters for early detection of cardiopulmonary compromise induced by carbon dioxide thoracoretroperitoneum in minimally invasive thoracolumboendoscopic spine surgery.

BACKGROUND: Using a novel endoscopic retroperitoneal approach for thoracolumbar anterior spine fusion, we examined the cardiopulmonary effects of the inevitably associated carbon dioxide (CO2) thoracoretroperitoneum and evaluated noninvasive parameters, which may provide early and adequate recognition of cardiopulmonary dysfunction. METHODS: Under balanced anesthesia and paralysis, six pigs subjected to endoscopic CO2 thoracoretroperitoneal spine fusion underwent extensive pulmonary and hemodynamic online monitoring throughout the operative procedure. Open thoracophrenolumbotomy in six pigs served as a control procedure. RESULTS: In contrast to unchanged cardiopulmonary parameters during open thoracolumbar spine surgery, CO2 thoracoretroperitoneum caused significant hypercapnia, hypoxia, and acidemia with concomitant tachycardia, pulmonary hypertension, and systemic hypotension. Ventilatory adjustment, CO2 evacuation, or both promptly reversed the cardiopulmonary effects. Noninvasively assessed end-tidal CO2, peak respiratory pressure, and heart rate were early clues for detecting the tension pneumothorax-like cardiopulmonary dysfunction, as indicated by a significant correlation with the invasively assessed pulmonary hemodynamic parameters and arterial blood gases. CONCLUSIONS: During endoscopic thoracolumbar spine fusion, CO2 thoracoretroperitoneum induces cardiopulmonary dysfunction, which, however, can be detected reliably by changes in end-tidal CO2, peak respiratory pressure, and heart rate, and which can be corrected immediately by appropriate ventilatory adjustments. Therefore, endoscopic CO2 thoracoretroperitoneal spine fusion might not necessarily require extraordinarily extensive and invasive monitoring of systemic and pulmonary hemodynamics, but ventilatory adjustment and intrathoracic pressure evacuation should be readily available to reexpand the lung, and to facilitate rapid normalization of hemodynamic conditions.

Experimental development and validation of a technique for lumboendoscopic anterior fusion of lumbar spine fractures: comparison of endoscopic and open surgery in a live porcine model.

BACKGROUND: Using a porcine model, this study describes the feasibility of a lumboendoscopically guided approach to the lumbar spine for anterior interbody fusion, and compares the results with that of the open procedure. The objectives of this study were to develop a minimally invasive approach to the lumbar spine for anterior fusion in pigs, and to test the validity and safety of the procedure in this porcine model. Besides posterior stabilization, considerable number of thoracolumbar spine (Th12-L5) fractures require intervention for anterior fusion to prevent loss of height of the injured segment and kyphotic deformation. Because anterior fusion needs major surgery (thoracophrenolumbotomy for Th12-L1), which is associated with high morbidity, this study aimed to develop a less traumatic minimally invasive approach. METHODS: Six pigs under balanced anesthesia were used to study the feasibility of the lumboendoscopic approach for bisegmental fusion (iliac crest bone block and dynamic compression plate) from Th15 to L6. In an additional six animals, lumboendoscopic fusion was performed at the level of diaphragm insertion (Th14-Th16), representing Th12-L1 in patients. For comparative analysis, six animals undergoing open thoracophrenolumbotomy and anterior Th14-Th16 fusion served as control subjects. RESULTS: Endoscopic anterior fusion could be successfully performed at all levels of the thoracolumbar spine without major complications. In three cases, unintended opening of the peritoneal cavity was observed, however, without the operative procedure being affected. Comparative analysis revealed a significantly longer p < 0.01 operation time (126 +/- 6.5 min) and increased femoral vein pressure (11.3 +/- 0.7 mmHg) in animals undergoing endoscopic surgery (open procedure, 76.0 +/- 11.6 min and 5.2 +/- 0.5 mmHg). However, the microvascular blood supply (perfusion) to the distal extremities, as assessed by laser Doppler flowmetry, was not affected. CONCLUSIONS: Our study demonstrates that lumboendoscopic anterior spine fusion in pigs is feasible at all levels from Th14 to L6, and can be performed in an acceptable operation time without major complications.

Effectiveness of a hands-on training course for laparoscopic spine surgery in a porcine model.

BACKGROUND: Although it is widely proposed that surgeons, before introducing a novel laparoscopic technique in man, should practice in an appropriate animal model for acquisition of the necessary technical skills, the effectiveness of those hands-on training courses are rarely documented. METHODS: In 1995 we have organized eight hands-on training courses for laparoscopic anterior interbody spine fusion in an in vivo porcine model. A total of 72 colleagues from 50 different centers of 12 countries participated, including orthopedic, trauma, visceral, neuro-, and vascular surgeons. Quality and effectiveness of the course were evaluated by a questionnaire after a 1.5- to 2.5-year period. RESULTS: During this time, 42.2% of the participating centers had applied the new technique successfully in man. Centers which participated in the course with a team that included a skilled laparoscopic surgeon and an orthopedic or trauma surgeon introduced the technique more frequently to clinical practice (57.9%) than those represented by only one participant (30. 8%). Moreover, there was a tendency toward a more frequent introduction of the technique to clinical practice in centers associated with university hospitals (57.1% vs. 29.2%), indicating the requirement of a particular infrastructure for this complex interdisciplinary procedure. Almost all participants (98.3%) agreed that for novel surgical techniques requiring advanced technical skills, there should first be training in a large animal model before the technique is applied in man. CONCLUSIONS: Complex laparoscopic procedures (i.e., laparoscopic spine surgery) can be successfully learned by in vivo hands-on training courses. We propose that for refinements and modifications of the technique (e.g. , the lumboscopic approach), there should also first be training in a large animal model before these are applied in man.

Loss of physiologic hepatic blood flow control ("hepatic arterial buffer response") during CO2-pneumoperitoneum in the rat.

UNLABELLED: We analyzed whether a compensatory increase of hepatic arterial (HA) flow, known as the "hepatic arterial buffer response" (HABR), may serve for maintenance of liver blood supply during laparoscopy-associated portal venous (PV) flow reduction. We assessed HA and PV flow, as well as hepatic tissue oxygenation (PO2) during CO2-pneumoperitoneum in anesthetized and mechanically ventilated Sprague-Dawley rats (n = 7). Control animals (n = 7) without pneumoperitoneum, but tourniquet-induced PV flow reduction served to demonstrate physiologic HABR. Although stepwise tourniquet-induced reduction of PV flow to 20% of baseline values led to a significant (P < 0.05) increase of HA flow from 4.3 +/- 0.7 mL/min to 9.9 +/- 1.7 mL/min, stepwise intraabdominal pressure-induced decrease of PV flow was paralleled by a linear reduction of HA flow from 2.4 +/- 0.3 mL/min to 1.2 +/- 0.5 mL/min at 18 mm Hg intraabdominal pressure. This loss of HABR was sustained during a subsequent 2 h-period of CO2-pneumoperitoneum contrasting the 2 h of maintenance of HABR in controls. Hepatic tissue PO2 decreased during the 2 h-period of pressure- and tourniquet-induced PV flow reduction by 35% to 51%, respectively. On tourniquet release, all variables regained baseline values, whereas evacuation of the pneumoperitoneum allowed all variables except hepatic PO2 to return to baseline, indicating prolonged tissue hypoxia despite restored total liver blood flow in the Laparoscopic group. Concomitantly, increased liver enzyme activities reflected moderate tissue damage after 2 h of pneumoperitoneum. In conclusion, intraabdominal CO2-insufflation-induced hemodynamic alterations may impair tissue oxygenation and enzyme release, indicating the potential risk for hepatic tissue damage after prolonged periods of laparoscopic interventions. IMPLICATIONS: We investigated the effect of CO2-pneumoperitoneum on liver blood flow, hepatic tissue oxygenation (PO2) and liver enzyme release. CO2-insufflation reduces portal venous flow without a compensatory increase of hepatic arterial flow ("hepatic arterial buffer response"), resulting in reduced hepatic PO2 and increased ratios of serum alanine aminotransferase to serum aspartate aminotransferase.

Treatment of severe injuries caused by attempted suicide: pattern of injury and influence of the psychiatric disorder on the postoperative course.

OBJECTIVE: To assess the influence of psychiatric disorders on the treatment and postoperative course of patients severely injured as a result of attempted suicide. DESIGN: Retrospective case study. SETTING: University hospital, Germany. SUBJECTS: 36 patients who had multiple injuries after attempting suicide during the five year period 1991-95. INTERVENTIONS: Operative and psychiatric treatment. MAIN OUTCOME MEASURE: Functional results assessed with the Trauma Outcome Profile (TOP) score, psychiatric state, and risk of further suicide attempts. RESULTS: 30 of the 36 patients attempted suicide by jumping from a height, and the most common injuries were fractures of the spine (n = 33) and lower limbs (n = 43). All patients had a psychiatric disorder, and 18 had previously attempted suicide at least once though had inflicted only minor injuries. 29 of the 36 were receiving psychiatric care at the time of the suicide attempt. Five patients died. 27 of the 31 survivors were available for follow up and 26 of them had good or excellent functional results. 30 of the 31 underwent psychiatric assessment (one refused) and none was judged to be at risk of a further attempt. CONCLUSIONS: The functional results were better than we expected. The psychological effect of severe injuries and a long hospital stay seems to reduce the risk of a further attempt, so all treatment (both surgical and psychiatric) is worthwhile.

[Laparoscopic-transperitoneal and lumboscopic-retroperitoneal surgery of the spine. Developments from animal experiments for use in clinical practice]. / Die laparoskopisch-transperitoneale und lumboskopisch-retroperitoneale Chirurgie der Wirbelsäule. Entwicklungen im Tierexperiment zur Anwendung in der klinischen Praxis.

With the use of an in vivo porcine training model we established the transperitoneal laparoscopic approach for the instrumentation of anterior lumbar spine fusion with Bagby-and-Kuslich (BAK) interbody implants as well as "Brantigan" cages. The transperitoneal laparoscopic approach caudally from the aortic bifurcation allows the spine fusion procedure of the caudal but not of the cranial part of the lumbar spine. Because ventral stabilization of the upper lumbar spine is frequently necessary, in particular in trauma patients with spine body fractures, an additional retroperitoneal minimal-invasive (lumboscopic) approach was established using again the in vivo porcine training model. We demonstrate that via this approach spine fusion can easily be performed including the Th12 segment after fenestration of the diaphragm. With the experience from the in vivo experiments, both techniques could safely and successfully be transferred to clinical practice with the advantage of markedly reducing the extent of operative trauma compared with the corresponding open approaches.