The increasing number of routinely performed laparoscopic operations causes the surgeons' "screen work" time to rise constantly. A new ergonomic workload on the surgeons' upper spine and shoulders is ...created as a result of the standard screen height position on top of the laparoscopy towers.
Eight surgeons in the authors' surgical department were evaluated for the inclination/reclination angle of their cervical spine when using the laparoscopy towers in the authors' department and also at their favorable screen height.
The laparoscopy towers used in the authors' department made 3 degrees to 14 degrees reclination of the cervical spine necessary. The interviewed surgeons preferred a position of slight inclination, with a median of 160 cm measured from the central screen height to the floor.
Monitors of laparoscopy towers should be adapted to the surgeon's preferred screen height: at eye level frontally with a neutral or slight inclination of the cervical spine. The authors suggest a central screen height of 160 cm, with the monitor positioned in front of the surgeon. Newer equipment from the industry should be provided.
Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to ...the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out.
A Medline, PubMed, Cochrane search.
Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay.
The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.
Background. The patient's view of the outcome after phlebectomy is mainly dependent on the cosmetic result.
Objective. To compare 5‐0 monofilament sutures with tapes and tissue adhesive for wound ...closure after varicose vein surgery.
Methods. Seventy‐nine patients undergoing varicose vein surgery were prospectively randomized in three groups (tissue adhesive, sutures, tape) for skin closure and compared. The follow‐up 1 year postoperatively was done by a senior dermatologist who was blinded in the method of skin closure.
Results. The cosmetic outcome showed little advantage for the suture group. Taping the incisions is faster than suturing them but without significance; closure with tissue adhesive takes nearly the double of time. The closure for one incision with tissue adhesive is 40 times more expensive than with tapes and 14 times more expensive than with sutures.
Conclusion. This study failed to demonstrate an advantage of tissue adhesive and tapes over monofilament sutures for skin closure after phlebectomy.
Abstract Background Sentinel node (SN) biopsy after preoperative chemotherapy (PC) in breast cancer patients is associated with a lower identification rate (IR) and an increased false-negative rate ...(FNR) compared with SN biopsy in untreated patients. Our aims were to examine the feasibility of SN mapping before PC and the possibility to assess the lymph node status after chemotherapy through a follow-up lymphatic mapping. Methods SN biopsy was performed in 45 clinically node-negative breast cancer patients before PC. A follow-up lymphatic mapping was done after completion of chemotherapy and irrespective of the lymph node status was followed by axillary lymph node dissection (ALND). Results SN mapping before chemotherapy identified a mean of 2.3 SNs in all patients (IR 100%). Nineteen patients revealed a negative SN; 26 patients had a positive SN (micrometastasis found in 6/26 patients). After PC follow-up lymphatic mapping was successful in 29 of 45 patients (IR 64%). IR for follow-up mapping was 80% for patients with a negative or micrometastatic SN before chemotherapy compared with 45% for patients with macrometastatic SNs ( P = .027, Fisher exact test). None of the patients with a negative or micrometastatic SN before chemotherapy revealed positive lymph nodes after PC ( P = .031, McNemar test) and the FNR for follow-up lymphatic mapping in these patients was 0%. Contrary to that, 15 of 20 patients with a macrometastasis before PC had positive nodes after chemotherapy, and the FNR of follow-up mapping in these patients was 50%. Conclusions Patients with a negative SN before PC may forego complete ALND after PC, whereas this may not be valid for patients with macrometastatic SNs. Follow-up lymphatic mapping in patients with positive nodal status before chemotherapy is associated with a low IR and a high FNR.
Background
In laparoscopy, 50% of all complications occur during establishment of the pneumoperitoneum. Elevation of the fascia is recommended for the Veress needle approach, although the benefit has ...not been proved to date. This study aimed to evaluate the intraabdominal changes during lifting of the fascia with regard to the distance from the fascia to the retroperitoneal vessels and the intestine for access in laparoscopy.
Methods
For 10 patients scheduled to undergo laparoscopic cholecystectomy, the operation started with the computed tomography (CT) scan. After orotracheal intubation, a CT scan of the umbilical region was performed. After a supraumbilical incision, the fascia was freed and elevated with stay sutures. During maximal elevation, a second CT scan was performed. Distances to the intestinal (small bowel) and retroperitoneal structures (iliac artery, vena cava) were measured. Intraabdominal pressure was measured with a transcystic balloon manometer before (a) and after (b) elevation of the fascia, after insertion of the Veress needle (c), and after completion of the insufflations (d).
Results
Lifting of the fascia increased the distance between the fascia and the intestinal structures in the patients with no prior abdominal surgery (mean distance, 1.92 cm; range, 0.87–2.67 cm) and the distance between the fascia and the retroperitoneal vessels (mean distance, 7.83 cm; range, 3–11 cm). The median intraabdominal pressures in terms of cm H
2
O were 5.4 for a, 1.1 for b, 1.1 for c, and 12. 5 for d.
Conclusion
Elevation of the fascia before the first entrance to the abdominal cavity for laparoscopy may increase safety due to a significant enlargement of distance between the fascia and the retroperitoneal structures.
In a prospective randomized study postoperative pain, analgesic consumption, return to physical activity and work, cosmetic result and experience with the type of operation were assessed in 86 ...patients undergoing inguinal hernia repair by means of either the Shouldice technique (n = 34), the laparoscopic transabdominal preperitoneal (TAPP) (n = 28) or total preperitoneal (TPP) (n = 24) repair. Patients having TAPP repair had decreased visual analogue scale scores for pain on the day of operation compared with those undergoing TPP and Shouldice repair (4.8 versus 6.5 and 6.2 respectively, P = 0.02) and on the first postoperative day compared with TPP (4.0 versus 6.0, P = 0.01). There was no difference between the three groups for days 2, 3, 4, 5 and 30 after operation. Patient satisfaction with the operation, analgesic consumption, return to physical activity such as walking, driving, climbing stairs, running, bicycling and sexual intercourse, as well as return to work, was comparable in the three groups. There was a better cosmetic result after TAPP and TPP repair. This study failed to demonstrate significant benefits from laparoscopic hernia repair over the Shouldice technique.
NOTES--A new era? Zehetner, Jörg; Wayand, Wolfgang U
Hepato-gastroenterology,
2008 Jan-Feb, Letnik:
55, Številka:
81
Journal Article
Recenzirano
After the first reports from the United States and India of accessing the peritoneal cavity via a transgastric route and performing operations without any abdominal incision, surgeons, as well as ...gastroenterologists worldwide, became interested in developing research projects in this topic. We evaluated the first papers and reports about the research and new techniques to focus on the possible advantages of NOTES (Natural Orifice Translumenal Endoscopic Surgery).
The literature was screened in the time period January 2000 to June 2007 for research and development in NOTES and several reports and abstracts from the year 2007 (January to June) were reviewed.
Several research groups in the U.S. and Europe have published in this field of research and their advances and results are discussed.
NOTES is a new era in surgery, but it will only partially replace laparoscopy as it will not be suitable for all patients and indications. To make NOTES suitable in daily surgical practice, it will take several years of research. NOTES research will boost the development of new endoscopes and instruments also helping to advance laparoscopic techniques.
Liver cirrhosis leads frequently to the development of ascites and a formation of varicose veins in the esophagus. The latter presents increased mortality risk. Recently, significant progress in ...laparoscopic technology enabled devascularization of the proximal stomach in a less invasive way. The results experienced by five patients are presented.
Laparoscopic azygoportal disconnection was performed by means of novel technique (Danis procedure) in five men with esophagus varices bleeding (2nd to 11th events) and liver cirrhosis stage Child-Pugh B and C. This procedure was performed after all other methods had either failed to prevent recurrent bleeding or were refused by the patient. Five ports were positioned on the upper abdominal wall. The veins in the lesser omentum were divided by means of the LigaSure-Atlas device. The stomach coronary vein was visualized, and all the proximal branches toward the esophagus as well as the short gastric vessels were divided. The diaphragm hiatus was opened, and the distal esophagus was dissected. The paraesophageal venous collaterals also were divided, and the remaining varicose veins of the esophagus were interrupted by transmural stitching.
All the patients survived the minimally invasive procedure. Two of them died 9 and 16 months after surgery, respectively, because of liver insufficiency. No bleeding event from varicose veins in the esophagus occurred postoperatively.
Laparoscopic azygoportal disconnection is a less invasive method for prevention of rebleeding from varicose veins in the esophagus. Further studies are necessary to confirm these preliminary results.
Modified logistic regression analysis of 24 variables in 300 patients undergoing laparoscopic cholecystectomy found the following parameters independently predictive for a difficult operation: right ...upper quadrant pain (p < 0.01), rigidity in right upper abdomen (p < 0.01), previous upper abdominal surgery (p < 0.01), biliary colic within the last 3 weeks (p < 0.05), white blood cell count > 10 x 10(9)/l (p < 0.05), thickening of the gallbladder wall (p < 0.05), hydroptic gallbladder (p < 0.05), pericholecystic fluid (p < 0.01), shrunken gallbladder (p < 0.01), and no filling of the gallbladder in preoperative intravenous cholangiography (p < 0.05).
Based on these variables a diagnostic model was developed to predict the difficulty of a laparoscopic cholecystectomy, with scores ranging from 0 (ideal case) to IV (conversion to open cholecystectomy expected) prior to surgery.
When the reliability of our model was examined in a second study in 340 consecutive patients undergoing laparoscopic cholecystectomy 80% of the patients were predicted correctly.
Our model should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties and the experience of the surgeon.
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