A. Ayalon

Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia

BackgroundThis study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair.MethodsClinical data from the first 100 cases were analyzed retrospectively.ResultsBetween 1997 and 2000, 64 women and 36 men (mean age, 58.4 ± 13.6 years; range, 27–87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 ± 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 ± 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n=6), seromas (n=11), prolonged ileus (n=4), and prolonged fever (n=3). Seven cases were converted; to repair accidental enterotomies (n=4) due to difficult adhesiolysis (n=2), or to control bleeding (n=1). Six patients underwent reoperation because of enetric leak (n=3) or bowel obstruction (n=3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12–54 months).ConclusionsLaparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.

Bowel Preparation Is Associated With Spillage of Bowel Contents in Colorectal Surgery

PURPOSEInfectious complications pose a significant cause of morbidity in colon and rectal surgery. This study was designed to assess the effect of bowel preparation on spillage of bowel contents into the peritoneal cavity during colorectal surgery, and its potential effect on the rate of postoperative infectious complications.METHODSThe quality of bowel preparation and the incidence of spillage of bowel contents were prospectively assessed in patients undergoing elective colon and rectal resection. The patients were followed for 30 days for postoperative infectious and noninfectious complications.RESULTSA total of 333 patients were included in this study, of which 181 did not receive mechanical bowel preparation. Intraoperative spillage of bowel contents occurred in 48 patients (14 percent), whereas in 285 patients (86 percent), spillage did not occur. There was a trend toward a higher rate of overall surgical infectious and noninfectious complications in patients who had spillage of bowel contents compared with patients without spillage; however, this difference was not statistically significant (18.7 vs. 11 percent, and 29 vs. 19 percent, respectively). Preoperative mechanical bowel preparation and colocolonic or colorectal anastomosis was associated with a higher rate of bowel contents spillage, although this difference did not reach statistical significance. Liquid colonic contents caused significantly higher rates of spillage.CONCLUSIONSSpillage of bowel contents into the peritoneal cavity during colon and rectal surgery may increase the rate of postoperative infectious complications. In addition, inadequate mechanical bowel preparation, leading to liquid bowel contents, increases the rate of intraoperative spillage.

Is mechanical bowel preparation mandatory for left-sided colonicanastomosis? Results of a prospective randomized trial

AbstractBackgroundPreoperative mechanical bowel preparation is aimed to reduce the risk of infectious complications, and its utility is a dogma in left-sided large bowel anastomosis. The aim of this study was to specifically assess whether colocolonic and colorectal anastomoses may be safely performed without preoperative mechanical bowel preparation.MethodsPatients undergoing elective colon and rectal surgery with primary colocolonic or colorectal anastomosis were prospectively randomized into two groups. The “prep” group had mechanical bowel preparation prior to surgery, while the “non-prep” group had surgery without pre-operative mechanical bowel preparation.ResultsTwo hundred forty-nine patients were included in the study, 120 in the prep group and 129 in the nonprep group. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups. Overall infectious complication rate was 12.5% in the prep group and 13.2% in the non-prep group. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.6%, 4.2%, and 1.6% of patients in the prep group and in 10.0%, 2.3%, and 0.7% of patients in the nonprep group, respectively (p=NS).ConclusionsThese results suggest that elective left-sided anastomosis may be safely performed without mechanical preparation. Multicenter studies to test the reproducibility of these results are required, to support a change in this time-honored practice.

Laparoscopically assisted reversal of Hartmann's procedure.

BackgroundRestoration of bowel continuity after Hartmann’s procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann’s procedure (LARH) to assess difficulties and potential advantages associated with this procedure.MethodsA retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons.ResultsA total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann’s procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality.ConclusionsLaparoscopically assisted reversal of Hartmann’s procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Laparoscopic management of surgical complications after a recent laparotomy

BackgroundThe use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures.MethodsFourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically.ResultsEleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space.ConclusionsWe conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.

Correct preoperative localization: Does it permit a change in operative strategy for primary hyperparathyroidism?

BACKGROUND A meticulous bilateral neck exploration by an experienced endocrine surgeon offers a high cure rate with low morbidity for patients with primary hyperparathyroidism. The advent of localizing studies raises the possibility of unilateral neck exploration. The cost-effectiveness of preoperative localizing studies and unilateral neck exploration in primary hyperparathyroidism are controversial issues. This study was designed to determine the risks of missing a contralateral pathologic parathyroid gland in patients with preoperative localization that was confirmed at neck exploration. METHODS Preoperative studies (ultrasonography, nuclear radioactive imaging scan, or both) were performed in 79 patients with primary hyperparathyroidism. In 58 patients a definite localization of an enlarged parathyroid gland was confirmed at operation. All patients underwent a meticulous bilateral neck exploration. RESULTS Unilateral neck exploration was feasible only in 73.4% of the patients, according to our localizing modalities, and an additional enlarged parathyroid gland on the contralateral side, not detected before operation, was revealed in five patients (8.6%). False-positive rates were 1.7% for ultrasonography and 13% for scan. CONCLUSIONS These results indicate an unacceptably high surgical failure rate for unilateral neck exploration guided by preoperative localizing studies compared with a bilateral neck exploration by an experienced endocrine surgeon, questioning the cost-effectiveness of preoperative localizing studies.

Laparoscopic interval appendectomy for periappendicular abscess

I read the article by Lidar Z et al., which appeared in the online publication of Surgical Endoscopy on the 12 July 2000, with immense interest and reflection. By default, the article addresses a double controversy regarding the management of acute appendicitis, namely, the value and role of both interval appendectomy and laparoscopic appendectomy. The value of interval appendectomy has long been debated. At best, the evidence from the literature suggests that only about 20% of patients benefit from this procedure to prevent recurrent acute appendicitis [1]. Similarly, laparoscopic appendectomy is not recommended unequivocally as the standard operative procedure in all patients [4]. Laparoscopic appendectomy is perhaps the best operative method for an obese female, who would require diagnostic laparoscopy initially for the confirmation of uncomplicated acute appendicitis. On intralaparoscopic diagnosis, appendectomy is undertaken immediately in the same anesthetic setting [4]. The other seemingly controversial matter inadvertantly raised in the article is the diagnosis and management of appendicular abscess, a specific complication of severe acute obstructive appendicitis in the form of a welllocalized pus-filled cavity. Because this is a fluid collection, usually the ultrasound is sufficient to make a definitive diagnosis without a routine resort to computed tomography (CT) scan as practiced by the authors. As with any other well-defined intra-abdominal pus collection, findings have shown percutaneous drainage to be a useful adjunct to combination intravenous antibiotics in its management [2]. It would be interesting to know the mean size of the abscesses because they resolved completely in all the patients with intravenous antibiotics alone. It is conventional practice that patients with an appendicular mass and no well-defined pus collection are managed with intravenous antibiotics alone to control the active localized infection and speed recovery. It is a question whether the abscess described by the authors in this article is in fact an appendicular mass. This doubt is further supported by the authors’ own findings concerning the appendices during interval laparoscopic appendectomy: No remnant abscess was found in any patient. In view of previous intra-abdominal sepsis, it should be anticipated that adhesions would occur to a significant degree between the bowel and the abdominal wall. In this situation, it is widely held that the open method for inserting the first port is strongly indicated to avoid untoward visceral injury by the Veress needle or the trocar [5]. As with open lower midline laparotomy, it is advisable that the urinary bladder be catheterized during any laparoscopic procedure in the pelvis. This may reduce the risk of injury to the bladder and also allow maximum potential of exploratory pelviscopy. The authors present a diagram of port placements, but it does not demonstrate the port positions exactly in relation to the surface anatomy, and there is no specific description in the text. The right 10-mm port is positioned perhaps at the midpoint between the umbilicus and the lateral border of the flank or in a location corresponding to the right midclavicular line. This would avoid injury to the inferior epigastric vessels, which could a cause of conversion. The 5-mm second working port is placed midway between the umbilicus and the symphysis pubis. These positions of the two working ports would allow maximum space for manipulation while preserving the optimal configuration with the laparoscopic view. The authors’ technique for approaching the appendicular vessels in the mesoappendix is simplified perhaps if coagulation diathermy is used instead of clips because the appendicular end artery is tiny. Sometimes, this end artery is thrombosed in severe appendicitis. Thereafter, the mesoappendix, which is devoid of any significant blood vessels in most areas except the free edge, can be diathermized close to the appendix shaft. We have observed that the small area of “trapped” tissues between the distal (stump) double sutures and the proximal (shaft) suture is hyperemic, and that the superficial subserosal vessels are engorged. It is prudent to diathermize these small vessels on the surface of the appendeal tissue before transecting between the two sutures. With regard to extraction of the appendix, the alternative method is by grasping the base of the transected appendix and then pulling it into the 10-mm right working port. Once the whole transected appendix is in the shaft of the 10-mm port, the latter is removed from the abdominal wall, together with the appendix and the laparoscopic grasping forcep in situ. This method obviates the use of an endobag, hence reducing the cost while avoiding subcutaneous fat contamination by the appendix. The authors also state that their experience in managing the periappendicular abscess does not seem to support reports on the increased incidence of intra-abdominal abscess after laparoscopic surgery for perforated appendix. This asCorrespondence to: A. H. Mat Sain Surg Endosc (2001) 15: 1247–1248 DOI: 10.1007/s004640080170

Analysis of Peripheral Blood Lymphocyte Cell Surface Density of Functional and Activation Associated Markers in Young and Old Hemodialysis Patients

Aging has been associated with specific shifts in various peripheral blood immune competent cell subsets. As part of pre-transplant immune profile evaluation possible parallel age-related changes in mean T-cell surface density of several cluster differentiation and activation linked antigens were into 2 groups: group 1-114 patients 40 years old or younger and group 2-36 patients 55 years old or older. Peripheral blood CD3+, DR+, CD3+DR+, CD4+, CD4+DR+, CD8+, CD8+DR+, CD56+, CD8+CD56+, CD3+IL-2-R+ and CD3+TR+ (interleukin-2 and transferrin receptors bearing CD3+ cells respectively), all mononuclear cells expressing IL-2-R and TR, and CD4+CD45+ cell subsets were analyzed and enumerated by 2-color flow cytometry. Subset relative levels as well as absolute counts were recorded. Cell surface density computation was performed using a computerized mathematical model based on fluorescence intensity vector analysis and cell size score determination based on light scatter pattern from raw data obtained by flow cytometry studies. Younger age was significantly associated with higher absolute cell count of CD3+ (p < 0.001), DR+ (p < 0.05), CD4+ (p < 0.01), CD8+ (p < 0.005), CD3+IL-2-R+ (p < 0.05), CD3+TR+ (p < 0.03) and IL-2-R+ (p < 0.05). Older patients had a slightly higher mean absolute count of CD4+CD45+ subset (p not significant) and significantly higher mean count for CD8+CD56+ cell subset (p < 0.001). When cell subset levels were compared between the 2 groups as the relative fraction of cells expressing a given marker out of all mononuclear cells gated out by flow cytometry, younger age was significantly associated with higher levels of CD3+ (p < 0.005), CD8+ (p < 0.001), CD4+DR+ (p < 0.004), CD3-TR+ (p < 0.05) and CD8+IL-2-R+ (p < 0.05). In contrast, slightly higher subset levels of CD56+ (p not significant), and significantly elevated levels of CD8+CD56+ (p < 0.0019) and CD4+CD45+ (p < 0.004) were observed in the older patients. Cell surface density analysis showed that younger patients had higher mean density per cell of CD3 (p < 0.05), CD8 (p < 0.001), IL-2-R on CD3+ cells (p < 0.05) and TR on CD3+ cells (p < 0.05). Mean cell surface density of CD56 on all CD56+ cells as well as on CD8+ cells was higher in older individuals (p < 0.001 and p < 0.003, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Laparoscopic splenectomy for torsion of wandering spleen associated with celiac axis occlusion

Background: Wandering spleen is a spleen lacking its normal ligamentous attachments, and thus subjected to free movement in the abdominal cavity, and even torsion around its pedicle. Surgical treatment includes either fixation (splenopexy) or resection (splenectomy). Both procedures can now be accomplished using the laparoscopic approach. Methods and results: We describe a case of a torsion of a wandering spleen, leading to recurrent episodes of ab-dominal pain, and eventually to splenic ischemia, ne-cessitating splenectomy. The diagnosis was complicated by associated angiographic findings of celiac axis occlusion, possibly by median arcuate ligament compression. Laparoscopic splenectomy was successful, and led to complete resolution of symptoms. Conclusions: Although a rare condition, wandering spleen can be diagnosed accurately by imaging studies, mainly CT scan and angiography. Nowadays, the laparoscopic approach is preferred and enables the surgeon to perform either splenopexy or splenctomy, depending on the vascular status of the spleen.

Down regulation of CD45 expression on CD4 T cells during acute renal allograft rejection: evidence of a decline in T suppressor/inducer activity.

Acute rejection is associated with the activation of helper and cytotoxic cells. A shifting balance between the suppressor/inducer CD45+ CD4+ and T helper/inducer (CD4+CD45−) cells may be responsible for the transition from quiescence to overt rejection. We examined the kinetics of CD45 expression on CD4+ T cells in renal allograft recipients from pretransplant values to acute rejection and after reversal of rejection, searching for a shift in balance between helper/inducer and suppressor/inducer cell subsets. Using two color flow cytometry, the peripheral blood levels of CD4+, CD4+CD45− [T helper/inducer (Thi)], CD4+CD45+ [T suppressor/inducer (Tsi)], CD3+, and CD8+ T cells subsets and their interrelationships, were determined in 49 patients prior to transplantation, and in 10 of them, during acute rejection and after its reversal. Results were analyzed and compared to data obtained from 10 healthy blood donors. Acute rejection was associated with a significant decline in CD45+ CD4+ expression compared to quiescent phase (22% ± 3.7%vs. 26.5% ± 3.2%, p = 0.05) and controls (29.5% ± 6.2%, p = 0.01). No difference was observed compared to pretransplant levels (19.9% ± 3.2%, p = ns). CD45−/CD45+ (Thi/Tsi) ratio was lowest during quiescence (0.75) compared to rejection (0.97, p = 0.05), in controls (0.98, p = 0.05) and pretransplant values (1.4, p = 0.01). Acute rejection was characterized by higher Thi/CD8+ and lower Tsi/CD8+ ratio (103 and 88 respectively, p = 0.045), compared to clinical quiescence (104 and 116 respectively, p = 0.039). These data suggest that acute rejection is associated with down regulation of CD4+CD45+ suppressor/inducer subset. This shift may account for the transition from quiescence to overt rejection, concurring with reports on CD4+CD45 regulatory function.