Christopher J. Saunders

Is outpatient laparoscopic cholecystectomy wise

The authors report a prospective analysis of their experience with 506 consecutive laparoscopic cholecystectomies to examine the appropriatenss of outpatient or same-day laparoscopic cholecystectomy. Thirty-eight patients experienced at least one postoperative complication. The complication was clinically evident or suspected in only 4 of these 38 patients within 8 h following surgery. Thirty-nine percent and 76% of complications were clinically detected at 24 and 48 h, respectively. Nausea and vomiting occurred among 32% of all patients on the day of operation and extended into the 1st postoperative day in 10%. Compared to predicted values, forced vital capacity was 61±5% 1 h postoperatively in 32 patients studied. At 6 and 24 h postoperatively, forced vital capacity was 63±7% and 66±7% respectively. Postoperative analgesic medication requirement was determined in 220 patients who were provided with a patient-controlled intravenous morphine analgesia machine with no basal rate. Consumption of morphine was highly variable but substantial on the day of operation: 17±16 mg. Most complications of laparoscopic cholecystectomy, including life-threatening complications, are not apparent by 8 h postoperatively and may not be apparent at 24 h. The potential for delay in the diagnosis and treatment of complications, variable but substantial analgesic requirements, impaired postoperative ventilation, and postoperative gastrointestinal dysfunction argue for the need to use great caution in selecting patients for outpatient laparoscopic cholecystectomy. Criteria are proposed to identify patients who are safest for outpatient laparoscopic cholecystectomy.

Transantral endoscopic orbital floor exploration: A cadaver and clinical study

&NA; A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4‐mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico‐orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area >2 cm2 and two fractures with an area of <2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a <2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists in the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture. (Plast. Reconstr. Surg. 100: 575, 1997.)

Hemodynamic effects of argon pneumoperitoneum

The hemodynamic effects of argon pneumoperitoneum were studied to define its possible role as an alternative gas for intraperitoneal insufflation during minimally invasive surgery.Adult pigs were anesthetized and placed on mechanical ventilation. Parameters measured or determined included mean arterial (MAP), pulmonary arterial (PAP), pulmonary arterial wedge (PAWP), right atrial (CVP), and inferior vena cava venous (IVC) pressures, total excretion of CO2 (VCO2), oxygen consumption (VO2), minute ventilation, and arterial blood gases. Also determined were cardiac output, stroke volume, and systemic vascular resistance all indexed to weight (CI, SVI, SVRI). Data were recorded during a 1-h baseline, 2 h of insufflation with argon gas at a constant pressure of 15 mmHg, and 1 h recovery after desufflation.There was no significant change from baseline in VCO2, VO2, MAP, PAP, PAWP, CVP, PaCO2, or arterial pH. Argon pneumoperitoneum significantly increased systemic vascular resistance index and exerted a depressant effect on stroke volume index and cardiac index by 25% and 30% from baseline values, respectively (P<0.05). Inferior vena cava pressure increased as a reflection of the intraabdominal pressure. Argon insufflation had no effect on respiratory function.Argon gas may not be physiologically inert, and in patients with cardiovascular disease its effects may be clinically important.

Arterial anatomy of the oral cavity: an analysis of vascular territories.

&NA; Knowledge of the specific cutaneous or surface regions supplied by constant named arterial sources has allowed for increasing clinical application of flap transfers of tissue. Despite the routine use of intraoral flaps for reconstruction of congenital or acquired defects of the oral cavity and pharynx, no previous investigation has centered on understanding the surface or mucosal arterial territories of the oral cavity. In a cadaver study, six mucosal territories of the intraoral cavity were defined using selective ink and lead oxide injections through named arteries. The anatomical boundaries of these territories are predictable and constant in location for different cadavers. The six contiguous territories are based on the buccal, labial, inferior alveolar, ascending palatine, ascending pharyngeal, and lingual arteries. This study supports the safe vascular basis of existing clinical procedures of the intraoral cavity and may have implications for the design of new intraoral reconstructive procedures. (Plast. Reconstr. Surg. 100: 582, 1997.)

arterial Vascular Anatomy of the Umbilicus

&NA; The rare occurrence of umbilical necrosis after performance of a transverse rectus abdominis muscle (TRAM) flap prompted this investigation into the specific arterial anatomy of the umbilicus using multiple anatomic techniques. Sixteen fresh cadavers were studied by using dissection of blue latex‐injected specimens, radiography of barium latex‐injected specimens, and selective ink injection of individual perforators. It was discovered that the umbilicus receives arterial inflow by means of three distinct deep sources in addition to the subdermal plexus. These deep sources are (1) the right and left deep inferior epigastric arteries that each give off several small branches, and a large ascending branch, which courses between the muscle and the posterior rectus sheath passing directly to the umbilicus; (2) the ligamentum teres hepaticum; and (3) the median umbilical ligament. The clinical implications of this study are that the umbilicus should have robust arterial inflow if only one rectus muscle is removed, such as during a unilateral TRAM flap, because the contralateral side should still provide large direct vessels from the deep inferior epigastric arteries to the umbilicus. During bilateral TRAM elevation, all of the large arterial sources are removed from the umbilical inflow and circulation must depend on small vessels from the ligamentum teres and median umbilical ligament. Care should be taken in this latter clinical situation to preserve these sources of blood flow during umbilical flap creation. (Plast. Reconstr. Surg. 102: 761, 1998.)

Percutaneous diagnostic peritoneal lavage using a Veress needle versus an open technique : A prospective randomized trial

OBJECTIVE To prospectively compare the speed, sensitivity, complications, and technical failures of percutaneous diagnostic peritoneal lavage (DPL) using a Veress needle versus open DPL. METHODS One hundred seventy-six blunt trauma patients requiring DPL were prospectively randomized to undergo either open DPL using a standard technique or percutaneous DPL using an 18-gauge Veress needle to penetrate the peritoneal cavity, with the lavage catheter then being inserted over a guide wire. RESULTS Mean time to successful placement of the lavage catheter for the percutaneous Veress needle technique was 2.73 minutes versus 7.28 minutes for the open DPL technique (p < 0.001). Sixteen percent of open lavage procedures took more than 11 minutes; the majority (60%) of Veress needle lavage procedures took less than 2 minutes. There were no false-negative findings in either group, and there was one false-positive result in each group. A wound infection after an open DPL was the only complication. Poor return of lavage fluid (<200 mL) accounted for most technical failures; this was more prevalent with the percutaneous method (11.2%) than with the open technique (3.8%) (p < 0.05). CONCLUSION The percutaneous DPL method using a Veress needle is significantly faster than the open DPL method. The Veress needle lavage was as safe and as sensitive as the open lavage; however, technical failure occurred more frequently with the Veress needle lavage than with the open DPL.

Bregmatic epidermoid inclusion cyst eroding both calvarial tables.

Dermoid and epidermoid cysts are uncommon masses in the head and neck region of children. Although the most common location of inclusion cysts in the head and neck is the bregma, masses in this region must be differentiated from midline hemangiomas, lipomas, hematomas, or encephaloceles. Inclusion cysts should be considered in the differential diagnosis of all midline cystic lesions in infants, because, if left untreated, it may lead to devastating complications. We present the case of a slowly enlarging midline mass in a female infant to illustrate the potential for serious sequelae from inclusion cysts.

Reconstruction of the Toddler Diaphragm in Severe Anterolateral Congenital Diaphragmatic Hernia with the Reverse Latissimus Dorsi Flap

The management of infants with severe congenital diaphragmatic hernia (CDH) continues to evolve. When a prosthetic patch is placed in the neonatal period for pleuroperitoneal separation, it ultimately will require a subsequent reconstruction for progressive pulmonary or abdominal symptomatology. The reverse latissimus dorsi (RLD) flap has been used for reconstruction in only several reports in the last 12 years. In this paper, a patient with severe anterolateral CDH is reconstructed with the RLD flap on an elective basis at 2 years of age. Elective repair was performed for the particular indication of chest wall restriction imposed by the nonpliable Gore-Tex patch. In this case, use of the RLD flap alone without the use of synthetic mesh has resulted in satisfactory results with 17 months of follow up.

Endoscopically assisted facial suspension for treatment of facial palsy.

Static suspension remains an option for certain patients with facial paralysis. Endoscopically assisted facial suspension obviates the need for a counter-incision at the oral commissure to distally inset the fascia lata graft as described in the standard technique. The endoscopic technique is simple, allows secure placement of perioral fascial strips, and can be performed as an outpatient.

Bregmatic masses in children.

Bregmatic masses often present a challenging diagnostic dilemma. We present two illustrative cases to demonstrate this clinical problem and present our recommendations for evaluation and treatment.