G. T. Deans

Absorption of bupivacaine from the pre-peritoneal space in laparoscopic hernia repair

SummaryLocal anaesthetic placed into the pre-peritoneal space during laparoscopic hernia repair may provide additional pain relief, reducing the requirement for post-operative analgesia. The systemic absorption of such drugs from this space has not previously been determined. Twenty patients undergoing laparoscopic transperitoneal hernia repair were randomly allocated to receive bupivacaine 1.5mg/kg or bupivacaine 1.5mg/kg with 1:200000 adrenaline. Venous blood samples were obtained at 10, 15, 30, 60 and 90 min following instillation of bupivacaine. Plasma levels of bupivacaine at these times were determined using high pressure gas liquid chromatography. No patient experienced signs or symptoms of bupivacaine toxicity. Mean plasma concentrations of bupivacaine peaked at 30 min and did not reach toxic levels. The addition of adrenaline did not significantly alter the systemic absorption of bupivacaine. Instilling bupivacaine 1.5mg/kg into the pre-peritoneal space is associated with a low risk of toxicity. ...

Iatrogenic laparoscopic spigelian hernia: A possible cause and prevention

SummaryFollowing laparoscopic hernia repair, small bowel hemiation occurred through the posterior rectus sheath of a cannula site despite closure of the anterior sheath. The proposed mechanism was coalescence of two adjacent 12 mm defects, resulting from the re-introduction of a displaced cannula. It is recommended that a displaced cannula be re-introduced along the original track using a blunt trocar. This should be done whilst observing the procedure with the video camera. Prevention of cannula site hernia can only be ensured with complete closure of both anterior and posterior rectus sheath.

‘Persistent gall-bladder’ after laparoscopic cholecystectomy

SummaryAn ultrasound scan is recommended for the investigation of post-cholecystectomy symptoms. In two patients ultrasound scan reported a persistent gall-bladder following laparoscopic cholecystectomy. ERCP identified a choledochal cyst in one and no abnormality in the other. Failure to detect choledochal cysts is equally likely following laparoscopic and open surgery, and ERCP should be considered the investigation of choice for recurrent symptoms following cholecystectomy.

Peritoneal lavage for treatment of bile leak complicating laparoscopic cholecystectomy

SummaryLeakage of bile following cholecystectomy can cause severe pain and necessitate further operation for satisfactory drainage. We have managed three such cases by percutaneous insertion of two drains, allowing continuous peritoneal lavage, with rapid symptomatic improvement. The technique has the theoretical advantages of diluting the bile to reduce infection, while maintaining the principles of a minimally invasive approach and is advocated in patients with severe pain from bile leaks following laparoscopic cholecystectomy.

Adrenal cyst complicating the treatment of prostatic cancer

SummaryA 46-year-old man developed suspected adrenal metastases while on cyproterone and goserelin therapy for prostatic carcinoma. He underwent laparoscopic adrenalectomy for, what proved histologically, to be a benign haematogenous cyst. Clinicians should be aware that adrenal imaging abnormalities in patients on cyproterone acetate could be related to benign, possibly drug-related changes rather than metastatic disease. If excision biopsy is required, laparoscopic adrenalectomy should be considered.

A method of objective measurement of rehabilitation after inguinal hernia repair

SummaryThis study describes an objective measurement of rehabilitation after inguinal hernia repair, by assessing the ability to drive. When performing an emergency stop the reaction time (RT) and the time taken to achieve full depression of the brake pedal (MPPT) were measured. The method was validated by testing reproducibility of measurements on 10 individuals, with no significant variation found on the different occasions. One hundred and seventy-five people (99 women) with valid driving licences were selected at random and assessed. The median age was 50 (range 19–85) yr and no significant correlation was found between age and the measured values. The results obtained were similar to the values used by the Highway Code to calculate stopping distances (mean MPPT 670 ms; Highway Code 700 ms). It is intended to use this method to study rehabilitation in patients following inguinal hernia repair.