RESUMEN
Laparoscopic repair of recurrent inguinal hernias is becoming increasingly accepted in surgical practice, using an extraperitoneal or transabdominal approach for the placement of mesh. Previous literature reflects that efforts to perform open repair of recurrent inguinal hernias often result in further recurrences, testicular damage, or nerve injuries. Our study reflects physical examination of 37 patients over 4 years that underwent laparoscopic repair of recurrent inguinal hernia(s). Early and late complications are presented. The re-recurrence rate at this short follow up to 54 months is quite low at 2.5%. The laparoscopic repair of recurrent hernia reflects a very low likelihood of recurrence, low occurrence of testicular damage, and less likelihood of other such complications as nerve or spermatic cord injury (none of these occurred in this study). Seroma was clinically significant in 3 patients and no infections were noted. Our study and ongoing careful follow-up are the subject of this report.
Asunto(s)
Hernia Inguinal/cirugía , Laparoscopía/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Femenino , Estudios de Seguimiento , Hernia Inguinal/diagnóstico por imagen , Hernia Inguinal/epidemiología , Humanos , Complicaciones Intraoperatorias/epidemiología , Masculino , Persona de Mediana Edad , Recurrencia , Testículo/lesiones , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: This study was performed to compare the clinical outcome after gallbladder aspiration with that after percutaneous cholecystostomy in non-critically ill patients with acute cholecystitis who were at high risk from surgery. MATERIALS AND METHODS: Medical records of 53 consecutive non-critically ill, high-surgical-risk patients admitted with acute cholecystitis between July 1995 and July 1999 were reviewed. Thirty-one had gallbladder aspiration and 22 had percutaneous cholecystostomy. The primary outcome measure of clinical response within 72 hr and the secondary outcome measures of overall positive response rate, complication rate, time to resolution, and rate of recurrence of acute cholecystitis were compared between the two groups. RESULTS: Gallbladder aspiration and percutaneous cholecystostomy were technically successful in 30 (97%) and 21 (97%) patients, respectively; of these, 23 (77%) and 19 (90%) patients responded clinically within 72 hr (p > 0.2). Complications occurred in three patients (12%) after percutaneous cholecystostomy and in none after gallbladder aspiration (p < 0.05). No significant difference was noted in the other secondary outcome measures of the two groups. CONCLUSION: We found no significant difference in the clinical outcomes of gallbladder aspiration and percutaneous cholecystostomy in the treatment of acute cholecystitis in high-surgical-risk patients who are not critically ill. However, we found gallbladder aspiration to be significantly safer. Therefore, gallbladder aspiration should be the procedure of choice in high-risk patients with acute cholecystitis who are not critically ill, and percutaneous cholecystectomy should be reserved as a salvage procedure if gallbladder aspiration is technically or clinically unsuccessful.
Asunto(s)
Colecistitis/cirugía , Colecistostomía , Succión , Enfermedad Aguda , Anciano , Colecistitis/diagnóstico por imagen , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento , UltrasonografíaRESUMEN
In a sample of 1,166 Catholic high school students (age = 13-18 years), the author used confirmatory factor analysis to validate a 30-item instrument that assesses 6 dimensions of attitude to Christianity (viz., attitude to prayer, attitude to God, attitude to Jesus, attitude to the Bible, attitude to Christian practice, attitude to social justice). Goodness-of-fit indices for the proposed measurement model revealed that the model fitted the data very well, thus confirming the instrument's structure. A correlation analysis revealed associations between religious behavior and attitude to Christianity.
Asunto(s)
Actitud , Catolicismo , Cristianismo , Religión y Psicología , Adolescente , Femenino , Humanos , Masculino , Nueva Gales del Sur , Inventario de Personalidad , Identificación Social , Justicia SocialRESUMEN
Incisional hernia repair poses a difficult problem for the general surgeon because of the high incidence of recurrence (50%) and a reported 10% infection rate. Use of a mesh by the anterior approach to replace or reinforce the defect has marginally reduced the recurrence rate, but not the infection rate, especially in obese patients. With the evolution of minimally invasive surgery, we thought that a potential was present to reduce the postoperative stay, lessen pain, and decrease the incidence of both recurrence and infection. From February 1991 through February 1998, a total of 176 patients with complicated umbilical and incisional hernias have been repaired; the follow-up has been from 1 to 84 months. The complication rate was 5.1%, with an infection rate of 1.7% and a 1.1% incidence of recurrence. Seventeen patients had combined procedures, including cholecystectomy, inguinal hernia repair, and antireflux procedures.
Asunto(s)
Hernia Ventral/cirugía , Laparoscopía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hernia Ventral/diagnóstico , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Recurrencia , Resultado del TratamientoRESUMEN
BACKGROUND: Management of cholelithiasis and choledocholithiasis usually requires two separate teams-the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. METHODS: In 1990-1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. RESULTS: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). CONCLUSIONS: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease.
Asunto(s)
Conducto Colédoco/cirugía , Cálculos Biliares/cirugía , Laparoscopía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Expanding upon our experience with laparoscopic surgery for colonic benign and malignant processes and for bowel obstruction, we have reviewed our experience with minimal access laparoscopic surgery for complicated diverticular disease. We propose an approach of surgical care incorporating diagnostic laparoscopy in those not responding to medical therapy alone. METHODS: Our study includes data from two different surgical teams working in separate hospital-and-patient environments. Our theory that laparoscopy could be widely applicable to this complex disease process is borne out by experience in both locations. One hundred forty-eight patients were managed by laparoscopic or laparoscopically assisted methods with 18 patients requiring drainage only without resection. RESULTS: Our management of 148 of 164 patients (90%) by laparoscopic approach was successful, with a very acceptable morbidity of 5% in the elective cases and decreased ileus (20% of open vs 7% laparoscopic) in acute complicated cases. Elective resections required hospitalization of 4-5 days, demonstrating the benefits of incorporating laparoscopy in the care of these cases, particularly when compared to standard open procedures requiring 8 days' hospitalization. CONCLUSIONS: We believe complications of diverticular disease including abscess, perforation, fistula, and bleeding can potentially be managed in this way by minimal access procedures, decreasing postoperative wound problems, decreasing length of hospitalization and overall morbidity, and improving patient care.
Asunto(s)
Diverticulitis del Colon/cirugía , Divertículo del Colon/cirugía , Hemorragia Gastrointestinal/cirugía , Perforación Intestinal/cirugía , Laparoscopía , Adulto , Anciano , Anciano de 80 o más Años , Diverticulitis del Colon/complicaciones , Diverticulitis del Colon/epidemiología , Divertículo del Colon/complicaciones , Divertículo del Colon/epidemiología , Femenino , Hemorragia Gastrointestinal/epidemiología , Hemorragia Gastrointestinal/etiología , Humanos , Perforación Intestinal/epidemiología , Perforación Intestinal/etiología , Laparoscopía/efectos adversos , Laparoscopía/métodos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Morbilidad , Complicaciones Posoperatorias , Estudios Retrospectivos , Rotura Espontánea , Resultado del TratamientoRESUMEN
UNLABELLED: Laparoscopy for colonic diseases began in 1990 and has established a role in benign disease. Early observations and experiences demonstrated feasibility of laparoscopic surgery for a variety of colonic disease processes, but the applicability to colonic carcinoma was unclear. METHODS: In 1990, we began a comparative study of open (OCR) vs. laparoscopic (LCR) approach to colon cancer. The study progressed 65 months, with 224 patients in OCR group and 191 patients in LCR group. Parameters studied are stage, location, length of specimen, number of lymph nodes resected, margins, postoperative course, wound complications, recurrence rates, and immediate and long-term survival. OCR were standardized by one group, and LCR were standardized by a second group. All patients undergoing LCR were given freedom to choose either OCR or LCR, and informed consent was obtained. RESULTS: Equal or greater lymph node retrieval, resections, and distal margins were evident with LCR. Benefits with LCR were shown with shorter hospitalization (5.7 vs. 9.7 days), less blood loss, less wound problems (1 vs. 14), and quicker return of bowel function. Survival, recurrence, and death rates were essentially the same. There were no trocar implants in the LCR group. CONCLUSION: After five years, this study shows that laparoscopy does no harm to the patient, offers comparable oncologic resections, and seems to be patient-friendly, with less pain, quicker return of bowel functions, shortened hospitalization, and quicker return to full activity.
Asunto(s)
Carcinoma/cirugía , Colectomía/métodos , Neoplasias del Colon/cirugía , Laparoscopía/métodos , Laparotomía/métodos , Recurrencia Local de Neoplasia/etiología , Anciano , Colectomía/efectos adversos , Femenino , Humanos , Laparoscopía/efectos adversos , Laparotomía/efectos adversos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Advances in laparoscopic surgery have drastically modified not only the thinking of most general surgeons, but have also helped to change the approach to many disease processes. The tremendous success of the laparoscopic approach to biliary tract disease as well as to appendicitis, trauma, and even colonic disease led us to consideration and evaluation of laparoscopy as a tool in the management of patients with acute and chronic intestinal obstruction. Forearmed with laparoscopic skills gained performing laparoscopic cholecystectomy, common bile duct exploration, appendectomy, and laparoscopic colon resection and cognizant of the many patients with simple adhesions, internal herniae, and volvulus, we included all patients with suspected intestinal obstruction who did not have resolution of signs and symptoms with conservative treatment in this study. Patients were treated initially with intravenous fluids, nasogastric suction, and correction of electrolyte disturbances. Laparoscopy was performed on 23 patients during the period of May 1991 through April 1993 with resolution of the problem laparoscopically in 20. Details of pathological processes, operations performed, technique, and guidelines for laparoscopy are included.
Asunto(s)
Obstrucción Intestinal/cirugía , Intestino Delgado/cirugía , Laparoscopía , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Obstrucción Intestinal/complicaciones , Obstrucción Intestinal/etiología , Laparoscopios , Laparoscopía/efectos adversos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Factores de TiempoRESUMEN
We report our experience with laparoscopic surgical treatment of gallstone ileus, along with cholecystectomy and repair of a cholecystoduodenal fistula. The technique and advantages are discussed. To our knowledge, this is the first such case done laparoscopically to be reported in the world literature.
Asunto(s)
Colelitiasis/complicaciones , Enfermedades del Íleon/etiología , Enfermedades del Íleon/cirugía , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Laparoscopía , Anciano , Anciano de 80 o más Años , Fístula Biliar/cirugía , Colecistectomía Laparoscópica , Enfermedades Duodenales/cirugía , Femenino , Enfermedades de la Vesícula Biliar/cirugía , Humanos , Fístula Intestinal/cirugíaRESUMEN
As is pointed out in multiple publications, laparoscopic cholecystectomy has rapidly gained recognition an acceptance in the management of chronic cholecystitis and most cases of acute cholecystitis.A low incidence of complications accompanies laparoscopic cholecystectomy now that experience has been gained with this procedure by laparoscopically skilled surgeons.v-¼ However, the management of stones found or suspected in the common bile duct continues to be controversial. The gold standard for treatment of choledocholisthiasis remains the open exploration of the bile ducts with a reported mortality of 0.3%-0.19% and a rate of retained stones of between 2-4 %. Both surgeons and gastroenterologists skilled in endoscopy have espoused endoscopic retrograde cholangiopanreatography and sphincterotomy (ERCP/ES) preoperatively or postoperatively for the treatment of known common bile duct stones This approach adds additional procedures and potentially compounds the complications of the separate operative interventions to deal with the diseased gallbladder and to clear the common bile duct of obstruction. In several series of patients the morbidity of endoscopic sphincterotomy has ranged from 9-16%, with bleeding, acute pancreatitis, acute cholangitis, residual stones, duodenal perforation, and common bile duct perforation the leading causes of complications. There continues to be an incidence of retained stones of 9.1-14.7% with ERCP/ES.Furthermore, as high as 86% of indiscriminate preoperative ERCP studies show no evidence of stones in the common bile duct, making this an unnecessary intervention in such cases. There has been no consistent reduction in subsequent mortality in complicated biliary cases by the use of ERCP/ES alone, even with the gallbladder left in situ.