RESUMEN
Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.
Asunto(s)
Colecistectomía Laparoscópica , Colecistitis/cirugía , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/métodos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
STUDY AIM: Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission. PATIENTS AND METHODS: Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve. RESULTS: Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death. CONCLUSION: Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.
Asunto(s)
Pancreatitis/clasificación , Índice de Severidad de la Enfermedad , APACHE , Enfermedad Aguda , Área Bajo la Curva , Enfermedades de las Vías Biliares/complicaciones , Estudios de Cohortes , Etanol/efectos adversos , Femenino , Predicción , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Pancreatitis/diagnóstico , Pancreatitis/diagnóstico por imagen , Pancreatitis/etiología , Admisión del Paciente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Tasa de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: This article describes a preliminary work on virtual reality applied to liver surgery and discusses the repercussions of assisted surgical strategy and surgical simulation on tomorrow's surgery. SUMMARY BACKGROUND DATA: Liver surgery is considered difficult because of the complexity and variability of the organ. Common generic tools for presurgical medical image visualization do not fulfill the requirements for the liver, restricting comprehension of a patient's specific liver anatomy. METHODS: Using data from the National Library of Medicine, a realistic three-dimensional image was created, including the envelope and the four internal arborescences. A computer interface was developed to manipulate the organ and to define surgical resection planes according to internal anatomy. The first step of surgical simulation was implemented, providing the organ with real-time deformation computation. RESULTS: The three-dimensional anatomy of the liver could be clearly visualized. The virtual organ could be manipulated and a resection defined depending on the anatomic relations between the arborescences, the tumor, and the external envelope. The resulting parts could also be visualized and manipulated. The simulation allowed the deformation of a liver model in real time by means of a realistic laparoscopic tool. CONCLUSIONS: Three-dimensional visualization of the organ in relation to the pathology is of great help to appreciate the complex anatomy of the liver. Using virtual reality concepts (navigation, interaction, and immersion), surgical planning, training, and teaching for this complex surgical procedure may be possible. The ability to practice a given gesture repeatedly will revolutionize surgical training, and the combination of surgical planning and simulation will improve the efficiency of intervention, leading to optimal care delivery.
Asunto(s)
Simulación por Computador , Hígado/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Procesamiento de Imagen Asistido por ComputadorRESUMEN
BACKGROUND: The possibility of performing minimally invasive exploration of the abdomen could avoid unnecessary appendectomies. Micro-optics and instruments of 2 mm in diameter allow this type of exploration, but the feasibility and the accuracy of the diagnosis resulting from this method have not been evaluated. METHODS: A prospective study of 36 patients (11 men and 25 women) operated on for acute right iliac fossa pain was carried out. The abdomen was explored with a 2 mm optic and with a 10 mm optic in order to characterize the aspect of the appendix. The results were compared with the postoperative pathologic findings of the appendix. RESULTS: The micro-optic procedure failed in 3 patients. The appendix was visualized in 26 patients: in 18 patients through the needle-optic alone, 8 patients requiring additional instruments. The appendix was visualized in all cases with the 10 mm optic. Appendectomy was performed in 34 patients: with microinstruments in 6, with 5 mm instruments in 26, and through a MacBurney incision in 2. The appendix was not removed in 2 patients. A correct diagnosis was made by microlaparoscopy and confirmed by the pathology in 21 patients (58%), made and confirmed in 32 patients with a 10 mm optic (89%). Minor complications included a cecal wall insufflation in 1 patient and a peroperative hemorrhage on a 2 mm port site in another with an uneventful postoperative course. One postoperative parietal hematoma required reoperating removal. No mortality was observed. CONCLUSIONS: The low quality of the image obtained with microlaparoscopy does not permit safely evaluating the aspect of the appendix in case of acute right iliac pain. This method is not recommended for routine abdominal exploration.
Asunto(s)
Abdomen Agudo/diagnóstico , Dolor Abdominal/diagnóstico , Apendicitis/diagnóstico , Apéndice/patología , Laparoscopía , Abdomen Agudo/etiología , Abdomen Agudo/cirugía , Dolor Abdominal/etiología , Dolor Abdominal/cirugía , Adolescente , Adulto , Apendicectomía/métodos , Apendicitis/etiología , Apendicitis/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Surgical simulation increasingly appears to be an essential aspect of tomorrow's surgery. The development of a hepatic surgery simulator is an advanced concept calling for a new writing system which will transform the medical world: virtual reality. Virtual reality extends the perception of our five senses by representing more than the real state of things by the means of computer sciences and robotics. It consists of three concepts: immersion, navigation and interaction. Three reasons have led us to develop this simulator: the first is to provide the surgeon with a comprehensive visualisation of the organ. The second reasons is to allow for planning and surgical simulation that could be compared with the detailed flight-plan for a commercial jet pilot. The third lies in the fact that virtual reality is an integrated part of the concept of computer assisted surgical procedure. The project consists of a sophisticated simulator which must include five requirements: a) visual fidelity, b) interactivity, c) physical properties, d) physiological properties, e) sensory input and output. In this report we describe how to obtain a realistic 3D model of the liver from bi-dimensional 2D medical images for anatomical and surgical training. The introduction of a tumor and the consequent planning and virtual resection is also described, as are force feedback and real-time interaction.
Asunto(s)
Procesamiento de Imagen Asistido por Computador/instrumentación , Robótica/instrumentación , Procedimientos Quirúrgicos Operativos/tendencias , Interfaz Usuario-Computador , Anatomía Transversal , Simulación por Computador , Predicción , Hepatectomía/instrumentación , Humanos , Neoplasias Hepáticas/cirugía , Fantasmas de ImagenRESUMEN
Surgical simulation increasingly appears to be an essential aspect of tomorrow's surgery. The development of a hepatic surgery simulator is an advanced concept calling for a new writing system which will transform the medical world: virtual reality. Virtual reality extends the perception of our five senses by representing more than the real state of things by the means of computer sciences and robotics. It consists of three concepts: immersion, navigation and interaction. Three reasons have led us to develop this simulator: the first is to provide the surgeon with a comprehensive visualisation of the organ. The second reason is to allow for planning and surgical simulation that could be compared with the detailed flight-plan for a commercial jet pilot. The third lies in the fact that virtual reality is an integrated part of the concept of computer assisted surgical procedure. The project consists of a sophisticated simulator which has to include five requirements: visual fidelity, interactivity, physical properties, physiological properties, sensory input and output. In this report we will describe how to get a realistic 3D model of the liver from bi-dimensional 2D medical images for anatomical and surgical training. The introduction of a tumor and the consequent planning and virtual resection is also described, as are force feedback and real-time interaction.
Asunto(s)
Simulación por Computador , Procedimientos Quirúrgicos del Sistema Digestivo , Telemedicina , Interfaz Usuario-Computador , HumanosRESUMEN
After observing a benign tumour of the small bowel which led to ileo-ileal invagination in an adult we recalled the main data on the epidemiology, aetiology and diagnosis. In infants, the diagnosis is usually made but in adults, the situation is much rarer and the clinical and radiographic signs are not specific. Echotomography of the abdomen is the most reliable examination. In the adult, surgery is always indicated because invagination is caused by an organic cause in 9 out of 10 cases.
Asunto(s)
Enfermedades del Íleon/diagnóstico por imagen , Intususcepción/diagnóstico por imagen , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/etiología , Abdomen Agudo/cirugía , Urgencias Médicas , Humanos , Enfermedades del Íleon/cirugía , Intususcepción/cirugía , Laparotomía , Masculino , Persona de Mediana Edad , UltrasonografíaRESUMEN
This study is an updating on synthetic prostheses used today to repair incisional hernias, eviscerations and abdominal wall defects due to a severe infection or a parietal excision of malignant tumours. The present prostheses are the fruits of the constantly developing plastic industry. Their characteristics and types (mesh or patch), together with the materials they are made of, are studied taking this development into account. The tissular reactions caused by prostheses are different depending on whether the material they are made of is an absorbable one or not. Published data on animal experimentation are largely used in this part of the study. A significant part is also allocated to the pathobiology of prostheses infection on which is based prevention of risk infection in the surgical practice. A synthetic prostheses has to be chosen depending on its characteristics and the tissular reactions it generates. In a septic environment, only absorbable prostheses can be used without risk. As for incisional hernias, which allows the authors to refer to their own expérience, the choice also depends on both the surgeon's own conception of the treatment and its purpose. The defect recovery after parietal excision of malignant tumours is eased by the use of a synthetic prostheses. In the future, synthetic prostheses will be even more used than today in the repair of abdominal wall. A present, the materials they are made of keep on being developed.