Laparoscopic cholecystectomy: strategy and concerns

After briefly describing the first laparoscopic cholecystectomy performed by Philippe Mouret, the authors review some of the differences in strategy, management and concerns between conventional and laparoscopic cholecystectomy. They address the problems relating to the required skills of triangulation and camera handling, the presence of common-duct stones and concomitant disease, the issues of drainage, hemostasis, access in difficult cases, iatrogenic trauma to the bile ducts and pertinent differences in cardiorespiratory function.

Prevention of vascular injuries in revision total hip replacement

Iliac-vessel injury from total hip arthroplasty is associated with hemorrhagic complications and an increased death rate. The authors identified seven patients who had severe medial displacement of the acetabular prosthesis and associated vascular injury to the iliac vessels after total hip replacement. One patient had two hip replacements. Preoperative findings included a pelvic mass (three hips), pelvic pain (eight), radiologic evidence of cement in the pelvis (three) and the acetabular prosthesis in the pelvis (eight), computed tomographic evidence of cement in the pelvis and proximity of the prosthesis to the iliac vessels (four), and arteriography showing displacement or compression of the iliac vessels (seven). Operative management in all cases involved medial exposure, mobilization and repair of the iliac vessels before revision of the hip prosthesis. Postoperative complications were deep vein thrombosis (three), in spite of prophylaxis, and occlusion of a vein interposition graft (one) requiring placement of a femoral crossover graft. There were no deaths, amputations or hemorrhagic complications. The authors advocate preoperative identification of patients who have iliac-vessel involvement by their total hip prosthesis and initial medial extraperitoneal exposure and repair of these vessels before removal of the displaced acetabular prosthesis.

Preoperative care of infants with nephroblastoma. The International Society of Pediatric Oncology 6 experience

The International Society of Pediatric Oncology (SIOP) recommends preoperative treatment in the management of eligible patients with Wilms' tumor. Until 1980, children younger than 12 months of age (infants) at diagnosis had been excluded from the SIOP trials. SIOP 6, conducted from 1980 to 1987, was the first SIOP study to include infants older than 6 months of age. This retrospective analysis of 145 infants registered to SIOP 6 demonstrates that in infants older than 6 months and having favorable histology (FH), a two-drug preoperative chemotherapy (CT) regimen of 4 weeks significantly ameliorated stage distribution as determined at delayed surgery but did not affect a good outcome. However, the CT dose utilized in SIOP 6 resulted in an unacceptable toxicity in this age group, and SIOP 9, the new SIOP study of Wilms' tumor, recommends a reduced dose of CT in infants. Preoperative CT is not recommended in infants younger than 6 months of age. Specifically, the high incidence (29%) of mesoblastic nephroma in this age group does not justify such an approach. Histopathologic diagnosis should be obtained in these patients before any treatment.

The pre-operative treatment of oesophageal carcinoma with synchronously administered chemotherapy and radiotherapy

Forty-six patients with either squamous cell cancer of the oesophagus or adenocarcinoma involving the lower oesophagus have been treated with synchronously administered radiotherapy and chemotherapy (5FU & Cisplatin) prior to resection of the oesophagus. Endoscopically, complete regression of tumour occurred in 21 patients (46%) and when the oesophagus was resected in these patients, it was found that 11 of the resected specimens contained residual tumour deep to the mucosa. Thus, the actual complete regression rate in the 46 patients was 22%. The postoperative mortality rate was 13% (22% in the first half of the series and 4% in the second half). The median survival rate was 36 months in the 24 patients operated on for squamous cancer of the oesophagus, and 14.5 months in 18 patients operated on for adenocarcinoma of the cardia. Eight patients are alive and disease free at more than three years from surgery, and all of these patients had a squamous cell carcinoma, and all had a complete histological response from their preoperative radiotherapy and chemotherapy.

Guidelines for the use of fresh frozen plasma. British Committee for Standards in Haematology, Working Party of the Blood Transfusion Task Force

Fresh frozen plasma should only be used to treat bleeding episodes or prepare patients for surgery in certain defined situations. Definite indications for the use of FFP: 1. Replacement of single coagulation factor deficiencies, where a specific or combined factor concentrate is unavailable. 2. Immediate reversal or warfarin effect. 3. Acute disseminated intravascular coagulation (DIC). 4. Thrombotic thrombocytopenic purpura (TTP). Conditional uses: FFP only indicated in the presence of bleeding and disturbed coagulation: 1. Massive transfusion. 2. Liver disease. 3. cardiopulmonary bypass surgery. 4. Special paediatric indications. No justification for the use of FFP: 1. Hypovolaemia. 2. Plasma exchange procedures. 3. 'Formula' replacement. 4. Nutritional support. 5. Treatment of immunodeficiency states.

Effectiveness of a preoperative teaching programme for cataract patients

Shortened hospital stays have necessitated examination of alternative approaches for pre and postoperative teaching. An investigation of one alternative became a study in which a home care preoperative teaching programme for older adults undergoing cataract extractions with lens implants was implemented and evaluated. The findings indicated that the teaching programme was effective and resulted in positive benefits.

[Acute appendicitis. Preoperative observation time and diagnostic accuracy]

The indication for operative treatment of suspected acute appendicitis is based mainly on clinical examination. In this retrospective study of 327 emergency laparotomies the accuracy of the surgeons diagnosis was 69.4%. The overall rate of unnecessary laparotomy was 28.4%, and 45.6% of the operated females, aged 12 to 40 years, did not actually require surgery. The median postadmission delay before operation was three hours 28 minutes. With increasing observation time, the diagnostic accuracy was significantly decreased from 77.7 to 52.2%, and the incidence of perforation rose from 18.6 to 33.3%. 8.7% of the patients with a surgical condition suffered from excessive delay (greater than 12 hours) before surgery. There was no correlation between time of admission and operation and accuracy of diagnosis, but a considerable variation in accuracy between different surgeons. The difficulty in obtaining a correct pre-operative diagnosis in patients with suspected acute appendicitis is still a clinical problem of major concern.

Information yield from routine pre-operative chest radiography and electrocardiography

Studies in First-World settings suggest that routine pre-operative investigations are of minimal usefulness. A retrospective study of 797 case records determined the yield of significant information from routine chest radiography and ECG in a provincial general hospital serving a broad socio-economic sector. The results were in agreement with those of other studies, viz. that routine investigation may be worthwhile only in older patients. Routine chest radiographs showed an overall positive yield of 6%; 17% in those over 60 years but only 2% in those under 60 years. Routine ECGs showed a positive yield of 7% overall; 7.4% in those older than 40 years and 4.5% in those under 40 years. Investigations indicated by history or physical examination had a significantly greater yield: 34% for chest radiography and 31% for ECGs. Positive results of indicated investigations were more evenly spread across the age groups. The pre-eminence of clinical skills in determining which patients require special investigations is reaffirmed.

Preoperative preparation for day surgery

Day surgery is expanding in the UK. It offers benefits for both the patient and the NHS. If this initial momentum is to be maintained it is vital that patients are carefully selected and prepared for day case procedures. Failure to do so will result in falling standards and loss of support from both clinicians and patients.

Ambulatory ophthalmic surgery and the Health Care Financing Administration's Outpatient Surgery Generic Quality Screen Guidelines

The quality of care rendered in ambulatory ophthalmic surgical centers is subject to the standards outlined in the Health Care Financing Administration's "Outpatient Surgery Generic Quality Screen Guidelines." Ophthalmic Surgery accounts for 28.2% of all ambulatory surgery performed in the United States. Diabetes, respiratory disorders, renal failure, and hypertension are a few of the clinical problems that are handled in a nontraditional fashion in ophthalmic surgery facilities throughout the United States with excellent results and low incidence of complications. Trends in the clinical management of patients in ophthalmic surgical centers are described by data obtained in a survey conducted by the anesthesia and surgical staff of the Parris-Castoro Cataract and Laser Center in Bel Air, MD. The survey addressed the current trends in obtaining history and physicals, electrocardiograms, chest radiographs, and laboratory studies before outpatient ophthalmic surgery.

Stair climbing, pre- and post-exercise arterial blood gases, and pulmonary function for pre-operative evaluation

In order to determine the relationship between pulmonary function, performance on stair climbing, pre- and post-exercise arterial blood gases and post thoracotomy complications, we performed a prospective study on 19 patients. Sixteen of seventeen patients could accomplish a five flight stair climb. All of the seventeen patients survived and could be weaned off the respirator. Four developed postoperative complications. MMEFP (per cent mid maximum expiratory flow) showed statistically significant differences between patients with and without complications.

[Current practice and attitude of anesthesiologists for prescribing preoperative investigative tests]

A telephone enquiry was undertaken to assess current practice among French anaesthetists, and to obtain their opinion, concerning preoperative laboratory screening tests. It included 204 anaesthetists, randomly selected from the membership directory of the French Society of Anaesthetics and Intensive Care. The sample was concordant with the distribution (sex and age) given by the specialists' list of the National Medical Council. It comprised 64.2% male anaesthetists, and the overall mean age was 44.2 years. On average, each anaesthetist carried out 26 elective and 4 emergency anaesthetist a week. An organized preanaesthetic consultation was available in only 73% of public hospitals. However, even when existing, it does not automatically concern all surgical stations of the hospital and only 59% of patients benefit from that consultation. In 55% of patients the screening tests had still been made before the preanaesthetic consultation for scheduled surgery. About 15% of patients were seen for the first time by an anaesthetist on the very day of surgery. A routine prescription of preoperative tests was not systematic. Non prescription ranged from 7 to 34% of patients, depending on the tests. The responders recognized that for the same tests the rate could be comprised between 21 and 66% of patients. Moreover, 38% of anaesthetists admitted that sometimes they did not see results of the prescribed tests before carrying out the anaesthetic. Overprescription of preoperative tests has been recognized. However, legal, organisational, relational or economical reasons are given which may explain difficulties met with to rationalize prescription of these tests.

Lymphoscintigraphy in malignant melanoma

The development and rationale for the use of lymphoscintigraphy in the preoperative evaluation of patients with malignant melanoma being considered for elective lymph node dissection is reviewed. This overview is updated by an analysis of 135 patients with early stage malignant melanoma involving the head, neck, shoulders, and trunk at Moffitt Cancer Center and Research Institute at the University of South Florida (Tampa, FL). High discordancy rates (overall, 41%) were seen between drainage patterns predicted from historical anatomical guidelines and those revealed by the lymphoscintigraphic examination. The high discordancy rate was most pronounced in the head (64%) and the neck (73%). Surgical management was changed in 33% of the patients, overall. A preoperative lymphoscintigram is recommended for all patients with melanoma with head, neck, and truncal lesions evaluated for elective lymph node dissection as the lymphatic drainage patterns are often unpredictable and variable.

Evaluation of pre-admission screening of elderly patients accepted for major joint replacement

Valuable orthopaedic operating time is frequently lost because patients are found to be medically unfit for surgery on admission. One hundred and forty seven consecutive patients aged 60 years or older, who had been accepted for major joint replacement and who lived within 15 miles of the Western Infirmary, Glasgow were screened at a preadmission clinic. The screening protocol had been agreed by orthopaedic and anaesthetic staff involved in major joint replacement surgery. Some 42 patients had medical illnesses which would have resulted in surgery being postponed and a further five had their surgery cancelled. Six patients passed fit for surgery at the pre-admission screening clinic were unfit for surgery on admission. Two patients in this group had their surgery cancelled. Using the guidelines suggested, pre-admission screening could be carried out by the patient's general practitioner (GP) or by a member of the medical staff when the patient attends the orthopaedic out-patient clinic. By following a simple protocol the amount of valuable operating time lost through unrecognised or poorly controlled medical illness could be greatly reduced. Pre-admission screening should result in more efficient use of scarce hospital resources and improved patient care.

Implication of altered pulmonary function in pneumonectomy for tuberculous destroyed lung

Twelve patients undergoing pneumonectomy for tuberculous destroyed lung were studied to determine the value of preoperative spirometry in the assessment of their pulmonary reserve, and prediction of their postoperative morbidity. Preoperatively, the mean functional losses (as percentage of predicted values) were 44.5% of FVC, 54% of FEV, and 44% of PFR. No significant alteration occurred in FVC, FEV1 or PFR post-pneumonectomy. All patients were in Class 1 (NYHA) pre- and postoperatively. It is concluded that operability in these patients cannot be based on broncho-spirometry. The assessment of preoperative clinical (symptomatic) stage and the cardiovascular status appears to be the major determinants of pulmonary functional results.

Routine use of vaginal ultrasonography in the preoperative evaluation of gynecologic patients. An adjunct to resident education

To determine the clinical utility of routine vaginal ultrasound in evaluating gynecologic patients, we prospectively studied 133 women scheduled to undergo elective surgery based upon abnormal clinical findings as determined by residents and faculty in a large, county-based teaching hospital. Patients were examined bimanually by the surgeons and then examined ultrasonographically using a 5.0-MHz vaginal probe. Surgery was scheduled within 48 hours of the clinical examinations. Vaginosonography demonstrated enhanced sensitivity, specificity and predictive value as compared to bimanual pelvic examination. The technique was quickly mastered by resident physicians, with discrepancies between preoperative ultrasound observations and actual surgical findings present in but 15 of 532 instances. Vaginal ultrasonography is an effective routine adjunct to physical examination in the preoperative evaluation of surgical patients. Furthermore, it has diagnostic capabilities superior to those of the bimanual pelvic examination and increases the accuracy of preoperative diagnoses in gynecologic patients.