Laparoscopic varicocele ligation

A laparoscopic varicocele ligation was performed in 49 men with a clinically proven varicocele. Patients were treated predominantly on a day case or overnight basis with minimal post-operative morbidity. Identification of the testicular artery was aided by a laparoscopic Doppler probe in the majority of patients and preserved in 39 cases. The varicocele persisted in 7 patients, 4 of whom have subsequently had an inguinal exploration confirming a missed testicular vein as the source. In all 7 patients the artery was identified without the use of the Doppler probe, this being suggestive of misidentification of the vessels at laparoscopy. The complications included 4 wound infections, 1 scrotal haematoma and 1 vasal injury which necessitated an open vasovasostomy. Laparoscopic varicocele ligation is a simple and safe technique, causing minimal morbidity and enabling a rapid return to normal activity. The success rate can be improved by accurate identification of the testicular vessels with the use of a laparoscopic Doppler probe.

Improved venous drainage of the radial artery forearm free flap: use of the profundus cubitalis vein

The radial artery forearm free flap (RAFFF) is a versatile and popular flap used in various reconstructive procedures. This flap contains two venous drainage systems: a superficial (cephalic) route, and a deep (venae comitantes) route. Most surgeons use either the deep venous system alone or in combination with a superficial vessel, hence requiring two venous anastomoses. The authors describe a novel technique of providing venous drainage for the RAFFF, incorporating both deep and superficial systems, and using one venous anastomosis. From 10 consecutive operative and five cadaveric dissections, it was noted that paired venae comitantes, corresponding to the radial artery, coalesce into a single vein at the level of the brachial artery bifurcation. The profundus cubitalis vein (vena anastomotica) connects this coalesced (deep) vein to the cephalic (superficial) vein at the level of the cubital fossa. Both the deep and superficial venous systems are drained via one large anastomosis, situated proximal to the profundus cubitalis interconnection. Advantages of this technique include: 1) improved venous drainage of the RAFFF; 2) rendering the venous anastomosis technically easier, due to its larger size; and 3) more available versatility in designing the venous portion of the vascular pedicle.

[Results of surgical therapy for venous insufficiency as a cause of erectile disorders]

Since penile vein ligation is usually associated with a poor postoperative outcome, a study was undertaken to evaluate possible prognostic factors for this procedure. A total of 44 patients with erectile dysfunction underwent ligation of all dorsal penile veins and resection of the deep dorsal penile vein for venous impotence. A comprehensive study of all patients was made. All patients did not respond to pharmacotherapy and had a venous leak. With a minimum follow-up period of 6 months, patients were categorized as follows: full spontaneous erections, those patients responding to pharmacotherapy and those showing no improvement. Out of 44 patients, 13 had full spontaneous erections postoperatively, 5 now responded to pharmacotherapy and 26 showed no improvement. The maintenance flow was 89 +/- 50 ml/min in the group with spontaneous erections and 85 +/- 49 ml/min in those showing no improvement (P = 0.78). Out of the 20 patients with normal single potential analysis of cavernous electric activity (SPACE), 12 had full erections postoperatively, 4 showed no improvement and 4 responded to pharmacotherapy. Of the 24 patients with abnormal SPACE, 1 developed full erections, 1 now responds to pharmacotherapy and 22 showed no improvement. Our results indicate that SPACE seems to be an important prognostic factor for the postoperative outcome of penile vein ligations for venous impotence.

[Resection of posterior tibial veins with ligation of arteriovenous anastomosis in acute ischemia of the lower extremities]

The paper deals with the pathophysiological validation and assessment of the efficiency of a new low-traumatic operation aimed at decreasing the degree of injured extremity ischemia in patients with atherosclerosis obliterans and decompensation of peripheral circulation. The essence of the operation is to remove arteriovenous shunting into the shin. Eighteen patients were operated on, out of them only 5 underwent a subsequent amputation. It is concluded that this intervention is promising and indications for it are defined in this paper.

[The realities and prospects for temporary intravascular prosthesis in emergency vascular surgery]

Results of using temporary prostheses in 58 patients with different injuries of blood vessels are analyzed. Most often tubular materials were used for the prostheses. The authors consider that temporary prostheses must be used only in cases of a real threat of irreversible ischemia of extremities and when specialized angiosurgical aid is not possible within 4-6 hours and more.

Snuff-box arteriovenous fistulas

A total of 192 AV fistulas were created at the anatomical snuff-box. One hundred and eighty-two (94.8%) of them were patent and ready for use at the end of one month. This fistula has several advantages over the more commonly performed Brescia-Cimino radio cephalic fistula at the distal forearm. Snuff-box fistula is easier to perform, has a better patency rate, fewer wound complications and preserves proximal sites for fistula.

Foot volumetry and duplex ultrasonography after saphenous and subfascial perforating vein ligation for recurrent venous ulceration

Forty-three patients undergoing superficial and perforating vein ligation for recurrent venous ulceration underwent preoperative and postoperative foot volumetry and postoperative duplex ultrasonography. Patients were followed for a median of 66 (range 18-144) months. Of nine patients who developed recurrent ulceration, six had femoral vein incompetence and all had popliteal vein incompetence demonstrated by duplex ultrasonography. Of the 34 patients who remained ulcer-free, five had femoral vein incompetence and a single patient had popliteal vein incompetence on duplex scanning, giving positive predictive values for recurrent ulceration of 55 per cent (femoral vein incompetence) and 90 per cent (popliteal vein incompetence). Patients with saphenofemoral incompetence on late follow-up were also more likely to suffer recurrence. Preoperative foot volumetry with tourniquet occlusion of superficial veins showed that the median expulsion fraction of patients who developed recurrent ulcer during follow-up was 0.8 (range 0.6-2.3) per cent compared with 1.5 (range 0.4-2.9) per cent for those who remained ulcer-free (P = 0.025); the median half-refilling time of patients with recurrent ulcer was 1.5 (range 0.5-5.5) s compared with 5.0 (range 0.5-23.0) s for those without recurrence (P < 0.01). Postoperative foot volumetry showed similar differences. Deep venous incompetence, particularly of the popliteal segment, as demonstrated by duplex ultrasonography and foot volumetry, is a useful predictor of recurrent ulceration after subfascial perforator and superficial venous ligation.

The pedicled arterialized venous flap

The arterialized venous flap, in which arterial blood flowing through a vein returns to the venous system through the pedicle, was devised to solve the problems of increasing flap size and raising the overall success rate. This flap can obtain satisfactory blood inflow and pressure. The flap was clinically applied to reconstruct skin defects in three cases, with two complete successes and one partial superficial necrosis. This technique provides a flap to cover a relatively large defect, with no shunt formation, and a high success rate.

[Laparoscope in urology]

From March 1992 to Nov. 1992, laparoscopic operations were carried out in 15 patients with urological diseases, including 7 ligation of the spermatic vein, 4 pelvic lymph node resection and 4 impalpable testis, and satisfactory results were obtained in all the 15 patients. We experienced that the laparoscopic treatment is a good way of operation. It may greatly reduce discomfort of the patients.

Percutaneous minisurgical phlebectomy

Percutaneous Minisurgical Phlebectomy is a safe and effective form of permanent treatment for side-branch varicosis in addition to other varicose veins (except the proximal part of the long saphenous vein) by means of multiple 1 to 2 mm incisions. The operation is performed using local anaesthesia in the outpatient department. There is no need for prophylaxis against thrombosis. Complications are rare and inconsequential.

[Section of the spermatic vein]

Surgical treatment of varicocele can be carried out using different techniques. The laparoscopic approach [1-2] represent a new trend that we used to ligate and dissect the spermatic vein in 10 patients, 8 with monolateral left varicocele and 2 with bilateral varicocele. The average time for laparoscopic surgery has been 45 minutes for monolateral varicocele and 65 minutes in the bilateral one. The absence of important complications during and after the operation has allowed to dismiss all patients 48 hours after the surgical treatment. The preferential direction of laparoscopic approach to varicocele is represented by the bilateral form.

[Ligation of the internal spermatic vein through 2 laparoscopic ports]

Thirty-three two port laparoscopic internal spermatic vein ligations have been performed in 31 patients in our Department. The procedure carried out through two 10 mm ports in a mean time of 25 minutes decreases both the invasivity of intervention and the costs when reusable instruments are used. The technique is feasible with an operative laparoscope (working channel diameter 4 mm) through which a grasp can be maneuvered. The two port procedure is as safe as the three port procedures. Preliminary follow up indicated only one recurrence of varicocele (4%). Out of the 19 patients treated for male subfertility who have at least a 6 month follow up, eleven reported an improvement in seminal quality. All the patients but one were discharged on the first postoperative day. Laparoscopic internal spermatic vein ligation provides a real alternative to different surgical techniques decreasing postoperative pain and shortening period of convalescence with immediate return to full activity. The advantages of laparoscopic internal spermatic vein ligation are increased with the two port procedure.

Analysis of microsurgical penile revascularization results by etiology of impotence

We reviewed the results of microsurgical penile revascularization, with or without a combined procedure to correct cavernosal venous leakage, in 50 consecutive patients with vasculogenic impotence. All patients underwent an extensive preoperative evaluation, including dynamic infusion cavernosography and cavernosometry, and selective penile arteriography. Overall 48% (24 patients) had an excellent postoperative result, 40% (20 patients) were improved and 12% (6 patients) failed, with a median followup of 24 months (range 19 to 56). Furthermore, these results appear durable with no significant difference in length of followup between groups irrespective of surgical outcome (p > 0.05). Analysis of surgical outcomes by preoperative etiology of impotence (pure arterial versus arterial combined with corporeal venous dysfunction) revealed a statistically significant advantage of an excellent surgical outcome in patients with pure arterial impotence compared to those with mixed etiology with results of 67% and 42%, respectively (p < 0.01). There was no significant difference in outcome when patients were analyzed with respect to age or duration of impotence (p > 0.05). We conclude that in patients with arteriogenic impotence identification of concomitant corporeal veno-occlusive dysfunction diagnosed by preoperative dynamic infusion cavernosography and cavernosometry may be helpful, not only in planning a more physiological surgical procedure but also in predicting long-term postoperative success.

Radiosurgery for venous angiomas

Radiosurgical treatment with the gamma knife for venous angiomas was used as an alternative to microsurgical removal in order to avoid abrupt cessation of venous drainage, which may be shared by the venous angioma and important parts of the brain. Thirteen cases of venous angioma were treated between 1977 and 1991. In two cases cavernous angiomas were also present and in one case a distant arteriovenous malformation (AVM) was also found. In two cases the angioma shared the venous drainage with an adjoining AVM; this is the first description of such pathology. For venous angiomas irradiation was prescribed to cover at least the convergence of the medullary veins. For AVM's close to a venous angioma the treatment was exclusively prescribed to the AVM nidus. After treatment, complete obliteration of the venous angioma was observed in one case, partial obliteration was observed in three cases, and five venous angiomas were unaffected by the treatment. Undue effects of radiation occurred in four cases: one focal edema and three radionecroses. Extirpation of the radionecrotic tissue 6 months after radiosurgery was necessary in one case. In the other three cases, the venous angioma was observed to be completely or partially obliterated, or unaffected by the treatment (one case each). In two cases of combined AVM and venous angioma, complete obliteration of the treatment AVM nidus was obtained. It is concluded that radiosurgery for venous angioma, although conceptually attractive, still does not fulfill the rigid criteria of minimal risk which must be set for the treatment of a lesion with a benign natural history.

The radial forearm flap donor site: should we vein graft the artery? A comparative study

Controversy exists in the literature regarding reconstruction of the radial artery after elevation of the radial forearm flap. The literature suggests that reconstructing the radial artery with a vein graft is an important aspect in the use of this flap. In our experience, this has never been performed with no sequela. We examined 13 consecutive patients who underwent radial forearm flaps for head and neck reconstruction over a 28-month period. The patients were examined and questioned about the function of their upper extremities in hope of evaluating the postoperative vascular status in each. Median follow-up was 6 months, with a range of 1 month to 24 months. No patient had preexisting trauma or congenital abnormality of either arm, so that the nondonor arm could be considered as a control for each patient. Evaluation consisted of history and physical examination. The following parameters in each patient were carefully accumulated: grip strength, cutaneous blood flow measured by using a laser Doppler flowmeter, transcutaneous oxygen levels, digital/brachial blood pressure ratios, cutaneous temperature from thumb/index and thumb/small pinch, and rapid rewarming at 1-minute and 5-minute intervals after cold immersion for 2 minutes. The radial forearm flap was elevated in each patient in the nondominant extremity. Grip strengths ranged from 19 to 77 kg, with a median of 30 kg. Early rewarming of the thumb/index was also an average of 1.5 degrees less than the temperature in the control arm and was statistically significant to (p = .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Alternative techniques for gaining venous access. What to do when peripheral intravenous catheterization is not possible

There are a number of therapeutic options for fluid administration in patients who lack usual venous access. Ways to establish this access include limb elevation and wrapping, the application of nitroglycerin ointment to dilate veins, and blood pressure cuff inflation. Ultrasonography can also be used to delineate vascular structures. Cutdown procedures are the oldest, most direct method to reach uncommon venous sites, such as the inferior epigastric, intercostal, iliac, and lateral thoracic veins. Today, cutdown procedures are regarded as the method of last resort, and they should be performed in operating suites or similar settings. Possible complications include inadvertent arterial puncture and hemorrhage.

[The CHIVA cure of varices of the lower extremities. La Cure Conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire]

Presentation of the characteristics of this technique described by the French physician C. Franceschi, in 1988. Our Department began to apply this method on may 1991 and we are the first team in Spain to carry out and systematize this cure. Up to date, 85 patients have been treated with a residual vein percentage of 18%. Morbidity is low and slight. There is no mortality. This method is considered interesting as it does not require hospitalization, conserves the vein capital of the patient, and has low labour and health care costs.

[Arterial vascular injuries in fractures or dislocations of the lower extremity. Therapeutic concept and results]

Combinations of fractures or dislocations with vascular damage of the leg have a high incidence of amputation or severe functional deficit. With this type of lesion 22 patients were treated at "Bergmannsheil" from 1986 to 1991. Using a pre-, intra- and postoperative protocol, the amputation rate decreased to 18%. More than 80% of the patients had a good function of their leg with only minor joint restrictions.

Microsurgical replantation of the avulsed scalp: report of six cases

This article reports the successful microsurgical replantation of six scalps avulsed for over 3 to 11 hr, after trauma and before repair, including five total and one partial avulsion. The authors believe that one key to successful replantation is effective vessel anastomoses. In the reported series, three scalps were reconstructed with two superficial temporal vessels and in five cases, with a 1:1 ratio between arteries and veins. The partially avulsed scalp was replanted successfully with only one artery and one vein. The management of postoperative complications is discussed.

Prefabricated venous flaps: an experimental study in rabbits

Prefabrication is a method for creating donor flaps by implantation of a nourishing pedicle prior to harvesting the flap. Based on the concept that implantation of a "flow-through" vein results in sufficient vascularisation to support a skin flap, we used a rabbit model to investigate the viability of prefabricated total venous perfusion (TVP) flaps. Prefabrication of an abdominal wall donor site was performed using the left epigastric vein in 25 male New Zealand white rabbits. An 8 x 10 cm skin flap was elevated 1, 2, 3, 4, and 6 weeks after prefabrication (n = 5 per group). A silicone sheet was implanted under the skin flap. The mean survival rate of skin flaps was 24%, 52%, 87%, 83%, 84%, respectively. Results of this study show that reproducible survival of a prefabricated TVP flap can be obtained when the flap is elevated more than 3 weeks after prefabrication.

[The surgical anatomical characteristics of the ureteral arteries and veins in nephroptosis and defects requiring surgical correction]

Specific features of blood supply and topography of the ureters in patients with nephroptosis, multiple arteries of the kidneys and ureteral duplication were established on the material of 42 preparations of the kidneys and ureters taken from corpses of people who died at the age from 20 to 78 years. Standard anatomical methods were used. It was shown that in people with nephroptosis at the sites of the approach of the upper ureter vessels, of cross of the ureters and the testicular (ovarian) and iliac vessels there are points of fixation around which the ureters undergo greatest deformities and might be responsible for disturbances of the urine outflow. The ureteral vessels are often involved in adhesions in the sites of deformities of the ureters. In cases with a duplication of the renal arteries as a rule have their beginning from the renal artery located below (72,2i%). With a greater distance between the beginning of the doubled renal arteries the upper ureteral arteries on one side, the lower artery of the kidney is located atypically (behind the inferior vena cava) and is not a source of blood supply of the ureter. In cases with a partial duplication (split) of the ureters in the abdominal part they are supplied with blood from the common source.

Upper-extremity deep venous thrombosis: analysis of 52 cases

In a review of 52 cases of deep venous thrombosis (DVT) of the upper extremity, the predisposing factors, clinical manifestations, topography of thrombosis, treatment employed, presence of complications, and evolution of the disease were investigated. In all patients, clinical manifestations were confirmed by bilateral phlebography and superior cavography. Thirty-five (67%) of the patients were male; the mean age was 45.4 years. Clinical manifestations were edema in 51 patients (98%), dilated collateral circulation in 37 (71%), and pain in 33 (63%). One patient presented with pulmonary embolism and another with phlegmasia cerulea dolens-like signs in an extremity. The right axillosubclavian segment was involved in 23 patients (44%), the left in 17 (33%), and both left and right segments associated with DVT of the superior vena cava in 11 (21%). One patient had left and right axillosubclavian thrombosis without superior vena cava involvement. The main predisposing factors identified were central venous catheterization in 15 patients (29%) and extrinsic compression, caused mainly by cancer, in 15 (29%). There were three cases of DVT related to effort and three to thoracic outlet syndrome. The majority of patients were treated with systemic heparin therapy followed by oral anticoagulation. During a follow-up of 6 months, nine patients died, one from pulmonary embolism; 21 patients (40%) were symptom-free, 11 (21%) had minimal edema, and seven (13%) had symptomless edema. Four patients (8%) were lost to follow-up. The overall incidence of pulmonary embolism was 4%.(ABSTRACT TRUNCATED AT 250 WORDS)