Surgical endoscopy
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High-risk patients may not be good candidates for laparoscopic surgery due to the metabolic consequences of transperitoneal absorption of insufflated CO(2) gas and the necessity of general anesthesia because CO(2) insufflation produces pain. Helium gas is metabolically inert and does not produce pain. Thus it permits an alternative approach to performing laparoscopic surgery in high-risk patients. ⋯ Helium gas should be considered the agent of choice for intraperitoneal insufflation in high-risk patients not only because helium avoids the metabolic consequences of CO(2) insufflation but also because it permits selected procedures to be performed under local-regional anesthesia. Helium may be contraindicated for laparoscopic procedures involving extraperitoneal insufflation due to the increased risk for pneumothoraces.
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Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. ⋯ Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.
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Randomized Controlled Trial Comparative Study Clinical Trial
Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy.
Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. ⋯ Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease.
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In most cases, myasthenia gravis (MG) and thymoma require complete removal of the thymus gland and resection of the pericardial fatty tissue. There is some debate however, over which surgical approach is best for thymectomy. We have developed a new technique for complete thoracoscopic thymectomy. ⋯ While the short-term improvement of MG after this procedure was comparable to that seen with conventional surgery, the short- and intermediate-term quality of life was much better. The preliminary results of thoracoscopic thymectomy appear to be excellent for both patients and neurologists. A prospective randomized trial has been designed to compare thoracoscopic thymectomy with the gold standard of median sternotomy for thymectomy.
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Comparative Study
Laparoscopic Heller's myotomy or botulinum toxin injection for management of esophageal achalasia. Patient choice and treatment outcomes.
Esophageal achalasia is a rare disease in which degenerating parasympathetic innervation of the lower esophageal sphincter (LES) leads to unopposed sympathetic tone and failure to relax on deglutition, resulting in a range of symptoms for the patient, most notably dysphagia, chest pain, regurgitation, and weight loss. Laparoscopic Heller's esophagomyotomy (Lap-HM) and botulinum toxin (BoTox) injection into the LES are two recently described methods for treating achalasia. No comparison of laparoscopic Heller's myotomy and botulinum toxin has yet been presented. ⋯ BoTox injection and Lap-HM both significantly reduce achalasia symptoms, but only Lap-HM improves esophageal clearance of barium. BoTox injection is the most popular treatment method from a patient perspective, although symptom recurrence or failure rates are high. Lap-HM is favored by younger patients and is equally effective after BoTox therapy failure.