Surgical endoscopy
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Comparative Study
Laparoscopic cholecystectomy. The early experience of surgical attendings compared with that of residents trained by apprenticeship.
During our first year of laparoscopic surgery, all cases were performed by attending surgeons; resident involvement was confined to camera work and occasionally to acting as first assistant. These residents were PGY3 or -4. During our second year, these same residents, who had learned the craft in the traditional apprenticeship method, on promotion to senior resident functioned as the primary surgeon in laparoscopic cholecystectomy cases, but under very close guidance by the credentialed attending. ⋯ Complication rates were similar in the first and second years. Training residents to do laparoscopic cholecystectomy can be done in a traditional residency program provided the attendings are adequately trained. However, the residents need a higher level of skill at this time than was necessary for open cholecystectomy and have to be further advanced in their training in order to perform this operation laparoscopically.
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Pneumothorax is an uncommon but potentially serious complication that can occur during laparoscopic procedures. A patient under-going laparoscopic cholecystectomy developed an 80% pneumothorax during the course of the procedure and required chest tube insertion. ⋯ The etiology of this complication as well as methods for avoiding this problem have been reviewed. Because of the potential serious nature of this complication, it is imperative that the surgeon be aware of the possibility and implement appropriate immediate therapy.
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It is postulated that laparoscopic cholecystectomy as "patient-friendly surgery" leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n = 382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. ⋯ The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of > 50 VAS points (n = 138) had higher preoperative pain levels (P = 0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P = 0.003-0.031). However, predictive values of these variables were too small to be of clinical benefit.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Reusable instruments are more cost-effective than disposable instruments for laparoscopic cholecystectomy.
Health care costs are rising rapidly, and surgeons can play a role in limiting costs of operations. Of the 600,000 cholecystectomies performed each year in the United States, approximately 80% are performed with laparoscopic technique. The purpose of this study was to compare the costs of reusable vs disposable instruments used during laparoscopic cholecystectomy. ⋯ Theoretical advantages of disposable instruments such as safety, sterility, and better efficiency are not borne out in literature review. In addition, the environmental impact of increased refuse from disposable instruments could not be exactly defined. With the consideration of significant cost savings and the absence of data demonstrating disadvantages of their use, reusable instruments for laparoscopic cholecystectomy, are strongly recommended.
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Extended laparoscopic operations are being performed increasingly in high-risk patients. To assess the effects of increased intraabdominal pressure (IAP) and positive end-expiratory pressure (PEEP) on the hemodynamic and respiratory system during extended procedures a carbon dioxide pneumoperitoneum was artificially induced in 10 dogs undergoing laparoscopic pelvic lymphadenectomy. ⋯ Measurement of arterial carbon dioxide and fractional end-tidal carbon dioxide revealed significant CO2 retention. We conclude from the results that laparoscopic pelvic lymphadenectomy should be performed in high-risk patients only under general anesthesia with expanded cardiopulmonary monitoring.