Journal of the American College of Surgeons
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To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. ⋯ The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.
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We have previously demonstrated that maintenance of a low central venous pressure (LCVP) combined with extrahepatic control of venous outflow reduced the overall blood loss during major hepatic resections. This study examined the overall outcomes and, in particular, renal morbidity associated with a large series of consecutive major liver resections performed with this approach. In addition, the rationale for the anesthetic management to maintain LCVP was carefully reviewed. ⋯ Major resection with LCVP allowed easy control of the hepatic veins before and during parenchymal transection. The anesthetic technique, designed to maintain LCVP during the critical stages of hepatic resection, not only helped to minimize blood loss and mortality but also preserved renal function.
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Comparative Study
Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy?
Chronic inguinodynia or neuralgia after conventional inguinal herniorrhaphy is rare, and diagnosing the exact cause is difficult. Treatment has ranged from local injection to remedial surgery with variable results. The increasing popularity of prosthetic mesh repairs (tension free, plug, or laparoscopic) has not eliminated these pain syndromes from occasionally occurring. Recommended management in these situations is extremely difficult. ⋯ Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia). It appears that coincident neurectomy affords better results than mesh removal alone. Relief with nerve block did not predict favorable outcomes. Despite the popularity and favorable outcomes of prosthetic mesh repairs, persistent postoperative pain still occurs in a small cohort of patients. This may become more evident with the rising interest in laparoscopy. Correcting this problem once presented can be a formidable task. Remedial inguinal surgery with mesh removal and neurectomy will cure selected patients.