תוצאת חיפוש

Retroperitoneoscopic Lumbar Sympathectomy

D. Seror, O Zamir, D. Eimerl, H.R. Freund

Depts. of Surgery and Anesthesia, Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem

We present our initial experience with retroperitoneoscopic lumbar sympathectomy in a series of 5 men aged 25-45 years. 3 suffered from ischemia of the lower limbs due to Buerger's disease, 1 had severe reflex sympathetic dystrophy and 1 had vasculitis with severe, non-healing lower leg ulcers.

The right retroperitoneal space was developed with a dissecting balloon-trocar introduced via a small lateral muscle- splitting flank incision. 2 additional 5 mm trocars were used for instrumentation and clipping. L2-L3 or L3-L4 ganglia were resected; mean operating time was 120 minutes. Only oral analgesics were needed for postoperative pain control and oral food intake was resumed the following morning. The procedure was successful in all and was without complications. Mean hospital stay was 2 days.

All patients reported significant relief of ischemia or dystrophic pain and/or improvement in trophic changes in the extremities. In the patient with leg ulcers, the largest was successfully covered with a skin graft. The retroperitoneoscopic approach to lumbar sympathectomy successfully combines the advantages of minimal invasive surgery and the reliability and effectiveness of well-established open sympathectomy.

Tension-Free Repair of Inguinal Hernia with Properitoneal Mesh

Eduard Ramadan, Dan Seror, Roman Belavsky, Zeev Dreznik

Dept. of Surgery A, Rabin Medical Center, Golda Campus (Hasharon Hospital) Petah Tikvah, and Sackler School of Medicine, Tel Aviv University

The results of properitoneal mesh repair of inguinal hernia were evaluated in 38 of 43 consecutive patients operated by Stoppa's technique. In 33 patients the hernia was bilateral and in 10 unilateral; in 20 it was recurrent. In 33/43 patients the mesh was fixed either by sutures or metal clips. The overall recurrence rate after 22 (14-36) months of follow-up, was 10.5%. This result was composed of a 3.0% recurrence rate in the fixated-mesh group, and 30.0% among those with non-fixated mesh.

The outcome following the Stoppa method for tension-free properitoneal mesh repair of inguinal hernia, compares favorably with those of other methods, provided proper attention is paid to adequate mesh placement and fixation. Further prospective studies are needed to define the role and indications for this technique in the laparoscopic era.

Preliminary Experience with Laparoscopic Repair of Inguinal Hernias

Herbert R. Freund, Dan Seror, Dan Eimerl, Oded Zamir

Surgery and Anesthesiology Depts., Hadassah-University Hospital, Mount Scopus, Jerusalem

During 1992-1996 we performed 163 laparoscopic hernia repairs in 100 men and 2 women. The mean age was 50.6; and in 61 the operation was bilateral. 66 were by transabdominal preperitoneal approach and 36 btotal extra-peritoneal approach. There were only a few minor complications and total recurrence rate was only 4.3%, partly attributable to our learning curve. Laparoscopic inguinal herniorrhaphy reduces postoperative incisional and muscular pain and causes less disruption in the postoperative period than open repair. Return to normal activity and work is faster for laparoscopic than for open repair, but operating room costs are higher (time and equipment). However, economic advantages for the national economy should be considered.

Nissen Fundoplication by Laparoscopy

Dan Seror, Oded Zamir, Raphael Udassin, Amos Vromen, Tanir M. Allweis, Herbert R. Freund

Depts. of Surgery and Pediatric Surgery, Hadassah-University Hospital, Mount Scopus, Jerusalem

Short term results following laparoscopic Nissen fundoplication were evaluated in 31 patients with symptomatic gastroesophageal reflux. 6 were females and 26 males, and they ranged in age from 5 months to 64 years (mean: 4.9 years in 19 younger than 18 years, and 39.3 years in 12 adults). Most of the adults who complained of pain and heartburn underwent pH monitoring, endoscopy, and manometry as needed. Milk scan was the most useful diagnostic tool for the evaluation of the children, who suffered mainly from gastroesophageal-related pulmonary disease. Indications for laparoscopic operation were identical with those for conventional open Nissen fundoplication. 1 case of dysautonomia died postoperatively; the rate of complications, mostly minor, was 22.5%. 3 patients required conversion to open Nissen fundoplication due to cardiorespiratory instability secondary to pneumothorax in 2, and to esophageal perforation in the third. 5 adults developed temporary dysphagia. 3 children had only partial improvement in their pulmonary disease following the operation, while the other 15 had complete relief. The total time for the laparoscopic operation averaged 245 minutes in adults, and 228 in children. Discharge was usually on the fourth postoperative day in adults (mean: 6.0 days). Regurgitation and heartburn were cured in 10 out of 11 adults (91%). All parents of children were satisfied. Symptomatic outcomes following laparoscopic Nissen fundoplication compare favorably with those of open surgery with respect to mortality, complications, and outcome.

Thoracoscopic Biopsy of Pulmonary Lesions in Nonpulmonary Malignancy following Chemotherapy

Oded Zamir, Myriam Weyl Ben-Arush, Dan Seror, Herbert R. Freund

Surgical Dept., Hadassah-University Hospital, Mount Scopus, Jerusalem and Miri Shitrit Pediatric Hematology and Oncology Unit, Rambam Medical Center, Haifa

The appearance of focal pulmonary lesions in a patient with a nonpulmonary malignancy is worrisome. Apart from metastasis, the differential diagnosis includes benign conditions such as infectious and granulomatous diseases, enlarged lymph nodes, atelectasis, radiation pneumonitis, and bronchiolitis obliterans with organizing pneumonia (BOOP). CT-guided needle biopsy is not always diagnostic and may not be feasible in very small lesions. Since open lung biopsy is associated with considerable morbidity, many physicians tend to postpone tissue diagnosis for a few weeks and perform a biopsy only if repeat chest CT scans show increase in size or number of the lesions. This approach may lead to undesirable delay of appropriate treatment. We report video-assisted thoracoscopic lung biopsy in 7 patients with nonpulmonary malignancy who developed lung lesions following chemotherapy and/or radiation therapy. Histological examination proved metastatic lesions in only 2. There were no operative complications and recovery was rapid and smooth in all patients. Thoracoscopic lung biopsy is an effective, minimally invasive diagnostic tool that obviates the need for thoracotomy in these patients.