Biomedical subjects

K L Harold

Publications and source records attributed to K L Harold.

7 recordsLinked to original sources

PubMed2003

Plastic wound protectors do not affect wound infection rates following laparoscopic-assisted colectomy.

BACKGROUND: Wound protectors are plastic sheaths that can be used to line a wound during surgery. Wound protectors can facilitate retraction of an incision without the need for other mechanical retractors and have been proposed as deterrents to wound infection. The purpose of this study was to define the ability of wound protectors to reduce the rate of infection when used in laparoscopic-assisted colectomy. METHODS: We completed a retrospective review of the medical records of patients undergoing nonemergent laparoscopic-assisted colectomy between February 1999 and November 2002. All completely laparoscopic cases were excluded. The wound protector, when used, was applied to the extraction incision during the externalized portion of the procedure (colon and mesentery transection, anastomosis). Outcomes for patients with and without the use of a wound protector were compared. RESULTS: A total of 141 patients underwent laparoscopic-assisted colectomy (98 for benign/malignant tumors, 35 for diverticular disease, and eight for Crohn's disease). There were no differences between the wound protector group ( n = 84) and the no wound protector group ( n = 57) with respect to mean age (55 vs 58 years), average body mass index (27 vs 29 kg/m2), gender, indication for surgery, comorbidities, antibiotics used, or mean operative time (185 vs 173 min). Nine patients in the wound protector group and eight in the no wound protector group developed a wound infection at the colon extraction site ( p = 0.42). Patients undergoing resection for Crohn's disease or diverticulitis had a higher infection rate (18.6%) than patients undergoing resection for polyps or cancer (9.2%; p < 0.05). No wound recurrence of cancer was observed in either group at a mean follow-up of 23 months (range, 3-48). CONCLUSIONS: The wound protector, although useful for mechanical retraction of small wounds, does not significantly diminish the rate of wound infection at the bowel resection/anastomotic site. Patients undergoing elective resection for inflammatory processes have higher infection rates than patients undergoing laparoscopic-assisted colectomy for polyps or cancer.

Adult↗

PubMed2003

Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries.

BACKGROUND: Advanced laparoscopic procedures have necessitated the development of new technology for vascular control. Suture ligation can be time-consuming and cumbersome during laparoscopic dissection. Titanium clips have been used for hemostasis, and recently plastic clips and energy sources such as ultrasonic coagulating shears and bipolar thermal energy devices have become popular. The purpose of this study was to compare the bursting pressure of arteries sealed with ultrasonic coagulating shears (UCS), electrothermal bipolar vessel sealer (EBVS), titanium laparoscopic clips (LCs), and plastic laparoscopic clips (PCs). In addition, the spread of thermal injury from the UCS and the EBVS was compared. METHODS: Arteries in three size groups (2-3, 4-5 and 6-7 mm) were harvested from freshly euthanized pigs. Each of the four devices was used to seal 16 specimens from each size group for burst testing. A 5-Fr catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end. This defined the bursting pressure in mmHg. The ultrasonic shears and bipolar thermal device were used to seal an additional 8 vessels in each size group, which were sent for histologic examination. These were examined with hematoxylin and eosin stains, and the extent of thermal injury, defined by coagulation necrosis, was measured in millimeters. Analysis of variance was performed and, where appropriate, a Tukey's test was also performed. RESULTS: The EBVS's mean burst pressure was statistically higher than that of the UCS at 4 or 5 mm (601 vs 205 mmHg) and 6 or 7 mm (442 vs 175 mmHg). EBVS had higher burst pressures for the 4 or 5-mm group (601 mmHg) and 6 or 7-mm group (442 mmHg) compared with its pressure at 2 or 3 mm (128 mmHg) ( p = 0.0001). The burst pressures of the UCS and EBVS at 2 or 3 mm were not significantly different. Both clips were statistically stronger than the thermal devices except at 4 or 5 mm, in which case the EBVS was as strong as the LC (601 vs 593 mmHg). The PC and LC were similar except at 4 or 5 mm, where the PC was superior (854 vs 593 mmHg). The PC burst pressure for 4 or 5 mm (854 mmHg) was statistically higher than that for vessels 2 or 3 mm (737 mmHg) but not different from the 6 or 7 mm pressure (767 mmHg). Thermal spread was not statistically different when comparing EBVS and UCS at any size (EBVS mean = 2.57 mm vs UCS mean = 2.18 mm). CONCLUSIONS: Both the PC and LC secured all vessel sizes to well above physiologic levels. The EBVS can be used confidently in vessels up to 7 mm. There is no difference in the thermal spread of the LigaSure vessel sealer and the UCS.

Animals↗

PubMed2002

Laparoscopic repair of traumatic diaphragmatic injuries.

BACKGROUND: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. METHODS: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15-63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0-6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5-420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). RESULTS: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5-12 cm). The mean operative time was 134.7 min (range, 55-200 min). The mean estimated blood loss was 108.5 ml (range, 30-500 ml), and the postoperative length of stay was 4.4 days (range, 1-12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6-14 days). CONCLUSIONS: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.

Adolescent↗

PubMed2002

Prospective randomized evaluation of surgical resident proficiency with laparoscopic suturing after course instruction.

BACKGROUND: Laparoscopic suturing is required to develop competency in advanced laparoscopy. METHODS: Manuals detailing laparoscopic suturing were give to 17 Surgery residents. One week later they performed a suture on a training model. Time (s), accuracy (mm), and knot strength (lb) were recorded. The residents were blindly randomized to intervention (n = 9) and control (n = 8) groups. The intervention residents attended a 60-min course with lecture, video, and individual proctoring. Two weeks later they performed a stitch with standard laparoscopic instruments and a stitch with a suturing assist device. Statistical analysis included a Wilcoxon rank-sum test. RESULTS: The intervention residents decreased their suturing time from the first to the second stitich (732.4-257.6s), the control and residents decreased their time from 500.2 s to 421.8 s. The time required to perform the second stitch showed no significant difference between the two groups (p = 0.46), but the difference in reduced time between the first and second stitch was significant (p = 0.001). Using the suturing assist device for the third suture, the intervention and control groups both decreased their times significantly. The control residents performed almost as quickly as the intervention residents with the suturing; device (p = 0.11). Accuracy and knot strength were not different in any test. CONCLUSIONS: Residents can improve suturing skill with a short didactic course and individual proctoring. A suturing assist device decreases time required by inexperienced surgeons to device perform an intracorporeal tie.

Audiovisual Aids↗

PubMed2002

Outcomes for laparoscopic bilateral adrenalectomy.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has become the preferred surgical approach to manage adrenal disorders. Bilateral adrenalectomy is performed for diseases that are unresponsive to medical management and, frequently, for neoplastic disease. The aim of this study was to review our experience with laparoscopic bilateral adrenalectomy and to evaluate its safety, efficacy, and outcomes. PATIENTS AND METHODS: Between July 1996 and May 2001, five male and two female patients with a mean age of 46 years (range 15-69 years) presented for bilateral adrenalectomy (pheochromocytoma [N = 3], Cushing's disease [N = 3], and metastatic cancer [N = 1]). All procedures were performed using a lateral transperitoneal approach. One gland was excised, the patient was repositioned to the opposite lateral decubitus position, and the remaining gland was removed. RESULTS: Laparoscopic bilateral adrenalectomy was completed in all seven patients. The mean tumor/gland size on the right was 5.0 cm (range 3.1-7.0 cm) and on the left was 5.6 cm (range 3.6-7.0 cm). The mean operative time was 308 minutes (range 190-430 minutes), and the mean estimated blood loss was 138 mL (range 30-300 mL). One patient with a pheochromocytoma experienced intraoperative hypertension necessitating treatment. There were no postoperative complications. The mean postoperative hospital stay was 5.1 days (range 3-9 days). All patients have been treated postoperatively with daily hydrocortisone and fludrocortisone replacement. After a mean follow-up of 33 months (range 2-45 months), six patients are alive. The patient undergoing bilateral adrenalectomy for metastatic lung cancer died from recurrent disease 13 months after resection. CONCLUSION: Laparoscopic bilateral adrenalectomy is safe and effective. Patients are discharged postoperatively in a relatively short time with few complications. Appropriate steroid replacement and close follow-up allows these patients to return to self-reliance.

Adolescent↗

PubMed2001

Minilaparoscopic appendectomy.

The purpose of this study was to evaluate the feasibility of using 2-mm laparoscopic instruments in the treatment of appendicitis and to identify risk factors that may limit their use. Minilaparoscopic appendectomy was performed through a 2-mm port in the umbilicus for a videoendoscope, a 2-mm working port in the right upper quadrant, and a 5/12-mm suprapubic port for an endoscopic stapler. Minilaparoscopic appendectomy was attempted in 26 consecutive patients with appendicitis. Thirty-two consecutive patients undergoing conventional laparoscopic appendectomy with 5- and 10-mm instruments and videoendoscopes before the availability of 2-mm instrumentation were analyzed for comparison. Statistical comparisons were made by the Student t test and Fisher exact test. Differences were considered statistically significant at a P value less than 0.05. There were no conversions to an open appendectomy in the minilaparoscopic appendectomy or conventional laparoscopic appendectomy group. The mean operative time was 69.5 minutes for the minilaparoscopic appendectomy group and 85.5 minutes for the conventional laparoscopic appendectomy group (P = 0.02). The mean postoperative length of stay was 1.7 days for the minilaparoscopic appendectomy group and 2.5 days for the conventional laparoscopic appendectomy group (P = 0.08). There was no significant difference in the complication rates (P = 0.31). Minilaparoscopic appendectomy was completed in 13 (50.0%) patients. Independent risk factors (P = 0.05) for conversion to 5- or 10-mm ports were a retrocecal appendix and increasing patient age. There were no differences in the mean postoperative length of stay (P = 0.12) or complication rate (P = 0.39) between the two groups, but mean operative time was longer (P = 0.05) in the converted group. Perioperative outcomes for minilaparoscopic appendectomy are comparable to those of conventional laparoscopic appendectomy. The use of 2-mm instrumentation in the management of appendicitis is limited in patients with retrocecal appendicitis. Increasing patient age and a history of abdominal surgery may influence the need to convert 2-mm ports to 5- or 10-mm ports.

Adolescent↗

PubMed1999

Long-term results of laparoscopic splenectomy for immune thrombocytopenic purpura.

OBJECTIVE: To assess the results of laparoscopic splenectomy as a treatment for immune thrombocytopenic purpura (ITP). MATERIAL AND METHODS: We conducted a retrospective study of all patients who underwent laparoscopic splenectomy for ITP at our institution between August 1992 and May 1997. RESULTS: Of 27 patients who underwent attempted laparoscopic splenectomy for ITP at our institution during the study period, 26 had completion of the procedure without conversion to an open splenectomy. The median postoperative hospital stay was 1.5 days, and no postoperative deaths occurred. In one patient, pancreatitis developed postoperatively. In four patients, splenectomy failed--two initially and two subsequently--and reinstitution of medical therapy was necessary. The other patients have remained free of medication, and 19 patients have platelet counts greater than 100 x 10(9)/L. The 3-year actuarial success rate was 81.5%. Response to corticosteroid therapy preoperatively may be an indicator of success of splenectomy. CONCLUSION: Laparoscopic splenectomy is safe and allows prompt recovery. Long-term response rates are similar to those achieved with open splenectomy.

Actuarial Analysis↗