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Pelviscopy in the mare.

A method of endoscopic examination of the internal genital (pelvic) organs of the mare is described. Special emphasis is placed on the induction of artificial pneumoperitoneum and the installation of an endoscopic peritoneal fistula device for prolonged observation. The potential of pelviscopy in the mare as a diagnostic aid, a new device for research in equine reproduction and as an auxillary aid to teaching is discussed.

Animals

Repair of massive inguinal hernia: with pneumoperitoneum and without using prosthetic mesh.

There was an unusual need for preoperative induction of an artificial pneumoperitoneum in two cases of inguinal hernia. Both hernias were very large and associated with extensive intertrigo. Daily insufflations of air were performed for 13 and 11 days, with the patients compensating for this increased intraabdominal pressure over this time. Operation with removal of the ipsilateral testicle, cord, and scrotum was then straightforward and convalescence uneventful. The pneumoperitoneum allowed a repair to be effected without using a prosthetic mesh.

Aged

Pneumoperitoneum associated with artificial ventilation.

Four adults injured in serious road-traffic accidents developed pneumoperitoneum after artificial ventilation. No case could be attributed to injury or to perforation of a hollow viscus in the belly, but doubt about this in one patient resulted in exploratory laparotomy. In three patients the origin of intraperitoneal air was considered to be leakage through minute ruptures in alveoli subjected to the stress of artificial ventilation, with air tracking to the mediastinum, pleural space, subcutaneous tissues of the neck and chest, and peritoneal cavity. The fourth patient later developed herniation of the stomach through a rupture in the diaphragm, the presence of a pneumothorax on the same side suggesting direct passage of air through the diaphragm. Pneumoperitoneum induced by artificial ventilation is probably more common than reports suggest and should be distinguished clinically and radiologically from that caused by rupture or perforation of a hollow viscus. This will reduce the number of needles laparotomies performed on patients who are already seriously ill.

Adult

[Pneumoperitoneum induced by artificial respiration and its diagnosis by peritonel lavage (author's transl)].

Ventilation with increased end-exspiratory pressure may, especially in cases of blunt chest trauma, result in pneumoperitoneum although there are no intestinal injuries. The case histories of four persons who developed this complication are reviewed. Differentiation between such a complication and a condition requiring laparotomy is often difficult because other injuries, particularly a cerebrocranial trauma, may obscure the clinical symptoms. Diagnostic peritoneal lavage may help towards differentiating between a ventilation-induced pneumoperitoneum and an "acute abdomen" caused by perforation or rupture of an intra-abdominal hallow organ.

Accidents, Traffic

[Necessity to control endexpiratory CO2-concentration during laparoscopic sterilisation under general anaesthesia with controlled ventilation (author's transl)].

During laparoscopy and intraabdominal insufflation of CO2 cardio-respiratory accidents following increased PaCO2 are possible. The continuous measurement of endexpiratory CO2-concentration by infrared absorption spectrometry is a simple method for controlling the level of ventilation. Respiratory acidosis under controlled artificial ventilation during laparoscopy can thus be avoided.

Acidosis, Respiratory

Direct laparoscope trocar insertion without prior pneumoperitoneum.

The results of direct trocar insertion without prior establishment of pneumoperitoneum are documented in 301 consecutive laparoscopies. No complications or technical failures attributable to the method were encountered. A reduction of complications associated with needle-induced pneumoperitoneum may be possible with this method.

Female

Indications for pneumoperitoneum in the diagnosis of congenital anomalies in the umbilical region.

Thirty pneumoperitoneograms were performed postmortem and 5 were performed for diagnosis: the technique itself, the radiological anatomy of the umbilical region, and the usefulness of the procedure in diagnosis are discussed. Pneumoperitoneum may be indicated in the investigation of a bleeding Meckel's diverticulum, in the exclusion or confirmation of remnants of the omphalomesenteric duct, in chronically moist lesions of the umbilicus resistant to symptomatic treatment, in suspected cases of non-communicating urachal cysts which cannot be diagnosed by cystogram, and in the differential diagnosis of abdominal tumours related to the umbilical region.

Abdominal Neoplasms

Liver-lung scan in the diagnosis of right subphrenic abscess.

To assess the value of liver-lung scanning in the diagnosis of right subphrenic abscess, 148 scans were reviewed against corresponding charts. Of 91 scans with adequate clinical data, overall scanning error was 19.3% with 14 false positive and 3 false negative scans. Among 49 scans (of the initial group of 91 studies) with presence or absence of actual pathology proved by surgery and/or autopsy, there were 3 true positive, 12 false positive, 29 true negative, and 3 false negative scans. Analysis of data indicated (1) lower accuracy of scan interpretations than generally reported, (2) low specificity for positive scans and high specificity for negative scans, (3) correlations of false interpretations with atypical degrees of liver-lung separation and with scanning defects in liver and lung, and (4) failure of rereading significantly to improve accuracy of interpretation.

Angiography

The diagnostic value of pneumoperitoneogram for splenomegaly in chronic liver diseases.

The splenic enlargement is an important symptoms of portal hypertension, and various attempts have been made to objectively describe it. But, endoscopic diagnosis for splenomegaly in chronic liver diseases may be sometimes difficult for these uncharacteristic appearances. The pneumoperitoneography was performed in 141 chronic liver diseases just before laparoscopic procedure, size and form of the spleen on X-ray film were measured and analysed. We have compared these results with the laparoscopic findings (the gross appearance of liver and spleen, the degree of portal hypertension, etc), the patterns on scintigram and the histological findings of the liver. There were fairely good correlation between the splenic findings on radiogram and above factors, especially the size of the spleen was gradually increased according to the degree of portal hypertension and the fibrous change of the liver specimens. In conclusion, the findings of spleen on pneumoperitoneogram were valuable for diagnosis of splenomegaly in chronic liver diseases.

Adult

Laparoscopy in the obese patient.

A series of 49 patients weighing over 200 pounds is described, and a technique essential to successful care of obese patients is given. The ability to determine the intra-abdominal location of the Verres needle in order to create a physoperitoneum is the most important consideration.

Body Height

Laparoscopy for the impalpable testes: experience with 53 testes.

Impalpable testes constitute approximately 20% of most series of undescended testes. From January 1986 to March 1991, we performed laparoscopies on 53 patients with impalpable testes. Thirty-two of them were found to have normal vasa and vessels entering each internal ring on the side in question. Of these, 14 were found to have "vanishing testes" at exploration, 12 others underwent successful orchiopexy, and the remaining 6 had excisional biopsies of fibrotic testicular remnants. Five patients had no visible vessels and a sixth had a blind-ending vas and vessels adjacent to the internal ring; in these cases no further investigations were deemed necessary. Fifteen patients were found to have abdominal testes and underwent high testicular vessel ligation and division at the time of the laparoscopy; 14 of them have undergone staged orchiopexy 6 months after laparoscopy and one is scheduled for this procedure. A 3-month follow-up of those who had orchiopexy showed excellent results in 10 patients and poor results in 3, all of whom had small testes that were unimproved or worse following vessel ligation. Four boys were spared operations as a result of findings at laparoscopy. Early in the series there was one failed laparoscopy, but it was successfully completed later. the procedure, but it was successfully treated with antibiotics. There were no other complications. Laparoscopy is a safe procedure that allows accurate diagnosis and may prevent additional intervention in the treatment of the absent testes. It facilitates the locating of the impalpable testis and the planning and timing of subsequent orchiopexy. We believe that laparoscopy is the preferred procedure in the management of impalpable testes.

Catheterization