A rare but critical complication of malignant pleural effusion management.

Laparoscopic surgery has led to great clinical improvements in many fields of surgery; however, it requires the use of trocars, which may lead to complications as well as postoperative pain. The complications include intra-abdominal vascular and visceral injury, trocar site bleeding, herniation and infection. Many of these are extremely rare, such as vascular and visceral injury, but may be life-threatening; therefore, it is important to determine how these types of complications may be prevented. It is hypothesised that trocar-related complications and pain may be attributable to certain types of trocars. This systematic review was designed to improve patient safety by determining which, if any, specific trocar types are less likely to result in complications and postoperative pain. To analyse the rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy, regardless of the condition. Two experienced librarians conducted a comprehensive search for randomised controlled trials (RCTs) in the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, CDSR and DARE (up to 26 May 2015). We checked trial registers and reference lists from trial and review articles, and approached content experts. RCTs that compared rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy. The primary outcomes were major trocar-related complications, such as mortality, conversion due to any trocar-related adverse event, visceral injury, vascular injury and other injuries that required intensive care unit (ICU) management or a subsequent surgical, endoscopic or radiological intervention. Secondary outcomes were minor trocar-related complications and postoperative pain. We excluded trials that studied non-conventional laparoscopic incisions. Two review authors independently conducted the study selection, risk of bias assessment and data extraction. We used GRADE to assess the overall quality of the evidence. We performed sensitivity analyses and investigation of heterogeneity, where possible. We included seven RCTs (654 participants). One RCT studied four different trocar types, while the remaining six RCTs studied two different types. The following trocar types were examined: radially expanding versus cutting (six studies; 604 participants), conical blunt-tipped versus cutting (two studies; 72 participants), radially expanding versus conical blunt-tipped (one study; 28 participants) and single-bladed versus pyramidal-bladed (one study; 28 participants). The evidence was very low quality: limitations were insufficient power, very serious imprecision and incomplete outcome data. Primary outcomesFour of the included studies reported on visceral and vascular injury (571 participants), which are two of our primary outcomes. These RCTs examined 473 participants where radially expanding versus cutting trocars were used. We found no evidence of a difference in the incidence of visceral (Peto odds ratio (OR) 0.95, 95% confidence interval (CI) 0.06 to 15.32) and vascular injury (Peto OR 0.14, 95% CI 0.0 to 7.16), both very low quality evidence. However, the incidence of these types of injuries were extremely low (i.e. two cases of visceral and one case of vascular injury for all of the included studies). There were no cases of either visceral or vascular injury for any of the other trocar type comparisons. No studies reported on any other primary outcomes, such as mortality, conversion to laparotomy, intensive care admission or any re-intervention. Secondary outcomesFor trocar site bleeding, the use of radially expanding trocars was associated with a lower risk of trocar site bleeding compared to cutting trocars (Peto OR 0.28, 95% CI 0.14 to 0.54, five studies, 553 participants, very low quality evidence). This suggests that if the risk of trocar site bleeding with the use of cutting trocars is assumed to be 11.5%, the risk with the use of radially expanding trocars would be 3.5%. There was insufficient evidence to reach a conclusion regarding other trocar types, their related complications and postoperative pain, as no studies reported data suitable for analysis. Data were lacking on the incidence of major trocar-related complications, such as visceral or vascular injury, when comparing different trocar types with one another. However, caution is urged when interpreting these results because the incidence of serious complications following the use of a trocar was extremely low. There was very low quality evidence for minor trocar-related complications suggesting that the use of radially expanding trocars compared to cutting trocars leads to reduced incidence of trocar site bleeding. These secondary outcomes are viewed to be of less clinical importance.Large, well-conducted observational studies are necessary to answer the questions addressed in this review because serious complications, such as visceral or vascular injury, are extremely rare. However, for other outcomes, such as trocar site herniation, bleeding or infection, large observational studies may be needed as well. In order to answer these questions, it is advisable to establish an international network for recording these types of complications following laparoscopic surgery.

STATEMENT OF THE PROBLEM Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent on the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds. The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The neck has been divided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common1 and can affect length of stay.2 Mortality, particularly for major vascular injuries may reach 50%.3 Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes.4 Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated. Controversy arises over management of the patient without significant symptoms. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Mandatory exploration, while seemingly safe and conservative, led to many nontherapeutic operations. This fact, along with advances in technology, such as high resolution computed tomography (CT), may eliminate the need to explore the neck to determine whether there are injuries. Also during the time that technology had been advancing, many reports have documented the safety of selective management of neck injuries that penetrate the platysma. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. This guideline was therefore initiated to examine the specific roles of mandatory exploration versus selective management based on physical examination and current imaging technologies for penetrating neck trauma. Goals of the Guideline This guideline is designed to answer the following questions regarding the management of penetrating injuries to zone II of the neck that penetrate the platysma. Is mandatory operative management or selective operative management appropriate? Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary? Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury? Is physical examination sensitive enough to rule out injuries to vascular structures or the aerodigestive tract? PROCESS The process used by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed on the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2007. Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the United States Department of Health and Human Services as follows: Class I—prospective, randomized, double-blinded study; Class II—prospective, randomized, nonblinded trial; or Class III—retrospective series, meta-analysis. An evidentiary table (Table 1) was constructed using the 112 references that were identified: Class I, 1 reference; Class II, 30 references; and Class III, 81 references. Recommendations were made on the basis of the studies included in this table. Level I recommendations, usually based on Class I data, were meant to be convincingly justifiable on scientific evidence alone. Level II recommendations, usually supported by Class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level III recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.Table 1: Penetrating Zone II Neck Trauma Evidentiary TableTable 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)RECOMMENDATIONS Selective Workup—Operation Versus Selective Nonoperative Management Recommendations Level I: Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations. Level II: High resolution CT angiography offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available. Level III: No recommendations. Scientific Foundation Nonoperative management of penetrating neck wounds was common in the early 20th century. Based on a review of civilian experience, Fogelman and Stewart5 recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. The rationale was that a significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries.6 In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al.7 estimated the cost of a negative exploration at $1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al.8 found that neck explorations under local anesthesia, compared with general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable.9,10 Mandatory exploration gained in popularity as studies showed that clinical symptoms were not present in 0% to 23% of the cases. However, mandatory exploration was negative 53% to 60% of the time and did not identify any injuries. In addition, some of the clinically silent injuries were venous and pharyngoesophageal injuries, which did not require operative therapy.11–13 Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed,14–34 though observation for up to 48 hours may be necessary,35 depending on the use of ancillary tests. Jurkovich et al.36 compared the results of mandatory exploration (the preference of the attending surgeon) in 47 patients with a selective approach in 53 patients using 43 angiograms and 14 endoscopies. In the mandatory exploration group, the negative exploration rate was 53%. In the selective approach group, 12 injuries were found but only five patients benefited from the work up. Some studies specifically recommended that to manage penetrating neck injuries, a well-staffed teaching hospital with a trauma service and immediate availability of radiologic and endoscopic evaluations is needed.37 However, it has been shown that selective management can be safe in community hospitals with experienced surgeons.38 Evidence of chest injury does not seem to be an indication for neck exploration.39 Debate on the issue of selective management continued as Meyer et al.40 questioned this new approach of selective exploration for penetrating neck injuries. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy, and esophagography in each patient before a mandatory exploration. Forty-eight injuries were identified in 35 explorations. Of concern was the fact that five patients had six major injuries that were not identified by the preoperative testing. Thus they believed that a mandatory exploration approach was indicated. More recent studies have consistently shown that the selective approach is a safe option. In a series of 128 asymptomatic patients who were observed by Biffl et al.,41 based primarily on physical examination, only one patient had a missed injury (from an ice pick). Only 15% of these patients required adjuvant tests. Sriussadaporn et al.42 also successfully observed 17 asymptomatic patients. Only 2 of 40 patients who underwent exploration did not need the operation, though they seemed to have deep wounds. In asymptomatic patients, Nason et al.43 found that 67% underwent negative explorations. All zone II vascular injuries were symptomatic. Narrod and Moore44,45 reviewed their 10-year experience with penetrating neck trauma. In the first 6 years, mandatory exploration led to a 56% rate of negative explorations. In the next 4 years, a selective management strategy was used. Forty-one of 48 patients who underwent exploration had significant injuries,45 whereas 29 asymptomatic patients were observed without any missed injuries. Few ancillary studies were performed in this group. In a large, retrospective study from Johannesburg, South Africa, Velmahos et al.46 compared results with patients who underwent immediate surgical exploration versus constant monitoring. In the exploration group, 3% of the explorations were unnecessary; mortality was 4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%. Criteria for observation versus exploration were not clear making the interpretation of the 9% missed injury rate difficult. The only randomized trial comparing mandatory neck exploration with a selective approach based on physical examination and radiographs was performed by Golueke et al.47 in 160 patients. There was no difference in hospital stay, morbidity, or mortality. Management of transcervical gunshot wounds deserves separate consideration because of the high likelihood of major injury.48 Hirshberg et al.49 explored 41 patients with transcervical gunshot wounds. Twenty-eight had more than one zone of the neck involved. Although seven patients did not have major injuries, 34 patients had 52 major injuries to cervical structures mainly involving vessels and the upper airway. Sixteen presented with life-threatening problems. They recommended mandatory exploration. In contrast, Demetriades et al.50 found that a selective approach based on physical examination, angiography, esophagoscopy, and esophagography was safe. Helical CT angiography is the newest technology to be tested for identifying vascular injuries from penetrating neck trauma, particularly arterial injuries. Because it might also be useful for identifying or ruling out other injuries (e.g., aerodigestive tract injury), this modality is particularly intriguing as a "one stop shop" to evaluate asymptomatic patients for selective operative management. The speed and resolution of this modality continues to improve. Gracias et al.51 have already recommended that if a CT demonstrates trajectories that are remote from vital structures, the need for additional invasive studies can be eliminated. In the setting of a mandatory exploration protocol, Mazolewski et al.52 found that CT angiography, compared with operative findings, was 100% sensitive and 91% specific in 14 patients. Both Munera et al.53 and Nunez et al.54 pointed out the utility of CT angiography for identifying nonvascular soft tissue injuries, and the vascular injuries. Inaba et al.55 reviewed their experience with 106 patients who had penetrating injuries to the neck. Fifteen required urgent operation. The remainder underwent CT angiogram. Two tracheal injuries and two carotid artery injuries were identified. No injuries requiring intervention were missed. Use of CT angiography can safely decrease the number of neck explorations and, more importantly, the number of negative neck explorations.56,57 In addition, CT angiography can decrease, though not eliminate, the need for formal angiography and esophagography in some patients.56 Management of neck wounds in the military setting may be different from that in the civilian world. Prgomet et al.58 found that injuries that did not penetrate the platysma did not cause significant injuries. Forty-nine of 84 patients who underwent immediate exploration had injuries to vital structures. They also found that it was safe to close the wound primarily if it was seen within 6 hours of injury. In their experience, even extensive laryngotracheal injuries could be repaired safely.59 There is little data on selective management of penetrating neck injuries in children. Small studies60,61 suggest that a selective management strategy is safe. Diagnosis of Arterial Injury Recommendations Level I: No recommendations. Level II: CT angiography or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck. Level III: CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed. Scientific Foundation In the era of mandatory neck exploration for penetrating trauma, there seemed to be little need for angiography, though some9 suggested that the angiogram could assist in operative planning and thereby minimize morbidity or rule out the need for exploration.62,63 Physical examination, however, seemed unreliable for ruling out arterial injury.64 Delayed pseudoaneuryms and neurologic events have been described in originally asymptomatic patients, prompting some to advocate angiography in all such patients.65 A negative arteriogram in a stable patient can rule out an arterial injury.66 North et al.67 reviewed the records of 139 stable patients with penetrating neck trauma. Patients who had at least soft signs of vascular injury (absent pulse, bruit, hematoma, or altered neurologic status) had a 30% incidence of vascular injury by angiography, whereas only 2 of 78 asymptomatic patients had injuries (one minor and one that did not affect management). Gunshot wounds were more likely than stab wounds to cause vascular injury. Similarly, Hartling et al.68 found, using angiography, that 43 patients with stab wounds to the neck and minimal symptoms had no significant injuries. Even in the 18 patients with physical findings consistent with a vascular injury, only two had significant injuries. Similarly, Rivers et al.69 questioned the value of angiography. Of 63 angiograms in 61 patients, only 6 were abnormal. Three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by arteriography in the absence of suggestive physical findings. No major arterial injuries that were missed preoperatively were discovered during exploration. Angiograms did not alter the course of management. Noyes et al.70 examined the accuracy of a selective management strategy. Arteriography and laryngoscopy/bronchoscopy were 100% accurate. In contrast, Sclafani et al.71 found that 10 of 26 patients who had positive angiograms for penetrating vascular injury to the neck had undergone the angiogram solely because of proximity. Physical examination had a sensitivity of 61% and specificity of 80%. They also found no differences in their results based on mechanism of injury. They suggested that proximity should not be abandoned as an indication for angiography in these patients. Menawat et al.72 performed angiography for proximity or soft signs of vascular injury. Fifteen injuries were found on 45 angiograms. Forty-two patients without any signs of injury were successfully observed without angiography or operation. Overall, only one patient had a significant injury that was not predicted by physical examination. In contrast, Nemzek et al.73 found that proximity, based on the addition of plain films or CT of the neck showing prevertebral soft-tissue swelling, missile fragmentation, or missiles adjacent to major vessels can be useful, but are nonspecific radiographic signs. To examine the cost effectiveness of angiography, Jarvik et al.74 studied 111 patients with penetrating neck trauma. Forty-five of the 48 patients with vascular injuries had abnormal clinical findings. Management in the other three patients was not altered by the angiogram. They calculated the cost of screening angiography in asymptomatic patients to be approximately $3.08 million per central nervous system event. Demetriades et al.75 prospectively compared physical examination and duplex US imaging with angiography in 82 stable patients with penetrating neck injuries. Only 11 patients had vascular injuries by angiography; and only two of these injuries needed to be repaired. The serious injuries were detected or suspected on physical examination, but six lesions that did not require treatment were missed (sensitivity 100% for serious injuries, but 45% for all injuries). By duplex US imaging, 10 of 11 injuries, including all serious ones, were identified, for an overall sensitivity of 91% (100% for clinically important lesions) and specificity of 99%. Further studies by Demetriades et al.76 included 223 patients. Of the 160 asymptomatic patients, 11 had injuries that did not require treatment. Overall, duplex US was 92% sensitive (100% for findings that required an operation) and 100% specific for defining an injury. Similarly, Bynoe et al.77 found that duplex US was 95% sensitive and 99% specific for vascular injuries after both neck and extremity trauma. The only missed injuries were two shotgun pellet injuries that did not need repair. In a prospective, double-blind study, Montalvo et al.78 found that US identified all 10 significant injuries in 52 patients with penetrating neck trauma. Duplex US did not identify reversible carotid narrowing in one patient and did not visualize two vertebral arteries. Another report by the same group79 found in 55 patients that duplex US had 100% sensitivity and 85% specificity. Corr et al.80 reported that duplex US picked up two intimal flaps that were not identified on angiography. Munera et al.81 prospectively studied 60 patients, who had 10 vascular injuries. There was one missed injury by CT angiography because the study actually did not include the entire neck. They later82 suggested that patients with bruits or thrills at admission may be better treated by undergoing conventional angiography because of the potential for endovascular therapy. Helical CT angiography is limited by artifact due to metal, which may obscure arterial segments; therefore, these patients should undergo conventional angiography. Ofer et al.83 reviewed their experience with CT angiography in 16 patients (12 with penetrating trauma and four with blunt) and found no missed injuries, although only one patient with penetrating trauma had a carotid injury (confirmed at operation). Diagnosis of Esophageal Injury Recommendations Level I: No recommendations. Level II: Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours. Level III: No recommendations. Scientific Foundation The problem with penetrating injuries to the esophagus is that there are frequently no findings on physical examination. Esophagography can miss the injury.84 This is of grave concern since late referral and management can lead to significant morbidity and mortality.85–87 Early diagnosis and management, often with primary repair, lead to good outcomes.88–90 Even gunshot wounds can be closed primarily91; more complex repairs may lead to strictures.92 Location of the injury can affect outcome as injuries above the arytenoid cartilages can be managed without intervention, whereas more inferior injuries require neck drainage to prevent a deep tissue infection.93 Madiba et al.94 also found that patients with small injuries and contained perforation on contrast studies could be observed without operation unless there was another indication for exploration. All 26 patients with injuries had odynophagia. Of 17 patients managed nonoperatively, only one developed local sepsis. Six patients had associated tracheal injuries. In addition, patients with tracheal injuries have worse outcomes if they have concomitant esophageal injuries.95,96 Noyes et al.70 found that esophagograms were 90% accurate and esophagoscopy was 86% accurate. Weigelt et al.97 used a strategy of esophagography followed by rigid esophagoscopy if the esophagogram were equivocal to identify esophageal injuries in patients who had no or minimal symptoms after penetrating neck trauma. All 10 injuries in 118 patients were identified. Wood et al.98 found that esophagography alone was 100% sensitive and 96% specific in 225 patients. Ngakane et al.99 reviewed 109 patients with penetrating neck trauma. All patients with gunshot wounds underwent esophagography, whereas patients with stab wounds were only studied if they had pain with swallowing. Twenty-nine studies were performed and four injuries were identified. All were observed without intervention. Repeat contrast studies demonstrated resolution of the injury. In 23 patients with esophageal injuries, Armstrong et al.92 found that esophagography only identified 62% of the injuries whereas rigid esophagoscopy detected all injuries. Srinivasan et al.100 found reasonable accuracy with flexible endoscopy. In 55 patients, flexible endoscopy identified the only two injuries, but suggested an injury in four patients, resulting in four negative explorations, for an overall sensitivity of 100% and specificity of 92%. Value of the Physical Examination Recommendations Level I: No recommendations. Level II: No recommendations. Level III: physical examination using for including of the carotid is sensitive for arterial and aerodigestive tract injuries that require repair. the potential morbidity of missed injuries, should have a for imaging Scientific Foundation Early reports suggested that the physical examination is unreliable to rule out a vascular injury. and found physical examination of neck and extremity injuries a 20% negative rate and a positive and found an overall accuracy of physical examination. and found that clinical signs were in 30% of patients with positive neck explorations and in of patients with negative neck explorations, their approach of mandatory exploration. More Demetriades et studied patients with penetrating neck injuries. patients underwent exploration for positive physical examination findings or a positive whereas asymptomatic patients were Only two of the patients required In a subsequent this demonstrated that physical examination did not miss any major vascular or esophageal injuries that required though minor injuries were identified by angiography of required and a selective approach based on and physical et observed asymptomatic patients without Of the 52 patients who underwent exploration based on physical examination, did not have significant injuries. Similarly, et found that only 1 of asymptomatic patients had a vascular injury detected by angiography. in this patient physical examination out 99% of vascular injuries and the for angiography was et found that if patients did not have physical examination findings of arterial injury expanding or than 10 a or or a neurologic no vascular injuries were present based on angiography, duplex or clinical They observed patients for at least 23 hours. et found that only 2 of 30 patients who underwent exploration for hard signs of vascular injury did not have a significant injury. of asymptomatic patients underwent angiography for proximity or of another Only one of these patients needed an operation. All other patients with negative physical were safely observed without et found that of patients with positive physical examination had a positive angiogram. Of the patients with negative physical only three had positive but needed operations. Overall, physical had sensitivity of and a negative value of Both sensitivity and negative value for injuries requiring operation were A recent study by et in on physical examination alone to rule out vascular injuries to gunshot wounds of the neck. Of patients with gunshot wounds to any zone of the had positive physical findings a vascular injury, whereas 10 patients with negative physical findings were found to have injuries by angiography, physical examination a negative value of The of these findings is to because they included all zones of the neck and did not the of the injuries that were identified. or are physical findings suggestive of aerodigestive tract injuries that may require operative intervention. et reviewed the of patients with or had and had or underwent and Patients without injuries or small were successfully observed without exploration. The study, though that to determine whether imaging to physical examination in the of patients with penetrating neck injuries was that by et Forty-two patients, who did not have need for operation at underwent soft tissue CT of the neck and esophagography before mandatory exploration. All tracheal and carotid injuries were identified by physical examination. Two of four esophageal injuries from stab were missed by both CT and CT was better than physical examination for identifying venous injuries, but of these did not require intervention. Selective management of penetrating injuries to zone II of the neck has common for asymptomatic patients. The roles of physical examination, duplex CT angiography, esophagography, and the the imaging modality that the potential for ruling out and esophageal injuries is CT angiography. are needed to this the resolution of CT accuracy imaging studies may early of patients with neck injuries.

Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured. The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026). This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.

Penetrating neck wounds complicate approximately 10% of all trauma presentations.1 While they are most commonly associated with violent acts, they are also encountered in road traffic collisions and other accidents. The adverse relationship between alcohol and trauma is well-documented.2 The mechanism of penetration is important in determining the extent of damage and treatment options. Ballistic missiles trauma can cause extensive damage which is highly correlated with the velocity. Stab wounds are relatively low velocity, but can still lead to serious injury. Management in both instances should initially follow ATLS guidelines, with careful attention to airway and cervical spine protection. As with any tissues, penetration and retention of foreign material carries an increased risk of infection. The neck has a dense concentration of neurovascular and aerodigestive structures passing through it, which can be damaged by injuries which penetrate the platysma muscle. It is useful to divide the neck horizontally into three zones. Zone I extends between the clavicles and the cricoid cartilage; it carries the highest mortality because of vascular injury and high-risk surgical exploration.3 Zone II is superior to Zone I and extends as far as the angle of the mandible. Zone III is the area between the angle of the mandible and the base of the skull. Zone II injuries are the most common followed by Zone 1 and finally Zone III.4 Injuries may occur in more than one zone. Inevitably vascular injury is the most frequent complication of penetrating neck trauma, occurring in one-quarter of all cases, and carrying a mortality of nearly 50%. Trauma to the trachea occurs in one-tenth of cases, and mortality in these cases approaches 20%.5 Other structures at risk of damage include the oesophagus, which can cause leakage of digestive enzymes and bacteria into surrounding tissues; and the cranial nerves. Extensive penetration may result in oropharyngeal trauma. Currently it is thought that penetrating neck injuries carry a 3–6% mortality rate.6 The mortality rate for Zone II stable injuries is generally perceived to be lower than this, although there are no large studies to back this up. In the postwar era it was shown that the mortality associated with penetrating neck wounds dropped from around 35% to 6% when immediate surgical exploration was performed.7 Now, with advanced imaging techniques and increasing experience, selected stable patients with no hard findings of injury can be managed by thorough examination and, if unremarkable, a period of observation rather than immediate surgical exploration. A review by Tisherman et al.8 on penetrating Zone II neck trauma found that selective operative management and mandatory exploration of penetrating injuries to Zone II had similar diagnostic accuracy, therefore selective management is recommended to avoid unnecessary operations. Stable patients without clear signs of vascular and visceral injuries can avoid mandatory surgery. Instead high-resolution CT angiography was recommended to give detail about vascular, tracheal and oesphageal injuries. CT without angiography can be used to rule out significant vascular injury if the trajectory is shown to be away from vascular structures. There are no studies on the management of retained organic material in stable Zone II neck injuries or data on the management of cases that have a delayed presentation. In general, however, it is recommended that patients with retained wood or vegetative material and pain have foreign body removal.9 Retained material such as thorns can lead to granulomatous formation. In one autopsy study of patients with tendon injuries organic matter was associated with purulent tendonitis, necrosis, foreign body granuloma, fibrosis and peritendonitis and calcification.10 Penetrating ingested foreign bodies can remain quiescent for years but can cause late mortality from diffuse and local suppurative processes especially if leading to vascular injuries.11 This case describes the delayed diagnosis of a penetrating neck injury by a piece of bamboo which missed all the major structures of the neck, and considers the consequences of retained organic foreign bodies in the soft tissues.

This was a retrospective comparative study. To compare the likelihood of approach-related complications for patients undergoing single-level lateral lumbar interbody fusion (LLIF) at L4-L5 to those undergoing the procedure at upper lumbar levels. LLIF has been associated with a number of advantages when compared with traditional interbody fusion techniques. However, potential risks with the approach include vascular or visceral injury, thigh dysesthesias, and lumbar plexus injury. There are concerns of a higher risk of these complications at the L4-L5 level compared with upper lumbar levels. A retrospective cohort review was completed for consecutive patients undergoing single-level LLIF between 2004 and 2019 by a single surgeon. Indication for surgery was symptomatic degenerative lumbar stenosis and/or spondylolisthesis. Patients were divided into 2 cohorts: LLIF at L4-L5 versus a single level between L1 and L4. Baseline characteristics, intraoperative complications, postoperative approach-related neurological symptoms, and patient-reported outcomes were compared and analyzed between the cohorts. A total of 122 were included in analysis, of which 58 underwent LLIF at L4-L5 and 64 underwent LLIF between L1 and L4. There were no visceral or vascular injuries or lumbar plexus injuries in either cohort. There was no significant difference in the rate of postoperative hip pain, anterior thigh dysesthesias, and/or hip flexor weakness between the cohorts (53.5% L4-L5 vs. 37.5% L1-L4; P =0.102). All patients reported complete resolution of these symptoms by 6-month postoperative follow-up. LLIF surgery at the L4-L5 level is associated with a similar infrequent likelihood of approach-related complications and postoperative hip pain, thigh dysesthesias, and hip flexor weakness when compared with upper lumbar level LLIF. Careful patient selection, meticulous use of real-time neuromonitoring, and an understanding of the anatomic location of the lumbar plexus to the working corridor are critical to success.

The lateral approach to the spine is generally well tolerated, but reports of debilitating injury to the lumbar plexus, iliac vessels, ureter, and abdominal viscera are increasingly recognized, likely related to the lack of direct visualization of these nearby structures. To minimize this complication profile, the authors describe here a novel, minimally invasive, endoscope-assisted technique for the LLIF and evaluate its clinical feasibility. Seven consecutive endoscope-assisted lateral lumbar interbody fusion (LLIF) procedures by the senior authors were reviewed for the incidence of approach-related complications. One patient had a postoperative approach-related complication. This patient developed transient ipsilateral thigh hip flexion weakness that resolved spontaneously by the 3-month follow-up. No patient experienced visceral, urological, or vascular injury, and no patient sustained a permanent neurological injury related to the procedure. The authors' preliminary experience suggests that this endoscope-assisted LLIF technique may be clinically feasible to mitigate vascular, urological, and visceral injury, especially in patients with previous abdominal surgery, anomalous anatomy, and revision operations. It provides direct visualization of at-risk structures without significant additional operative time. A larger series is needed to determine whether it reduces the incidence of lumbar plexopathy or visceral injury compared with traditional lateral approaches.

Minimally invasive surgery (MIS) techniques, particularly lateral lumbar interbody fusion (LLIF), have become increasingly popular for adult spinal deformity (ASD) correction. Much discussion has been had regarding theoretical and clinical advantages to addressing coronal curvature from the convex versus concave side of the curve. In this study, the authors aimed to broadly evaluate the clinical outcomes of addressing ASD with circumferential MIS (cMIS) techniques while accessing the lumbar coronal curvature from the concave side. A multi-institution, retrospective chart and radiographic review was performed for all ASD patients with at least a 10° curvature, as defined by the Scoliosis Research Society, who underwent cMIS correction. The data collected included convex versus concave access to the coronal curve, durable or sensory femoral nerve injury lasting longer than 6 weeks, vascular injury, visceral injury, and any additional major complication, with at least a 2-year follow-up. Neither health-related quality-of-life metrics nor spinopelvic parameters were included within the scope of this study. A total of 152 patients with ASD treated with cMIS correction via lateral access were identified and analyzed. Of these, 126 (82.9%) were approached from the concave side and 26 (17.1%) were approached from the convex side. In the concave group, 1 (0.8%) motor and 4 (3.2%) sensory deficit cases remained at 6 weeks after the operation. No vascular, visceral, or catastrophic intraoperative injuries were encountered in the concave group. Of the 26 patients in the convex group, 2 (7.7%) experienced motor deficits lasting longer than 6 weeks and 5 (19.2%) had lower-extremity sensory deficits. It has been reported that lateral access to the convex side is associated with similar clinical and radiographic outcomes with fewer complications when compared with access to the concave side. Advantages to approaching the lumbar spine from the concave side include using one incision to access multiple levels, breaking the operative table to assist with curvature correction, easier access to the L4-5 disc space, the ability to release the contracted side, and, often, avoidance of the need to access or traverse the thoracic cavity. This study illustrates the largest reported cohort of concave access for cMIS scoliosis correction; few postoperative sensory and motor deficits were found.

Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity.

The methods used to obtain laparoscopic and thoracoscopic access are associated with complications ranging from cannula slippage to visceral and major vascular injuries. This study evaluates the use of a radially expandable access device in pediatric minimally invasive surgery with a focus on the incidence of major and minor cannula-related complications. From 1994 to 1999, 2,157 patients at seven institutions underwent minimally invasive procedures using a radially expandable access device (StepTM). Their ages ranged from 1 day to 21 years (mean 7.2 years). The number of devices used per case ranged from one to seven (mean 3.3). Access was obtained using a Veress needle inserted into a radially expandable sleeve, followed by dilatation with a 3-mm, 5-mm, 7-mm, or 12-mm diameter cannula. Factors monitored included abdominal wall bleeding, vascular and visceral injuries, cannula slippage, and loss of pneumoperitoneum. A total of 7,117 cannulas were inserted. There were no major vascular or visceral injuries (0/1,000). Cannula slippage occurred in 19 cases (8.8/1,000), with subsequent loss of pneumoperitoneum occurring in 4 cases (1.9/1,000). There were only 3 cases of abdominal wall bleeding (1.4/1,000). Only one incisional hernia occurred (0.46/1,000), despite the fact that 83% of the fascial defects were left open. In comparison with the literature, the incidence of injury in this series was significantly reduced (p < 0.00001). The StepTM radially expandable access device is safe and effective for laparoscopic and thoracoscopic procedures in children of all ages, including small neonates. This device significantly reduces the risk of entry-related injuries and minimizes the inconveniences of cannula slippage and loss of pneumoperitoneum.

Injuries missed at initial operation have the potential to cause the most disastrous complications in trauma patients. Over the past 5 years, 12 patients have required re-operation for 14 injuries missed at initial laporatomy and/or thoracotomy. Six missed injuries were vascular, two each in the thorax, pelvis, and retroperitoneum. The other eight were visceral: three small bowel (one patient), two pancreatic, and one each of the heart, ureter, and diaphragm. Five patients (42%) died, three with missed vascular and two with missed visceral injuries. Three died due to complications directly related to their missed injuries, while the unrecognized injury did not play a significant role in the other two. Indications for re-operation in patients with vascular injuries were hypotension in two patients, persistent output from drains in three, and refractory acidosis in one. Re-exploration in visceral injuries was for clinical sepsis in three patients, DIC in one, cardiac tamponade in one, and persistent chest tube drainage in one. Eleven of the 12 patients presented to the E.D. in shock. All patients had multiple injuries with a mean of 3.25 organ systems injured. Hypotension, coagulopathy, and/or hypothermia (T < 92$dG) were felt to have contributed to missing the injury in five of the patients with vascular, and three of the patients with visceral injuries. In the four other patients, injuries were missed due to inadequate exploration or a low index of suspicion in the presence of multiple injuries. Mean time to re-exploration was significantly less in survivors for both vascular (4.4 vs. 11.2 hr) and visceral injuries (4.3 vs. 9 days). In nonsurvivors, the delays in re-exploration were due to incorrectly ascribing blood loss to coagulopathy in four and intra-abdominal sepsis to pneumonia in one. Missed injuries, although rare following surgical exploration for serious trauma, result in preventable morbidity and mortality. Patients with clinical indications of ongoing bleeding should be re-explored within 4 hours, and those with clinical sepsis or early multiple organ failure should undergo abdominal re-exploration within 4 days to detect undiagnosed injuries.

When I was a resident, my leader taught me that the gold standard forpatients with stress incontinence is the Marshall–Marchetti–Krantz(MMK) procedure. But a few years later, urologists who could performadvanced techniques showed me needle suspension as the best methodat a urological meeting. Fortunately my boss gave me a chance for ahand-to-hand lesson of the stamay procedure by the specialist. Sincethen, I have been selecting this procedure for a few years. Withoutdoubt, this needle suspension was the gold standard at that time.But now most urologists do not select this technique because of badresults. After I had mastered the technique of tension-free vaginal tape(TVT), I could see the smiling faces of patients after the operation. Atthat time I believed that TVT would be the gold standard for thiscondition. But the present status is what you know.Recently most specialists, including myself, believe that using‘mesh’ is the best operation for patients with pelvic organ prolapse. Isthis tendency good for the patients in the long run? No one can predictthe results of this procedure more than ten years from now.God knows what procedure will be the gold standard in the future.Assistant Professor Yasuyuki Suzuki

Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date. A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay. A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms-8.2%, new lower extremity weakness-5.8%, wound infection-1.4%, cage subsidence-0.8%, psoas hematoma-0.5%, small bowel obstruction and ischemia-0.3%, and 90-day readmission-1.9%. In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

INTRODUCTION: The prone transpsoas lateral lumbar interbody fusion (PTP) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of the literature on the clinical outcomes of this procedure, with all the published being of a small sample size. METHODS: A retrospective electronic medical records review was conducted in ten centers for patients who underwent PTP. We collected the intraoperative data (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries), postoperative complications, the patient-reported outcome measures (PROMS) such as back pain visual analogue scale (VAS), and hospital stay. RESULTS: A total of 350 patients were included in the study. There was a significant improvement in the mean VAS by 4.4 ± 6.7 (p &lt; 0.001). 2.8% had ALL rupture, 1.2% had cage subsidence, 0.4% had a vascular injury, and none had visceral injuries. The mean operative time was 229.9 ± 144 minutes, the mean EBL was 134.3±210.2 mL, and the mean hospital stay was 2.6 ± 2.2. In regard to postoperative complications, there was 8.9% new sensory symptoms, 6% transient hip flexor weakness, 1.4% wound infection, 1.4% cage subsidence, 0.6% psoas hematoma, 0.3% ureteric injury, 0.3% small bowel obstruction/ischemia, and 1.6% 90-days readmission. CONCLUSIONS: Multicenter consecutive case series show that PTP is well tolerated and has satisfactory clinical outcomes.

Recent reports by the Australian Safety and Efficacy Register for New interventions and Procedures (ASERNIP-S) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) concluded that insufficient evidence is available to assess the safety of the open versus closed laparoscopy in regard to major vascular and visceral injuries. The aim of this study was to assess the relative safety of open and closed laparoscopy with respect to rates of major vascular and visceral injuries. A combined prospective/retrospective review of a single-surgeon series of 5900 open laparoscopies was performed. A meta-analysis of all reported series of open and closed laparoscopy was conducted using PubMed and MEDLINE search engines to compare major vascular and visceral injury rates. Medicolegal and manufacturer device reports were also reviewed. The case series of 5900 open laparoscopies reported a single visceral injury and no major vascular injuries. The meta-analysis revealed 336 major vascular injuries in 760,890 closed laparoscopies, a mean rate of 0.044%, 1 injury per 2272 cases, compared with 0 injuries in 22,465 open laparoscopies (P = 0.003). Visceral injuries occurred more frequently, 515 injuries in 760,890 closed laparoscopies (mean rate, 0.07) and 11 injuries in 22,465 open laparoscopies (mean rate, 0.05; P = 0.18). Medicolegal and device reports revealed a further 647 major vascular injuries and 500 major visceral injuries. In contrast to the conclusion formed by the RANZCOG and ASERNIP-S, the available evidence shows that open laparoscopy eliminates the risk of major vascular injury and reduces the rate of major visceral injuries. Open laparoscopy using the Hasson cannula should be the preferred method of peritoneal access.