Diaphragmatic Surgery Research Articles

Percutaneous closure of a large iatrogenic fistula between the inferior vena cava and the pulmonary vein in a child

We hereby describe a complex late postoperative veno-venous fistula in a child, successfully treated by an interventional percutaneous procedure. It is a unique complication of diaphragmatic hernia surgery that has never been reported before: a late postoperative iatrogenic fistula, between the inferior vena cava and the right lower pulmonary vein, discovered in a 6-year-old boy operated at the age of 4 months for a right diaphragmatic hernia. The right to left shunt was completely and uneventfully suppressed by a percutaneous procedure separating the systemic venous return from the pulmonary venous return with an Amplatzer Vascular Plug II.

Ovarian cancer in the elderly: Impact of surgery on morbidity and survival

Background Elderly ovarian cancer patients often undergo non-optimal surgery due to their age despite of the high risk of recurrence. The aim of this study was to determine if more postoperative complications occurred in patients over 70 years and to compare extent of surgery with younger patients. Materials and methods Between 2001 and 2009, 172 patients with ovarian cancer were included. We compared patient characteristics, surgical course, postoperative complications and outcome for patients under and over 70 years. Results 143 patients were under 70 years and 29 over. There were no difference between the two groups for tumors characteristics, time of surgery, FIGO stage, standard surgical procedures and rate of optimal resection. Patients over 70 years had less peritoneal surgery ( p < 0.001) especially diaphragmatic surgery ( p = 0.006), pelvic ( p = 0.02) and para-aortic ( p = 0.003) lymphadenectomy. There was no difference in the occurrence of per- or post-operative complications and patients over 70 years had shorter duration of hospitalization ( p = 0.04). There was no difference between the two groups for disease-free survival (DFS) ( p = 0.08) but overall survival (OS) was better in patients under 70 years ( p = 0.002). Conclusion Elderly ovarian cancer patients undergo less extensive surgery and have lower OS despite similar postoperative morbidity, optimal resection and DFS. OS decrease could be explained by difference in the management of recurrences.

Complications de la chirurgie radicale des cancers de l’ovaire de stade avancé

Treatment of advanced ovarian cancer should include surgery with optimal cytoreduction, which is the first prognosis factor. This surgery usually requires extensive resection (pelvic surgery, extensive lymphadenectomy, upper abdominal surgery and sometimes multiple intestinal resection). The complete surgery usually requires a resection of the diaphragm peritoneum in 10 to 100% of cases, intestinal resection in 20 to 100% of cases, splenectomy in 1 to 33% of cases, pancreatectomy in 0 11% of cases, resection of liver metastases in 0 to 16% of cases and cholecystectomy in 2 to 20% of cases. The main complications reported were digestive fistula (1.4 to 8.2%), lymphocyst (0.6 to 32%), septic complications (3.7 to 41.4%) and pulmonary complications (0 to 59%) in case of diaphragmatic surgery. The postoperative mortality ranges from 0.3 to 5.7%. Radical surgery increases the rate of complete cytoreduction with significant morbidity and postoperative mortality. Because these complications decrease survival, it is essential to assess the risk of occurrence of these events to inform patients.

Morbidity of diaphragmatic surgery for advanced ovarian cancer: Retrospective study of 148 cases

Background Treatment of Advanced Ovarian Cancer (AOC) includes surgery with complete cytoreduction, one of the strongest prognostic factors. To achieve complete cytoreduction, diaphragmatic surgery is often required. There is currently a lack of information in the literature regarding the morbidity and impact of this type of surgery. The aim of this study is to report specific pulmonary morbidity and overall morbidity associated with diaphragmatic surgery in patients with AOC. Materials and methods We conducted a multicentric (6 centres), retrospective study that included 148 patients operated on between 2004 and 2008. Patient characteristics, surgical course and postoperative complications were collected. Results The complete cytoreduction rate was 84%. The surgery was categorised by timing as initial, interval or recurrence surgery in 38%, 51% and 11% of patients, respectively. In 69% of patients, one or more postoperative complications occurred: pulmonary complication (42%), digestive fistula (7%) or lymphocyst (18%). The pulmonary complications were pleural effusion (37%), pulmonary embolism (5%), pneumothorax (4%) and pulmonary infection (2%). These complications required revision surgery, pleural evacuation, or lymphocyst evacuation in 13%, 14%, and 11% of the cases, respectively. Postoperative mortality was 3%. Risk factors for pulmonary complications were the addition of extensive upper surgery to the diaphragmatic surgery ( p = 0.014) and the size of the diaphragmatic resection ( p = 0.012). Conclusions Diaphragmatic surgery achieved complete removal of the tumour but resulted in pulmonary complications in addition to complications of radical surgery.

789 The Potential Benefit of Nj Tube Placement at the Time of Congenital Diaphragmatic Hernia Repair Surgery

Aims: A previous retrospective review of CDH cases repaired from 1996-2007 revealed a mortality rate comparable to other centres. A follow-on study was then begun to more accurately examine mortality, morbidity and any benefit of NJ tube placement in successful feeding establishment. Methods: : Data were gathered from patient notes during their PICU and ward admissions and analysed using Microsoft Excel. Results: From Oct 2007 to Jan 2010, there were 17 episodes of CDH repair among 15 patients. 3 patients died, giving a survival rate of 80% which is improved on the previous figure of 70%. Patients had an average of 17days TPN [range 0-38] with an average of one episode of CONS sepsis per patient. 7 patients had an NJ tube passed, taking an average of 5.3days to achieve jejunal placement. One tube was sited radiologically, but successful placement failed completely in 3 patients. Mean time to establish full feeds was 21 days [range 1-65], but this was reduced to 3.8days in patients after an NJ was successfully sited. Conclusions: Time to achieve full enteral feeds was significantly reduced post NJ tube placement. However, the failure to place an NJ in almost onethird of patients attempted must be noted, as must the 5 day delay in attaining successful tube position. We would recommend routine placement of NJ at the time of hernia repair. This would likely reduce TPN requirements, dependence on central venous access and episodes of sepsis.

Comparison of diaphragmatic surgery at primary or interval debulking in advanced ovarian carcinoma: An analysis of 163 patients

Aims of the study and methods Survival, complications and recurrences after diaphragmatic surgery at primary or interval debulking surgery were compared. One hundred and sixty three consecutive patients with stage III/IV ovarian cancer underwent diaphragmatic surgery between September 1993 and December 2007. Primary debulking was performed in group 1 (89) patients and interval debulking was performed in group 2 (74) patients. Cytoreductive outcome, overall survival (OS), disease-free survival (DFS) and post-operative complications were analysed. Results Despite differences in baseline mean age ( p = 0.015), in FIGO stage III/IV ( p = 0.036) and in mean largest diameter of metastatic disease at the beginning of debulking surgery ( p = 0.037), the optimal debulking rates (residual tumour less than 1 cm) were similar ( p = 0.065). Excision of diaphragmatic metastases was most frequently performed in group 1 (77.53%) and coagulation was most frequently performed in group 2 (58.10%). Similar overall survival and disease-free survival rates were found. After the propensity matching procedure, the largest diameter of metastatic disease at the time of debulking and no residual tumour (complete debulking) were demonstrated as independent prognostic factors for OS. Plaque-like lesions on the diaphragm metastases were significantly ( p = 0.015) more associated with diaphragm recurrence than papillary lesions. Minor and major complications related to diaphragmatic surgery as well as mean operating time, post-operative care in intensive care unit and length of hospitalisation were significantly higher in group 1 rather than in group 2 ( p = 0.043). Conclusions Diaphragmatic dissemination resulted in similar survival and cytoreductive rates after primary and interval debulking. However, the morbidity was less after interval debulking as fewer surgical procedures were performed.

Incidental events of diaphragmatic surgery in 82 patients with advanced ovarian, primary peritoneal and fallopian tubal cancer

Surgical resections, such as peritoneal stripping (peritonectomy) are performed for disseminated diaphragmatic lesions of advanced ovarian cancer. This study retrospectively investigated the incidental events of diaphragmatic surgery. The records of patients with advanced mullerian carcinomas, including ovarian, primary peritoneal and fallopian carcinomas, who underwent diaphragmatic surgery were reviewed. Based on our criteria, stripping was performed for surface disease on the diaphragm, and full-thickness resection was performed for bulky disease. In certain cases, both procedures were performed. We analyzed intra- and post-operative incidental events in 82 patients. The χ(2) and Fisher's exact tests were used in the statistical analysis. There were 82 stage III-IV cases of which 56 patients underwent stripping, 12 underwent full-thickness resection and 14 patients underwent both procedures. Unexpected open chest surgery following stripping occurred in 1 out of 63 patients (1.6%) in the primary, 4 out of 13 patients (30.8%) in the interval and 0 out of 6 patients (0.0%) in the secondary debulking surgery groups. The incidence of unexpected open chest surgery was high in the interval debulking surgery group (p<0.001). Regarding post-operative events, accumulation of pleural effusion was identified in 43 patients (52.4%). The incidence of pleural effusions was not significantly different between the two procedures. No complications were encountered, nor was a chest tube required, during unexpected open chest surgery and postoperative pleural effusions. Therefore, it was concluded that special attention should be paid during interval debulking surgery even though it was possible for surgical resections of diaphragmatic lesions to be performed safely.

The Role of Diaphragmatic Surgery During Interval Debulking After Neoadjuvant Chemotherapy

The purpose of this retrospective study was to evaluate diaphragmatic surgery in achieving optimal cytoreductive results and its associated complications during interval debulking surgery in patients with advanced ovarian cancer. After retrospective review of medical records, diaphragmatic surgery was performed in 74 of 128 consecutive patients with advanced epithelial ovarian cancer who underwent interval debulking, between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination of stripping with coagulation (group 3), and diaphragm full-thickness resection including muscle with pleura (group 4). Cytoreductive outcome, morbidity, overall survival, and disease-free survival were analyzed. Two patients (2.7%) had International Federation of Gynecology and Obstetrics stage IIIB disease; 46 (62.16%), stage IIIC; and 26 (35.13%), stage IV. After 3 to 4 cycles of neoadjuvant platinum-based chemotherapy, the diaphragmatic disease was coagulated in 43 patients (58.10%) and was only stripped in 10 (13.51%); in 19 patients (25.67%), a combination of these techniques was applied; and in 2 (2.70%), the disease was resected, with the adjacent infiltrated part of the diaphragmatic muscle and the pleura above it. Debulking to no residual was achieved in 95%, 100%, 100%, and 50% for groups 1, 2, 3, and 4, respectively. The median disease-free survival was 15, 14, and 14 months, and the median overall survival was 34, 30, and 51 months for groups 1, 2, and 3, respectively, and were not reached for group 4. Minor and major complications were comparable among the groups. Pleural effusions were the most frequent associated complication, and chest tube placement (1.3%) or thoracocentesis (4%) were necessary for the relief of respiratory distress. The perioperative mortality rate was 0%. Diaphragmatic surgery during interval debulking enhances optimal cytoreduction rates and improves survival with acceptable and manageable morbidity. In patients with thick (>4 mm) or large (>1 cm) lesions, stripping the diaphragm or full-thickness resection of the diaphragmatic muscle is preferred.

Surgical Procedures and Morbidities of Diaphragmatic Surgery in Patients Undergoing Initial or Interval Debulking Surgery for Advanced-Stage Ovarian Cancer

Surgical management of advanced-stage ovarian cancer (ASOC) can require diaphragmatic surgery (DS) to achieve complete cytoreduction. The aim of this study was to evaluate modalities and morbidities of DS at the time of initial surgery (INS) and interval debulking surgery (IDS; performed after neoadjuvant chemotherapy). Retrospective review of patients undergoing (unilateral or bilateral) DS at the time of INS or IDS for ASOC. Between 2005 and 2008, 63 patients were studied. Treatment of the diaphragm was unilateral in 31 patients and bilateral in 32 patients. DS was performed respectively at the time of INS in 22 patients (35%) and IDS in 41 (65%) patients. Complete cytoreductive surgery was achieved in 95% (21 of 22 in the INS group and 39 of 41 in the IDS group). Surgical procedures used during DS were (in the INS and IDS groups, respectively) stripping in 14 (64%) and 16 (39%), coagulation in 2 (9%) and 10 (24%), and both procedures in 6 (27%) and 15 (37%). An intraoperative chest tube was placed in 14% of patients in each group. Postoperative chest complications requiring treatment occurred in 6 cases: pulmonary embolism (3 cases), symptomatic pleural effusion requiring chest drainage (1 case), and pneumothorax necessitating chest drainage (2 cases). Rate of overall morbidity related to DS was not statistically different in patients undergoing INS and IDS. Surgical treatment of this upper part of the abdomen is key to achieving complete cytoreductive surgery in ASOC.

Upper abdominal surgery in advanced and recurrent ovarian cancer: Role of diaphragmatic surgery

Objective Upper abdominal spread of primary and recurrent ovarian cancer is often considered to be a major obstacle to achieve optimal residual disease at the end of surgery. In this study, we investigate the role of diaphragmatic debulking in the natural history of advanced and recurrent epithelial ovarian cancer patients, and the morbidity of this procedure according to clinico-surgical characteristics. Methods Data from 234 consecutive patients with primary and recurrent advanced ovarian cancer, operated at Catholic University of Rome and Campobasso from January 1, 2005 and December 31, 2008, were retrospectively reviewed. Results Eighty-seven patients (37.2%) underwent a diaphragmatic surgery. Median age was 55 years (range 37–76). Diaphragmatic debulking was performed in 50 out of 120 patients at primary surgery (41.7%), in 16 out of 74 at interval debulking surgery (21.6%) and in 21 out of 40 secondary cytoreductions (52.5%). In the whole study population optimal residual disease at the end of surgery was achieved. The most frequent post-operative complication was pleural effusion, observed in 37 patients (42.5%). Presence of a post-operative pleural effusion was correlated liver mobilization (52.3% vs. 16%; p < 0.0027) and large diaphragmatic disease (> 5 cm) removal (54.1% vs. 23.5%; p < 0.034). Conclusions Diaphragmatic surgery represents a crucial step in the debulking of advanced and recurrent ovarian cancer patients. Considering the natural history of advanced epithelial ovarian cancer and the rate of patients needing diaphragmatic debulking during primary cytoreduction, interval debulking surgery and secondary cytoreduction, this procedure should be present in the surgical repertoire of a gynecologic oncologist.

Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB–IV epithelial ovarian cancer

Objectives The aim of this study was to describe the role of diaphragmatic surgery in achieving optimal debulking in patients with advanced ovarian cancer and the assessment of the relative post-operative complications. Methods Retrospective review was performed of medical records of 89 patients with epithelial ovarian cancer who underwent diaphragmatic surgery during their primary debulking surgery between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination stripping with coagulation (group 3) and diaphragm full thickness resection (group 4). Cytoreductive outcome, morbidity, overall survival (OS) and disease-free survival (DFS) were analysed. Results Eight (8.9%) patients had FIGO stage IIIB, 64 (72%) stage IIIC and 17 (19.1%) stage IV disease. In 20 patients (22%) the diaphragmatic disease was coagulated, in 31 patients (35%) was only stripped, in 31 patients (35%) a combination of these techniques was applied and in 7 (8%) the disease was resected with the adjacent infiltrated part of the diaphragm muscle and the pleura above it. Debulking to no residual tumor was achieved in 90%, 86%, 86% and 100% for groups 1, 2, 3 and 4 respectively. Median DFS was 15, 15, 17 and overall survival OS for groups 1, 2, and 3 was 40, 42, and 50 months respectively and was not yet reached for group 4. Minor and major complications were comparable among the groups. Pleural effusion was the most frequent associated complication and chest tube placement (17%) or thoracocentesis (12%) was necessary for the relief of respiratory distress. The perioperative mortality rate was 0%. The majority of cases were treated in the last five years of our 15-year experience. Conclusions Diaphragmatic surgery increases the rates of optimal primary debulking surgery and improves survival with an acceptable and manageable morbidity rate. In patients with thick (> 0.3 cm) or large (> 4 cm) lesions stripping the diaphragm or full thickness resection of the diaphragmatic muscle is preferred.

Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer

To determine the morbidity of diaphragmatic peritonectomy. Prospective cohort study. A Gynecology Department of a University Hospital. From 2005 to 2007, thirty-seven consecutive patients underwent surgery for stage IIIC or IV ovarian cancer. Patients were separated into a diaphragmatic surgery group (n = 18) and a control group (n = 19). Diaphragmatic surgery may consist of coagulation, stripping or muscle resection. Postoperative course and outcome were analysed. Patients in group 1 (diaphragmatic surgery) underwent more intestinal resection (89% versus 37%, P = 0.01) and pelvic (94% versus 63%, P = 0.02) or para-aortic lymphadenectomy (94% versus 53%, P = 0.04). Neither the mean estimated blood loss (960 ml versus 909 ml) nor the rates of intra-operative blood transfusion (11 versus 9) were significantly different between the two groups. The mean operative time was higher in group 1 (480 minutes versus 316 minutes, P < 0.05). There were thirteen postoperative complications in group 1 and eight in group 2 (P = 0.065). In group 1, the main complication was pleural effusion (seven cases): four patients required secondary pleural drainage, two required only pleural puncture and one had both procedures. There were more complete cytoreduction in group 1 than in group 2 (89% versus 63%, P = 0.068). Diaphragm peritonectomies and resections are an effective way to cytoreduce diaphragm carcinomatosis and increase the rate of optimal debulking surgery. Such procedures frequently result in pleural effusion, but with no long-term morbidity.

Role of Diaphragmatic Surgery in 69 Patients With Ovarian Carcinoma

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

Role of diaphragmatic surgery in 69 patients with ovarian carcinoma

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

Incidence and management of pleural effusions after diaphragm peritonectomy or resection for advanced mullerian cancer

Objectives. Diaphragm peritonectomy or resection is an effective way to cytoreduce diaphragm disease but frequently results in sympathetic pleural effusions. Our objective was to determine the incidence and management of effusions that developed after diaphragm surgery in patients with advanced mullerian cancer. Methods. We reviewed the records of all patients with stage IIIC–IV epithelial ovarian, fallopian tube, or peritoneal cancer who had diaphragm peritonectomy or resection as part of optimal primary cytoreduction at our institution from 2000–2003. All patients had preoperative and serial postoperative chest X-rays to detect and follow pleural effusions. Factors evaluated included the presence and size of preoperative and postoperative effusions, their laterality, and subsequent need for thoracentesis and/or chest tube placement for symptomatic effusions. Results. Of the 215 patients who had primary cytoreduction during the study period, 59 (27%) underwent diaphragm peritonectomy or resection. In addition to standard cytoreduction, 31 (53%) of these 59 patients had diaphragm surgery alone, while 28 (47%) had diaphragm surgery in combination with other upper abdominal resections. Laterality of diaphragm surgery was as follows: right only, 43 (73%); left only, 2 (3%); and bilateral, 14 (24%). Intraoperative chest tubes were placed in 7 (12%) patients. In the remaining 12 patients with preoperative effusions, postoperative effusions on the same side as the diaphragm surgery increased in 6 patients (50%), and 3 patients (25%) required postoperative thoracentesis or chest tube. In the remaining 40 patients without preoperative effusions, ipsilateral effusions developed in 24 patients (60%), and 5 patients (13%) required postoperative chest tubes. The overall rate of new or increased ipsilateral effusions was 58%; the overall rate of postoperative thoracentesis or chest tube placement was 15%. In 75% of the patients, thoracentesis or chest tubes were placed within 5 days of surgery (median, 3 days; range, 2–24). Conclusions. More than half of patients developed ipsilateral pleural effusions after diaphragm peritonectomy for cytoreduction. Most were managed conservatively without requiring a chest tube or thoracentesis. The incidence of symptomatic effusions was not high enough to recommend routine chest tube placement at the time of diaphragm peritonectomy or resection.

Surgical treatment of diaphragm disease correlates with improved survival in optimally debulked advanced stage ovarian cancer

Background. Diaphragm involvement by ovarian cancer is often considered to be a major obstacle to successful cytoreductive surgery. Lack of evidence of survival benefit, concerns over safety and lack of experience are common justifications for this belief. In this study, we sought to evaluate the therapeutic value of diaphragmatic surgery in advanced ovarian cancer. Methods. Relevant data from all consecutive patients with stage IIIC and IV epithelial ovarian cancer, primarily operated at Mayo Clinic from 1994 through 1998, were collected and analyzed. Statistical analyses were performed using χ 2 test, Cox regression model and Kaplan–Meier curves including log rank test. For comparison of trends in performing procedures, an additional 91 consecutive patients undergoing surgery from August 1, 2002 and August 31, 2004 were analyzed. Results. 244 eligible patients were identified. Mean age was 64 years (range: 24–87), and 5-year overall survival (OS) was 31.5%. For the entire cohort, residual disease (RD) was the only independent prognostic factor in multivariate analysis ( P < 0.0001) when considering other factors including demographic, intraoperative findings and procedures performed. For the subgroup of patients with tumor involving the diaphragm ( N = 181), patients who underwent diaphragm surgery (stripping of the diaphragmatic peritoneum, full or partial thickness diaphragm resection, excision of nodules or CUSA) had improved 5-year OS relative to those that did not (53% vs. 15%; P < 0.0001). Furthermore, in multivariate analysis of patients with diaphragm disease, both RD and performance of diaphragm surgery were independent predictors of outcome ( P < 0.001). Considering the subgroup of patients with RD < 1 cm, we noted a strong survival advantage for those patients who underwent diaphragm surgical procedures (5-year survival: 55% vs. 28%; P = 0.0005). Over time, we noted a statistically significant increase in the rate of diaphragm procedures for patients with diaphragm involvement from 1994–98 relative to 2002–3 (22.5% vs. 40%: P = 0.022). Conclusions. Surgical procedures to treat diaphragm disease increase the rate of complete and optimal debulking and correlate with improved survival even compared to patients optimally debulked without diaphragm surgery performed.

Meetings of the Scientific Club of the Rybinsk Medical Section

Dr. Bronnikov A.N.: On the technique of diaphragmatic hernia surgery. The reporter pointed out that there is no unanimity among surgeons as to how to operate on diaphragmatic hernias - both thoracic and abdominal and mixed ways are used here, and Professor Sokolov is also an advocate of the transpleural method, but the reporter disagrees with him due to the impossibility to inspect abdominal organs which may be injured by this method.