Difficulty Of Dissection Research Articles

Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration.

Neurological deterioration is commonly seen after surgical excision of clival meningiomas; however, an understanding of the risk factors associated with postoperative deterioration can lead to improvements in outcome. In 75 patients with clival meningiomas operated on over a 7-year period, the following data were studied; preoperative variables such as presenting Karnofsky scale score, age, sex, and prior operations or radiation therapy. Radiological findings on magnetic resonance imaging or arteriography, such as the development of the arachnoidal cleavage plane between tumor and the brain stem, brainstem edema, tumor size, extent of compression on the brain stem, vascular encasement, and blood supply from the basilar artery were among other data studied. In addition, intraoperative findings such as development of the arachnoid plane, vascular encasement, and the difficulty of dissection were noted. Finally, each patient's neurological and functional statuses were recorded at 1 week postoperatively and at follow-up examinations. Early postoperative functional deterioration occurred in 45 patients (60%) and ranged from mild (30 patients) to severe (three patients). Significant improvement had occurred by the time of follow-up examination in all but four patients; however, permanent postoperative dysfunction was present in 12 patients. Statistical analysis revealed significant correlations between early functional deterioration and preoperative Karnofsky scale scores, male gender, radiological findings of the absence of an arachnoid plane, edema of the brain stem, and arteriographic supply from the basilar artery. Operative features included difficulty with dissection, an absent arachnoidal cleavage plane, and incomplete tumor resection. Permanent functional deterioration was statistically associated with the following: blood supply from the basilar artery, difficulty of dissection, incomplete tumor resection, and early postoperative dysfunction. Logistical regression analysis revealed that the most important risk factor for early postoperative deterioration was tumor size. Patients with large or giant tumors had a 6.7 to 13 times greater risk of functional deterioration, respectively, than patients with small- or medium-sized tumors. Excluding tumor size, the most important factor for permanent deterioration was blood supply from the basilar artery. Patients in this category had a 4.4 times greater risk of permanent functional deterioration. Three stages of tumor relationship to the brainstem arachnoid and pial membranes are proposed. Based on the results of this clinical study of clival meningiomas, suggestions are made for changes in the management strategy of these difficult lesions.

Peritumoral edema in meningiomas: microsurgical observations of different brain tumor interfaces related to computed tomography.

Although generally benign tumors, meningiomas may be associated with extensive peritumoral brain edema as seen on computed tomographic scans. Fifty-two patients with intracranial meningiomas were studied, and the hypodense areas on computed tomographic scans were related to the intraoperative microsurgical findings and to the sizes of the tumors. We have identified three kinds of tumor-brain interfaces characterized by different difficulties in microsurgical dissection: smooth type, transitional type, and invasive type. These different microsurgical interfaces seem to correlate very precisely with computed tomographic images of halo-like and finger-like hypodense areas, allowing prediction of the microsurgical effort to be made in the surgery of meningiomas. The size of the tumor seems to be important in our subjects in determining the amount of edema produced. Indeed, a positive correlation (P < 0.001) was found between the sizes of the tumors and the extent of peritumoral hypodensity. A positive correlation (P < 0.002) also has been found between grade of edema and cortical penetration. Cerebral cortex disruption was systematically observed by us in invasive-type meningiomas and in 3 of 21 cases (14.3%) in transitional-type meningiomas. No penetration was observed in smooth-type meningiomas.

Prospective Analysis of 40 Initial Laparoscopic Colorectal Resections: A Plea for a Randomized Trial

The experience reported herein is on our initial 40 cases of laparoscopic-assisted (LA) colorectal resection that were prospectively evaluated. The operations were performed for colonic tumors of the right segment (n = 4), sigmoid (n = 11), or rectum (n = 7), diverticular disease (n = 17), and chronic constipation (n = 1). Among 22 tumors, 11 were malignant. The operative procedures were 4 right hemicolectomies, 28 segmental left colectomies, 5 anterior resections, 2 abdominoperineal resections, and 1 total colectomy. Thirty-one patients (77.5%) had a successfully completed LA resection. The reasons for conversion in the majority of the cases (66.6%) were difficulties in dissection. In the entirely LA procedures, the mean flatus postoperative day was 3, the mean postoperative hospitalization was 10.7 days, and there were 8 complications (25%) in 7 patients. Two patients were reoperated 2 and 3 months later for adhesion and ischemic stenosis of the colon above the anastomosis. There was 1 death in the LA group (3.2%). The length of operative specimen was 19.6 cm, and the mean number of resected lymph node was six. In contrast to laparoscopic biliary surgery, the benefits of LA colorectal surgery are not obvious. A randomized trial comparing LA and open colorectal resection must be carried out.

A comparison of early effects with two dose rates in brachytherapy of cervix carcinoma in a prospective randomised trial

This phase III randomised trial examined the early effects of two low dose rates (0.38 and 0.73 Gy/h) in brachytherapy of stage I and IIp cervical cancer patients. A total of 204 patients were included between January 1985 and September 1988. Since the main analysis of this paper concerned surgical difficulties, only the 155 patients (76%) on whom surgery was performed at the Institut Gustave-Roussy were retained in this analysis. Treatment consisted of uterovaginal 137Cs irradiation followed by immediate or deferred surgery. The two groups were similar for pretreatment characteristics except for endocervix involvement. Their brachytherapy parameters were also similar (60 Gy pear dimensions, doses to critical organs, total kerma, etc.). The factors with a poor prognosis were, for surgical difficulties, older age, stage II and a small irradiated pear volume; for difficulties with haemostasis, immediate surgery, stage II and previous surgery; and for difficulties in dissection, lymph node involvement. The dose rate significantly influenced surgical difficulties for the stage IIp patients operated on by deferred surgery. Those treated with the higher dose rate showed a 2-fold increase in surgical difficulties compared to those irradiated at the lower dose rate ( P = 0.03). The independent prognostic factors for sterilisation of the surgical specimen were small tumour size and absence of lymph node involvement. An inverse dose rate effect was observed for medium size tumours, with significantly more sterilisations observed in stage IIp patients in the lower dose rate group ( P < 0.01).

Laparoscopic cholecystectomy in patients admitted with acute biliary symptoms

Laparoscopic cholecystectomy has become the standard of care for the elective management of cholelithiasis. Little information exists, however, regarding the appropriateness of this procedure in the setting of acute symptomatology. We retrospectively reviewed our experience with 516 laparoscopic cholecystectomies performed at a single institution from May 1990 to May 1991. Seventy-five (14.5%) of these patients were admitted from the emergency department with acute abdominal pain (100%), fever (4 of 75, 5%), and/or an elevated white blood cell count (22 of 75, 29%). There were 54 females and 21 males, with a mean age of 50.0 +/- 2.4 years (range: 17 to 89 years). Laparoscopic cholecystectomy was attempted in all patients, and was successful in 68 of 75 patients (91%). Seven procedures were converted to open cholecystectomy because of the difficulty in dissection precluding safe laparoscopic cholecystectomy. The time from admission to surgery (mean: 3.4 +/- 0.3 days), as well as the total hospital stay (mean: 5.5 +/- 0.6 days), was much longer than in the elective circumstance. Mean laboratory values for the group as a whole were as follows: white blood cell count (mean: 9.6 IU/L +/- 0.4 IU/L, range: 4.1 IU/L to 19.5 IU/L), alkaline phosphatase (mean: 97.0 IU/L +/- 13.7 IU/L, range: 27 IU/L to 375 IU/L), and alanine aminotransferase (mean: 78.3 IU/L +/- 13.7 IU/L, range: 15 IU/L to 701 IU/L). Patients requiring open cholecystectomy were older (mean: 61.4 +/- 4.4 versus 48.8 +/- 2.6), were more likely to be febrile (3 of 7, 42%, versus 1 of 68, 1%), and were more likely to have a significant leukocytosis (mean: white blood cell count 12.9 +/- 1.8 x 10(3) cells/mm3 versus 9.2 +/- 0.4 x 10(3) cells/mm3) than were those undergoing successful laparoscopic cholecystectomy. Laparoscopic cholecystectomy can be performed safely in the majority of patients presenting with acute biliary symptoms. Patients with a triad of acute abdominal pain, fever, and elevated white blood cell count, particularly elderly patients, are more likely to require conversion to open cholecystectomy, however.

Laparoscopic subtotal cholecystectomy.

Subtotal cholecystectomy is a definitive and safe operation to treat diseases of the gallbladder, whenever there are major difficulties in dissection from the liver. Described herein is successful experience with 6 patients using this technique, through the laparoscopic approach. In cases with severe inflammatory changes, gallbladder embedded in liver tissue, and liver cirrhosis, they enabled reduction of operative time and avoidance of excessive bleeding that could have caused the conversion of the laparoscopic approach to open laparotomy.

Treatment of stages B3 and C seminoma with chemotherapy followed by irradiation therapy: Southwest oncology group study

Beginning in 1981, 28 patients with advanced seminoma were treated with combination chemotherapy followed by irradiation to evaluate the possibility of improved survival using both modalities. The treatment protocol consisted of two courses of vincristine, actinomycin-D, and cyclophosphamide followed by reassessment. Those initially presenting with Stage B3 disease who achieved a complete response to two cycles of chemotherapy then underwent irradiation. All others were given a third course of chemotherapy before undergoing irradiation. The pre-radiation portion of this protocol produced a complete response rate of only 25 percent, substantially less than other, more recent, protocols. Radiation therapy produced a complete response in 69 percent of those who did not achieve a complete response from chemotherapy, increasing the complete response rate from 25 percent to 64 percent. Given this response rate to radiation therapy and the difficulty of dissection and associated morbidity with the surgical excision of postchemotherapy residual masses, the best option at this time may be observation with salvage chemotherapy and/or radiation reserved for those with disease progression.

Laparoscopic Cholecystectomy: A Multicenter Study

Laparoscopic cholecystectomy has been developed as an alternative to open cholecystectomy for the treatment of symptomatic cholelithiasis. A collaborative study of 261 patients undergoing laparoscopic cholecystectomy at three Texas institutions was performed to determine the effectiveness and safety of this technique. There were 65 males and 196 females with a mean age of 49 years (range 17-94 years). Acute cholecystitis was present in 38 patients and chronic cholecystitis in 223 patients. Mean length of surgery was 80 minutes (20 min to 4 hr). Fifteen patients were converted to the open technique intraoperatively due to bleeding, adhesions, or difficulty of dissection. There were no perioperative deaths and morbidity was 3% including urinary retention, small bowel obstruction, arrhythmia, wound infection, and bile leakage. There were no common duct injuries. Hospitalization ranged from outpatient surgery to 7 postoperative days with a mean of 1.2 days. We conclude that laparoscopic cholecystectomy can be performed safely and with low morbidity and offers shorter hospitalization and postoperative recovery.

Newly described muscle attachments to the anterior band of the articular disk of the temporomandibular joint

The presence of these two muscle attachments will be helpful in treating TM disorders. Why they have not been previously described is a mystery, but it is more understandable when the difficulty of dissection is noted. Freeing the disk while investigating the retrodiskal area, and then performing fiber-by-fiber dissection of the deep masseter muscle are uncommon procedures. Muscle fibers often exist from the deep masseter muscle to the capsule of the TMJ, and these muscles could easily be mistaken for the fibers already known and, therefore, ignored when the masseter was removed in dissection. If the first specimen dissected had not been a well-developed male with strong tendon attachment, the attachments would have been missed in this case as well.

Surveillance hémodynamique au cours de l'exérèse micro-neurochirurgicale par voie sous- et rétrosinusienne en position assise du neurinome de l'acoustique

Haemodynamic data (thermodilution Swan-Ganz catheter and radial artery cannula) were collected in 17 patients (52.4±8 yr) during retrosigmoid approach for removal of an acoustic tumour in the seated position. Measurements were made before stimulation of posterior fossa structures (period 1) and during tumour dissection along the brain stem (period 2). Significant increases in systolic, diastolic and mean blood pressures, in pulmonary capillary wedge pressure, in cardiac index and in stroke index were observed during period 2, whereas heart rate, right atrial pressure and systemic vascular resistances were unaffected. The greater the size of the tumour and the difficulties in dissection, the greater were these intraoperative haemodynamic changes. In addition, the pulmonary arterial blood temperature and the noradrenaline plasma concentrations (double isotope enzymatic assay) increased significantly during period 2. In conclusion, the prolonged microsurgical technique of acoustic tumour dissection through the retrosigmoid approach may modify left ventricular loading conditions and may lead to pulmonary oedema, even if intravascular volume expansion was minimal and ventricular function was near normal.

The difficulties of complete pelvic lymph node dissection in radical hysterectomy for carcinoma of the cervix

Three hundred patients with carcinoma of the uterine cervix were treated by radium insertions followed by radical hysterectomy and lymph node dissection. Preoperative lymphography was performed and peroperative radiographs were taken to ensure as complete a dissection as possible. The surgical technique used is described, and a survey is given of the anatomic localization and radiologic appearance of certain lymph nodes which caused particular problems during dissection.

THE INNER CORD--SYSTEMATIC APPROACH TO INGUINAL HERNIA.

Introduction Every surgeon has encountered difficulty in dissection of the indirect inguinal hernia sac. If the hernia is large, hypertrophy of the musculofascial tissues of the cord occurs and the sac so envelopes the cord structures that in freeing it by his usual method the surgeon may soon find himself in a maze of tissue planes. Other difficulties arise in being unable to locate a small patent process vaginalis of a communicating hydrocele, with the excessively fatty cord, or when there is a sliding component to the hernia. Surgical atlases and textbooks depict, and it is likely most surgeons use, a technique of total cord mobilization with opening and dissection of the sac from the cord structures. However, to turn things about and to dissect the cord structures from the sac simplifies the isolation of the hernial sac in all types of indirect hernia. The technique is described in this

The surgical problem of submasseteric abscess

Perusal of the dental literature has revealed scant reference to the subject of submasseteric abscess and its limitary effect in the spread of dental infection. It is apparent that the astute surgical axiom—‘pus needs drainage’—continues to be defied and reliance placed upon therapeutic measures alone, regardless of the state of infection. From such errors of judgement may arise a refractory case or change in the formal nature of the presentation. Confirmatory evidence of this tendency is shown in the radiographs of bone destruction which occurred beneath mature submasseteric pus formations. A discussion on the controversial matter of the regional anatomy was thought to be apposite, and it does seem that differences in interpretation may be due to inherent difficulties in dissection. Time alone will provide the full answer to the enigma; does an anatomical submasseteric space exist; is it an artefact; or is the pus disposal merely sub-periosteal? One thing cannot be controverted—that is, the reality of the surgical condition.