Main Intraoperative Complications Research Articles

A case series of laproscopic management of hydatid cyst of liver

Background:Hydatid cyst is zoonosis caused due to Echinococcus species mainly, Echinococcus granulosus and Echinococcus multilocularis. It was first described by Hippocrates as “liver full of water”. In developing countries like India, Iran, China and Mediterranean countries it is still remains a major problem. It can involve any organ and can mimic almost any pathological condition.Methods: The present study was carried out from January 2014 to December 2015. Total 20 cases of liver hydatid operated laproscopically studied prospectively. Omentoplasty with external drainage was done as sole operative modality. Postoperative follow up was done on 2nd week, 1, 3 and 6 months. Results:Among the observed patients most common age group was 31-40 years (40%), with male predominance (60%). Abdominal pain was most presenting symptom (65%). Right lobe involved involved in 75% patients. Cysts are usually single (90%). Bleeding and contamination of peritoneal cavity with scolices was main intra-operative complication (5% each). Mean operative time was 99.95 minutes. In post-operative period biliary leak was major complication (10%). Cosmetic results were good with barely visible scar (90%).Conclusions:Surgery is the gold standard treatment for hydatid liver and laproscopic technique is gaining more and more importance with advantage of being minimal invasive and less complications with better patient satisfaction.

Deep sclerectomy with supraciliary hema implant (Esnoper® V-2000): results and complications.

The aim was to report the results of deep sclerectomy (DS) with supraciliary hema implant and the influence of the surgical complications on intraocular pressure (IOP). Forty-eight eyes of 41 patients with open angle glaucoma (OAG), who underwent DS with supraciliary hema implant (Esnoper(®) V-2000), were included in this study. A significant IOP reduction was observed, changing from a preoperative mean of 24.6 ± 6.33 mmHg to 16.5 ± 4.4 mmHg (p < 0.001) at 12 months and 16.1 ± 3.4 mmHg (p < 0.001), at 24 months. Similarly, a significant reduction in the number of glaucoma drugs needed was observed, varying from 2.71 to 0.22 (p < 0.001) and 0.4 (p < 0.001), 1 and 2 years after surgery. Goniopuncture with the Nd:Yag Laser was performed in 30 eyes (62.5%) with a mean time between the surgery and the procedure of 150 days, producing a mean IOP reduction of 4.0 mmHg (p < 0.001). The main intraoperative complications were microperforation of the trabeculodescemetic membrane (TDM) in 1 eye (2.08%) The main early postoperative complications were seidel at 24 h in 11 eyes (22.91%), hyphema in 7 eyes (14.58%), choroidal detachment in 3 eyes (6.25%) with macular folds in 2 (4.16%) and need for additional mitomycin injections in 2 eyes (4.16%). All these complications were spontaneously resolved. No correlation between these complications and final IOP was found, but a significant correlation between the presence of hyphema and higher IOP 24 months postoperatively (p = 0.048) was observed. DS with supraciliary hema implant is a safe and effective technique for the management of OAG. The presence of hyphema during the first week after the surgery could be considered as a negative prognostic factor in DS with supraciliary implantation.

Hemipelvectomy: Outcome in 84 dogs and 16 cats. A veterinary society of surgical oncology retrospective study

To report clinical findings, perioperative complications and long-term outcome in dogs and cats that had hemipelvectomy surgery for treatment of neoplasia. Multi-institutional retrospective case series. Dogs (n = 84) and cats (16). Medical records (January 2000 to December 2009) of dogs and cats that had hemipelvectomy at participating institutions were reviewed. Postoperative progress and current status of the patient at the time of the study was determined by either medical record review, or via telephone contact with the referring veterinarian or owner. Complications were infrequent and usually minor. Hemorrhage was the main intraoperative complication; 2 dogs required blood transfusion. One dog developed an incisional hernia. In dogs, hemangiosarcoma had the worst prognosis with a median survival time (MST) of 179 days. MST for chondrosarcoma (1232 days), osteosarcoma (533 days), and soft tissue sarcoma (373 days) were not statistically different. Median disease-free interval (DFI) for local recurrence of all tumor types was 257 days. Cats had 75% survival at 1 year, which was significantly longer than dogs. Survival times for most tumor types can be good, but surgical margins should be carefully evaluated to ensure complete tumor removal. Adjuvant therapies may be advisable particularly for dogs to reduce rates of local recurrence or distant metastasis.

Dislocation of Temporomandibular Joint

Sagittal split ramus osteotomy (SSRO) has wide-ranging indications and results in simultaneous improvements in occlusion and facial appearance. Thus, it is the most frequently used osteotomy for jaw deformities. Its main intraoperative and postoperative complications are massive bleeding, atypical fractures, inferior alveolar nerve paralysis, and relapse. This report describes a case of temporomandibular joint dislocation, a rare complication of SSRO. The patient was a 23-year-old man with mandibular prognathism which was treated by bilateral SSRO. Postoperative x-ray showed that the left temporomandibular joint was dislocated anteriorly. Thus, the patient underwent reoperation, including reduction and re-fixation. Subsequently, it was discovered that the patient had a previous history of recurrent dislocation of the temporomandibular joint. This case illustrates the need for practitioners to be mindful of temporomandibular joint dislocation as a rare complication of SSRO.

Use of a revision cup for treatment of Zurich cementless acetabular cup loosening

Loosening of the acetabular cup is one of the most common complications following total hip replacement and has an incidence rate of 1.8% to 36.8%. The objective of this study was to describe the surgical technique for the application of a cementless acetabular component specifically designed for treatment of cup loosening and preliminary clinical experience. The Kyon revision cup is composed of two components; the first is a perforated titanium outer shell with holes for 2.4 mm titanium screws, which is impacted into the acetabulum after removal of the loose cup and reaming of the acetabulum. It is secured with a variable number of screws. The second component is an inner plain titanium cup with an ultra-high-molecular-weight polyethylene insert, which is impacted into the outer shell to obtain press-fit stability. This revision cup was used in 31 dogs with cup loosening and a minimum follow-up period of six months. There were four intra-operative complications and two postoperative complications. The main intra-operative complication was difficulty inserting the inner cup into the outer shell. Postoperative complications included craniodorsal hip luxation in one dog, which was successfully managed, and cup loosening in another dog, which required explantation of the prosthesis. The main advantage of the revision cup appears to be increased implant stability afforded by screw fixation. Our initial clinical results in 31 dogs were promising; all but one dog had a successful clinical outcome.

The Anterior Extraperitoneal Replacement of the Intervertebral Disk L5/S1—Safe Solution for Treatment of Degenerative Disk Disease. Experience with 187 Patients

Introduction Despite increased use of anterior spinal surgery, there is little documentation of the specific types and frequencies of complications associated with its use. Review of the spinal surgery literature revealed a dearth of studies that address the morbidity and mortality rates in large samples of patients who had undergone anterior surgery specifically at level L5/S1. The aims of this study were to report prospectively the incidence and specific types of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at level of the L5/S1 intervertebral disk. Materials and Methods We reviewed all cases of anterior surgery at level L5/S1, treated at the Department of Neurosurgery from January 2001 to June 2011. The study group consisted of 187 patients: 111 women and 76 men, average age 45 years, range 24 to 76 years. The preoperative diagnosis was degenerative disk disease in 96 (51%), failed back surgery syndrome (FBSS) in 55 (30%) and spondylolisthesis in 36 patients (19%). They suffered from low back pain (LBP) and radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. Total 69 (37%) patients had undergone one or more prior abdominal surgeries including appendectomy in 34 (18% of 187 patients), Pfannenstiel incision in 40 (36% of 111 female); and cholecystectomy in 4, gastric surgery and inguinal hernia in 2 each and umbilical hernia in 1. The whole operation, including surgical approach, was performed by an experienced neurosurgical team. ALIF (Anterior Lumbar Interbody Fusion) was performed in 155 patients, including 96 patients with stand-alone fusion, 12 patients with concomitant anterior plating (Oracle plate, Synthes, USA) and 47 patients with additional posterior TP (transpedicular) fixation (USS, Synthes, USA). Arthroplasty (TDR) was done in 32 patients. The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disk L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented. Results Intraoperative pathological-anatomical anomalies were found in 38 patients (20%). We had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, ileus, LS plexus injury, retrograde ejaculation or sterility. Intra- and postoperative minor complications were found in 24 patients (11%), the main intraoperative complication was peritoneal opening without visceral injury in 9 patients (5%), and the main postoperative complication was weakness of the right abdominal wall in 5 patients (2.5%). At follow-up we found no hardware failure on X-ray (implant displacement or pseudoarthrosis). Clinically, no patient was worse after surgery. Total 176 patients were satisfied with the surgery and reported improvement, 11 patients were not improved and we later indicated posterior TP fixation at L5/S1 segment for enhancement of the stability. Conclusion Retroperitoneal access and surgery at level L5/S1 disk space is a safe procedure when performed by a knowledgeable and experienced spine team and can be used with confidence when the nature of a patientás spinal disorder dictates its use. During surgical planning for an anterior approach to the LS spine the surgeon must assess carefully the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Cepellades J, Pellisé F, Rovira A, Grivé E, Pedraza S, Villanueva C. Magnetic resonance anatomic study of iliocava junction and left iliac vein positions related to L5-S1 disc. Spine 2000;25:1695–1700 Cho DS, Kim SJ, Seo EK, Chung IH, Oh ChS. Quantitative anatomical and morphological classification of the ilias vessels anterior to the lumbosacral vertebrae. Journal of Neurosurgery Spine 2005;3:371–374 Ebraheim NA, Xu R, Farooq A, Yeasting RA. The quantitative anatomy of the iliac vessels and their relation to anterior lumbosacral approach. Journal of Spinal Disorder 1996;9:414–417 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592–1599 Korge A, Siepe C, Mehren C, Mayer HM. Minimally invasive anterior approaches to the lumbosacral junction. Oper Orthop Traumatol 2010;22:582–592 Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 1997;22:691–700 McAfee PC, Regan JJ, Geis WP, Fedder IL. Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK. Spine 1998;23:1467–1484 Rajaraman V, Vingan R, Roth P, Heary RF, Conklin L, Jacobs GB. Visceral and vascular complications resulting from anterior lumbar interbody fusion. Journal of Neurosurgery (Spine 1) 1999;91:60–64

Comparison of Complications of Anterolateral and Lateral TransPsoatic Retroperitoneal Approaches to the Th12-L5 Intervertebral Disks. Experience with 208 Patients

Introduction Anterior lumbar interbody fusion using supportive cage is a common surgical method for treating degenerative lumbar spinal diseases. Improved surgical techniques and better results have led to renewed interest in this procedure and to the development of new lateral transPsoatic minimally invasive access to the lumbar disks. The aim of this study was to compare the rate of complications during traditional anterolateral and new lateral transPsoatic retroperitoneal approaches to the intervertebral disks (IVD) at levels Th12-L5. Materials and Methods We reviewed all cases of the IVD anterolateral and lateral surgery at level Th12-L5, treated at the Department of Neurosurgery from January 1996 to June 2011. The ALIF (Anterior Lumbar Interbody Fusion) group consisted of 120 patients: 53 women and 67 men, average age 44 years, range 17 to 76 years; and the XLIF (Extreme Lateral Interbody Fusion) group consisted of 88 patients: 50 women and 38 men, average age 51 years, range 17 to 74 years. They suffered from low back pain (LBP) and usually radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography, and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. The preoperative diagnosis of ALIF group was degenerative disk disease at 39 levels, failed back surgery syndrome (FBSS) at 27, spondylolisthesis at 27, and posttraumatic disk injury at 35 levels. The preoperative diagnosis of XLIF group was DDD at 39, FBSS at 22, spondylolisthesis at 17, retrolisthesis at 5, and posttraumatic disk injury at 9 levels. The whole surgery, including surgical approach in the lateral decubitus position, was performed by an experienced neurosurgical team. The surgical steps in the minimally invasive anterolateral retroperitoneal approach and lateral retroperitoneal transPsoatic approach from the left side to disks Th12-L5 are described. Intraoperatively during XLIF procedure, the surgeon identified the lumbar nerve roots with stimulator to prevent their injury. All surgical intraoperative and postoperative complications directly related to the spinal surgery were documented. Both study groups were compared to each other. Results In both the groups, we had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, injury of ureter or kidney, ileus, retrograde ejaculation, or sterility. In ALIF group, intra- and postoperative minor complications were found in 35 patients (29%), the main intraoperative complication was the necessity to perform sympathectomy of lumbar sympathetic chain to obtain wide access to the disks in 19 patients (16%). For all of these patients with symptoms of sympathectomy the thermography was done as a sensitive test. The main postoperative complications were numbness of left anterolateral thigh or groin or transient pain of left groin in 16 patients (13%). In XLIF group, we had partial and transient injury of L5 nerve root (just the first patient) during implant insertion at level L4/5 (one patient, 1%), without using an intraoperative neuromonitoring (IOM). Since this major complication, we started using IOM strictly and didnát have more nerve injuries. In XLIF group, intra- and postoperative minor complications were found in 20 patients (23%), mainly transient pain of left groin in 11 patients and sympathectomy in 4 patients. At follow-up, we found no hardware failure on X-ray (implant displacement). Total 198 patients were satisfied with the surgery and reported improvement, 10 patients were neither improved nor worsened. Conclusion Rate of minor complications was similar in both groups, in ALIF group 29% and in XLIF group 23% of treated patients. Only one major complication, nerve root injury, was due to underestimation of XLIF procedure in the beginning. Retroperitoneal access and surgery at levels Th12-L5 disk space is a safe procedure when performed by a knowledgeable and experienced spine team. IOM during XLIF surgery is fully recommended. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Crock HV. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique. Clinical Orthopaedics 1982;165:157–163 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592–1599 Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 1997;22:691–700 Mehren C, Mayer HM, Siepe C, Grochulla F, Korge A. The minimally invasive anterolateral approach to L2-5. Oper Orthop Traumatol 2010;22:221–228 Zdeblick TA, David SM. A prospective comparison of surgical approach for anterior L4-L5 fusion. Spine 2000;25:2682–2687

A comparative study of laparoscopic partial hepatectomy by clamp-crush and ultrasurgical techniques in rams

Th e p r e s e n t study was designed to evaluate the feasibility and safety of laparoscopic partial hepatectomy via two techniques in rams. Tw enty - fo ur adult l oc al b re ed ra ms we re used , which divid ed rando mly and equ ally i nto two grou ps. All ani mals s ubje cted to laparoscopic partial hepatectomy. operations were performed under the effect of general anesthesia by using 5% thiopental sodium at a dose rate of 15 mg/kg B.W., intravenously and maintenance was done by inhalation (halothane) (2- 2.5%). Animals placed in a reverse Trendelenburg (30o) and left lateral position. P neumoperitoneum was achieved under (10 - 12mmHg). Four (10 mm) ports were made on ventral abdominal wall. Liver parenchyma was controlled with modified liver clamp. In first group, partial hepatectomy was done by Clamp-crush forceps. While in second group, Ultra- surgical device was used. Following operations, certain parameters such as rectal temperature, respiratory rate, heart rate, food intake, and secondary health problemes had been recorded. Also the operative and resection times and blood loss were estimated. Liver enzymes (alinine transaminase, aspartate transaminase, alkaline phosphate , total serum bilirubin and total serum proteins were me asured . Histopathological examination of liver biobsies was performed at 3 rd , 7 th , 15 th days and four months post-surgery. The main intra-operative complication was the bleeding. Result indicated that the vital parameters were within the normal rang. Shorter operative and resection times were noticed in second group when compared with first group. There were no significant differences in the mean values of blood loss in both groups. Also no bile collection were seen in the abdominal cavity or subphrinic region during the exploratory laparoscopy at (3, 7, and 15 days) and four months post-surgery. There were no significant differences in the mean values of the liver function test (liver enzymes) in two groups. Macroscopic examination revealed the presence of adhestion between liver and adjcent structures with varing degree. The normal structures of the liver which consist of hepatocytes and central vein returned within 4 months post operations in second group. We can conclude that the laparoscopic partial hepatectomy in ra ms can be safely perfor med under Ultrasurgical technique with a modified liver clamp which reflected minor secondary complications and early liver regeneration.

Surgical complications of the anterior approach to the L5/S1 intervertebral disc

The aims of this study were to describe the incidence and type of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at the level of the L5/S1 intervertebral disc. A retrospective review of 175 patients: 103 women and 72 men, average age 45, who had undergone anterior spinal surgery at level L5/S1 from January 2001 to February 2011. The preoperative diagnoses were: degenerative disc disease in 87 (50%), failed back surgery syndrome in 53 (30%) and spondylolisthesis in 35 patients (20%). The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disc L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented. Intraoperative pathological-anatomical anomalies were found in 34 patients (19%) and intra - and postoperative minor complications in 24 patients (12%) but no serious complications. The main intraoperative complication was peritoneal opening without visceral injury (5%) and the main postoperative complication was weakness of the right abdominal wall (3%). . Retroperitoneal access and surgery at level L5/S1 disc space is a safe procedure when performed by a knowledgeable and experienced spine team. During surgical planning for an anterior approach to the LS spine, the surgeon must carefully assess the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications.

High Complication Rate With Anterior Total Hip Arthroplasties on a Fracture Table

Recent attention in THA has focused on minimally invasive techniques and their short-term outcomes. Despite much debate over the outcomes and complications of the two-incision and the mini-lateral and mini-posterior approaches, complications arising from use of the anterior THA on a fracture table are not well documented. We determined the intraoperative and postoperative complications with the anterior approach to THA through an extended single-surgeon patient series. We reviewed 800 primary THAs performed anteriorly with the aid of a fracture table over 5 years and recorded all intraoperative and postoperative complications up to latest followup (average, 1.8 years; range, 0-5 years). Patients with severe acetabular deformity or severe flexion contractures were excluded and those surgeries were performed with a lateral approach during the time period of this study. Intraoperative complications included 19 trochanteric fractures, three femoral perforations, one femoral fracture, one acetabular fracture, one bleeding complication, and one case of cardiovascular collapse. There were no ankle fractures. Postoperative complications included seven patients with dislocations; seven with deep infections; one with delayed femur fracture; 37 with wound complications, among which 13 had reoperation for local débridement; 14 with deep venous thrombosis; and two with pulmonary embolism; and 31 other nonfatal medical complications. The main intraoperative complications of trochanteric fractures and perforations occurred mostly early in the series, while the main postoperative complications related to wound healing were prevalent throughout the entire series. Despite potential advantages of use of a fracture table, surgeons should be aware of the potential complications of trochanteric fractures, perforations, and wound-healing problems associated with this technique. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Intravitreal dexamethasone implant (Ozurdex®) in patients with chronic uveitis

Abstract Purpose To evaluate the safety and efficacy of dexamethasone intravitreal implant (Ozurdex®) in eyes with chronic uveitis with or without cystoid macular edema. Methods A consecutive series of 20 eyes from 18 patients, mean age 49 +/‐21 years, with chronic uveitis (&gt;3 years), 13 eyes with and 7 eyes without cystoid macular edema (CME), was included. Visual acuity, foveal retinal thickness, a full ophthalmological examination and immunosuppressive medication were obtained before injection and over the course (54 days +/‐41 days) after injection. Results In all eyes dexamethasone intravitreal implant (Ozurdex®) could be implanted successfully. Mean visual acuity (LogMAR) increased from 0.82 to 0.65 after an average of 35 days. CME disappeard in 8 of 13 eyes after 35 days (median) and was reduced in 5 eyes. Immunosuppressive medication could be reduced in 9 of 11 patients, 2 patients continued their medication because of their second uveitic eyes. The main intraoperative complications were one subconjuctival substance‐release before scleral penetration, a postoperative increase of intraocular pressure in 5 of 20 eyes, which could be controlled with topical therapy, one retinal detachment and one dislocation of the device into the anterior chamber in an aphacic and vitrecomized eye. First loss of efficacy was observed 3‐4 months after injection. Conclusion Dexamethasone intravitreal implant (Ozurdex®) can improve visual acuity and reduce CME and concomitant immunosuppressive medication in patients with chronic uveitis. The observed efficacy lasts for at least 3 months, we suggest a contraindication for aphacic eyes.

Ovário-histerectomia laparoscópica em felinos hígidos: estudo comparativo de três métodos de hemostasia

Foram avaliadas 24 gatas, hígidas, sem raça definida, distribuídas em três grupos de oito animais. Descreveu-se o acesso laparoscópico para ovariossalpingo-histerectomia (OSH) e comparou-se o uso do eletrocautério bipolar (grupo I), do clipe de titânio (grupo II) e da ligadura com fio de sutura (grupo III) para a oclusão dos vasos ovarianos e uterinos. Hemorragia e enfisema subcutâneo foram as principais complicações observadas no transoperatório e hematoma subcutâneo e deiscência de sutura, as do pós-operatório. O procedimento cirúrgico e a técnica operatória mostraram-se viáveis nos três grupos. O uso do eletrocautério bipolar apresentou vantagens na comparação com os outros métodos de hemostasia.

Safety and efficacy of manual small incision cataract surgery for brunescent and black cataracts

To evaluate the safety, visual outcome and complications of manual small incision cataract surgery (MSICS) in the treatment of patients with brunescent and black cataract (BBC). In a non-randomised interventional case series, 102 consecutive patients with BBC underwent cataract extraction by MSICS, with staining of the anterior capsule by trypan blue. Of the 102 eyes with BBC, MSICS was performed through superior scleral tunnel (SST) in 31 eyes (30.4%) and through temporal scleral tunnel (TST) in 71 eyes (69.6%). The main intraoperative complication was posterior capsule rupture in two patients (2.0%). Postoperatively, 20 eyes (19.6%) developed corneal oedema. Mild iritis was seen in six eyes (5.9%) and moderate iritis with fibrin membrane formation occurred in three eyes (2.9%). On the 40th postoperative day, 80 patients (78.4%) achieved uncorrected visual acuity of 6/18 or better, and 99 (97.1%) had best-corrected visual acuity of 6/18 or better. Patients in the SST group had significantly higher postoperative astigmatism compared to those in the TST group (-1.08 D vs -0.72 D, P=0.017). MSICS with trypan blue staining of the anterior capsule is a safe and effective method of cataract extraction for patients with BBC.

Vaginal hysterectomy and oophorectomy in women with 12–20 weeks’ size uterus

To compare the surgical outcomes of vaginal hysterectomy and prophylactic oophorectomy in women with a uterine size<12 weeks' gestation and 12-20 weeks' gestation, without decensus. In this prospective comparative study, 241 consecutive vaginal hysterectomies were planned for women with benign disease of the uterus. All hysterectomies were performed by the same surgeon (author), and divided into 2 groups: a uterine weight >280 g (n=83, 280-1150 g) and a uterine weight <280 g (n=158). The 2 groups were compared for success rates of hysterectomy and bilateral oophorectomy vaginally, operative time, change in haemoglobin, haemorrhage, length of hospital stay, operative complications, and febrile morbidity. All 241 hysterectomies were completed successfully vaginally, and no patients required laparotomy or additional procedures in both groups. No significant intra- and post-operative complications requiring admission to the hospital were encountered in either group. Mean operating time was significantly longer in the uteri >/=280-g group than in the <280-g group (69.4+/-24.4 versus 108.2+/-41.2 min, p<0.0001). The rate of intraoperative haemorrhage (8.43 versus 1.2%) and the change in haemoglobin were significantly higher in the >/=280-g group compared with the <280-g group (p<0.01). Significant positive linear correlation between uterine weight and operative time was seen in all 241 hysterectomies (p<0.001). The rate of bilateral oophorectomy was similar between the uteri >/=280-g group (89.8%) and the <280-g group (92.9%). The main intraoperative complication of the 241 vaginal hysterectomies was bladder injury that occurred in 1 case (0.4%) in the <280-g group. There were no statistically significant differences in intra- and post-operative complications, febrile morbidity, and postoperative hospital stay between the groups. Our findings demonstrate that despite the prolonged operating time and increased intraoperative blood loss, vaginal hysterectomy can be safely performed on a large uterus. Routine bilateral prophylactic oophorectomy can be performed in all patients who have sufficiently long infundibulopelvic ligaments to permit removal of the entire ovary.

Different Profiles of Patients Who Require Dialysis After Cardiac Surgery

This study was aimed at evaluating the determinants of postoperative dialysis-requiring acute renal failure and at identifying eventual correlations between the different etiologic mechanisms and postoperative prognosis. We evaluated the preoperative and intraoperative features of the 69 out of 6,542 consecutive cardiac surgery patients who developed postoperative dialysis-requiring acute renal failure at our Institution during a 10-year period. Age, valvular and aortic surgery, hypertension, extracardiac vasculopathy, timing of surgery, cardiopulmonary bypass time, and preoperative creatinine level greater than 2.0 mg/dL were identified as predictors by multivariate analysis. In a second analysis, patients were divided in two groups according to the preoperative creatinine level: group A (preoperative creatinine 2.0 mg/dL or less; 38 cases) and group B (preoperative creatinine 2.1 mg/dL or more; 31 cases). The two groups significantly differed in preoperative and intraoperative characteristics and in postoperative outcome: group A patients were younger, had a lower incidence of cardiac and vascular risk factors and comorbidities, were mainly operated on urgent or emergent basis for valvular or aortic pathologies, had longer cardiopulmonary bypass and cross-clamp time, and worse in-hospital outcome but higher midterm survival. Group B patients were older, had a higher prevalence of comorbidities, required more often in-hospital or after-discharge dialysis, had lower in-hospital mortality, but reduced midterm survival. Postoperative dialysis-requiring acute renal failure can be the result of two different pathophysiological pathways: complicated perioperative course due to urgent-emergent surgery or main intraoperative technical complications in patients with preoperative normal renal function and uncomplicated perioperative course associated with reduced preoperative kidney function. The two patient groups significantly differ in baseline preoperative features, as well as in in-hospital and in midterm outcome.

Clinical results of ZSAL-4 angle-supported phakic intraocular lenses in 190 myopic eyes

To evaluate the efficacy and safety of angle-supported phakic intraocular lenses (IOLs) in myopia. Private practice, Siena, Italy. This prospective noncomparative single-surgeon interventional case series comprised 190 consecutive myopic eyes of 115 patients having implantation of a ZSAL-4 IOL (Morcher GmbH) through a 5.5 mm x 3.0 mm sclerocorneal tunnel along the steepest meridian with a surgical iridectomy. Preoperatively, the mean spherical equivalent was -14.37 diopters (D) +/- 4.40 (SD) and the mean astigmatism, 1.66 +/- 1.36 D. Postoperatively, the mean defocus equivalent (DEQ) was 1.55 +/- 1.06 D and the mean astigmatism, 1.41 +/- 1.11 D. The mean surgically induced astigmatism (vector analysis) was 1.03 +/- 0.77 D (95% confidence interval [CI], 0.92 to 1.15); 146 eyes (77%) were within +/-2.0 D of the DEQ, 76 eyes (40%) were within +/-1.0 D, and 36 eyes (19%) were within +/-0.5 D. The safety index was 1.25 and the efficacy index, 0.78. The improvement in best spectacle-corrected visual acuity (0.17) was statistically significant (95% CI, 0.14 to 0.2). Complications were intraocular pressure spike due to topical steroids, 18%; chronic iridocyclitis, 1%; explantation of unstable IOL, 1%; explantation of IOL for iridocyclitis, 0.5%; pupil ovalization, 11%; halos, 18%; and macular hemorrhage, 1%. Angle-supported IOLs can effectively correct high myopia, although residual refractive errors may require secondary procedures. The main intraoperative and postoperative complications were halos, steroid response, and incorrect IOL sizing. The role of surgery in inducing macular hemorrhages should be assessed further.

Smoking and complications of onlay bone grafts and sinus lift operations

Purpose To compare the incidence of complications related to onlay bone grafts (OBGs) and sinus lift operations (SLOs) among smokers and nonsmokers. Materials and methods Data from 143 operations performed during the years 1995 to 2003 were analyzed. There were 64 OBGs and 79 SLOs. Patients were divided into 3 groups: nonsmokers, mild smokers (up to 10 cigarettes per day), and heavy smokers (more than 10 cigarettes per day). Duration of smoking (less or more than 10 years) was recorded. OBG complications were classified as minor (hematoma, swelling, inflammation, or temporary paresthesia) or major (graft exposure or mobility). For the SLO, perforations of the schneiderian membrane were the main intraoperative complication; postoperative complications mostly consisted of swelling, acute or chronic sinus infection, or bleeding. Results Of smokers having OBG, 50% experienced complications, compared to 23.1% of nonsmokers. Major complications were observed in one third of the smokers, compared to only 7.7% in nonsmokers. There was also a tendency toward complications in former smokers, although this relationship was not statistically significant. There was no relationship between SLO complications and smoking or a past smoking habit. Discussion In the present study, smokers demonstrated significantly higher postoperative complications following OBG operations. Smoking did not influence the results in the SLO group. There was no statistically significant difference between complications and past smoking. This finding indicates that the risk of complications can be reduced up to the normal nonsmoker complication rate when smoking ceases. Conclusions This study established a relationship between OBG complications and smoking in this patient population. A higher incidence of complications was found in the smoking group. There was no significant influence of smoking on SLO complications.— Reprinted with permission of Quintessence Publishing.

Block Excision of Tumors of the Anterior Uvea: Report on 68 Consecutive Patients

This study describes the authors' surgical technique and the results in 68 consecutive patients with tumors of the iris and ciliary body involving the angle removed by block excision and tectonic corneoscleral grafting between 1980 and 1995. There were 41 (60.3%) women and 27 (39.7%) men whose ages ranged from 14 to 85 years (median, 41 years). Follow-up ranged from 0.5 to 15.2 years (median, 6.3 years). Tumors of the iris and ciliary body with chamber angle involvement were removed with a modified block excision consisting of simultaneous en bloc removal of the tumor with adjacent iris and cornea and sclera in full-thickness. The resulting defect of 6 to 20 mm (median, 9.0 mm) diameter is covered with a tectonic corneoscleral graft. Forty-nine tumors (72.1%) were classified as malignant tumors of the iris and ciliary body. Twenty-one (44.7%) of 47 malignant melanomas showed histologic evidence of scleral invasion of more than one third of scleral thickness. Extrascleral extension of the tumor was present in seven (14.9%) patients with malignant melanomas and in four (21.1%) patients with benign tumors of the iris and ciliary body. The 10-year survival probability of patients with malignant melanomas was 91.4%. The main intraoperative complication was vitreous hemorrhage in 24 (35.3%) patients, and the main postoperative complication was complicated cataract, occurring in 22 (32.3%) patients. Two local tumor recurrences (2.9%) were observed. Four eyes (5.8%) had to be enucleated after block excision. Best-corrected postoperative visual acuity was better than 20/60 in 36 (52.9%) patients. The authors' results indicate that block excision with tectonic corneoscleral grafting may be the treatment of choice for progressive circumscribed tumors of the iris and ciliary body involving the anterior chamber angle up to 150 degrees of its circumference.

No Incision Transvaginal Retropubic Urethropexy for the Treatment of Female Stress Urinary Incontinence

From August 1991 until April 1994, a total of 45 simplified double-needle bladder neck suspensions for genuine stress incontinence were performed to assess the effectiveness and perioperative morbidity of the procedure. After a mean follow-up of 26 months, the cure rate was 82.2%. The average operating time was 20.4 min, and the average hospital stay was 2.4 days. The main intraoperative complication was suture in the bladder in 10 (22.2%) patients, and the main postoperative complication was urinary retention in 7 (15.5%) patients. We believe that the fast operative time, relatively high success rate, acceptable morbidity, and technical simplicity make this an ideal operation for the correction of stress urinary incontinence. (J GYNECOL SURG 12:1, 1996)

Laparoscopic Nissen-Rossetti fundoplication

From January 1992 to July 1994, 148 patients with symptomatic gastroesophageal reflux and/or hiatal hernia underwent Nissen-Rossetti fundoplication by a laparoscopic approach. There was no conversion and no postoperative death. The main intraoperative complications were hemorrhage (n = 12), pleural opening (n = 5), and gastric perforation (seromuscular effraction) (n = 1). Laparoscopic reoperation was necessary in two patients as a result of bleeding, and there were two cases of food impaction. The median hospital stay was 4.9 days; 117 patients were observed for follow-up for 3-31 months (median 6.2 months). Eleven cases of dysphagia extending beyond 2 months have been observed. In five of those cases, endoscopic dilatation provided effective treatment of dysphagia and in four others, a further laparoscopic intervention enabled a cure to be obtained. Eighty-four percent are satisfied with their decision to have the operation. The laparoscopic Nissen-Rossetti fundoplication can be carried out safely and effectively with positive results similar to those obtained with the open procedure and with all of the advantages of the minimally invasive approach.