THE APPLICATION AND EVALUATION OF PERITONEOSCOPY

Peritoneoscopic examination has now been accepted throughout the world as a safe diagnostic procedure in lieu of laparotomy in selected cases.Laparotomies for diagnostic purposes alone should be condemned.Peritoneoscopy should not be done without a definite purpose and the procedure should not be expected to accomplish more than the purpose for which it is done. Indications for the procedure are set forth in detail. Experience has established definite contraindications, which are reviewed.The procedure is especially indicated for patients who are aged, emaciated, anemic, or poor surgical risks for any reason.All patients having ascites of undetermined cause should be examined by peritoneoscopy.The method is especially indicated for examination of patients with liver disease of all types, for pelvic examinations, for use to determine existence of ectopic pregnancy, and for tumor localization.Considerable use was made of the procedure during World War II to determine the extent and site of intra-abdominal injuries caused by crushing, explosions, and falls from high places.The procedure permits early and correct diagnosis, early decision as to the advisability of operation, and determination as to operability in cases of malignant gastric lesions. It is a safe method for obtaining biopsy specimens from intra-abdominal tissue and organs.Accuracy of diagnosis in cases in which the method can be used is considerably greater with peritoneoscopic examination than with clinical information alone.     

Granulocytic Leukemoid Reactions Associated with Malignant Disease

Large upper abdominal incisional hernias have always been a vexing problem to surgeons because of the rigidity of the costal arches.With the increasing longevity of our population and the constant improvement in ways to sustain older patients during operative procedures, incisional hernias, especially of the upper abdominal area, will undoubtedly become more prevalent.A new anatomical procedure for repair, which was used in 16 cases, eliminates the necessity of the use of various prosthetic materials: extrapleural sectioning of the costal cartilages from approximately the seventh to the tenth rib permits the directional pull of the attached musculature to narrow the defect, thus allowing repair of the hernia without tension.The procedure is technically a simple one and postoperative complications are minimal.     

A NEW APPROACH TO CORRECTION OF D-LOOP TRANSPOSITION OF THE GREAT ARTERIES

An operative procedure is described for repair of transposition of the great arteries in which the left ventricle is the "aortic" ventricle and the right ventricle is the "pulmonic" ventricle. The technical feasibility of this procedure is supported by its successful application in experimental animals. A modified procedure, which may be applicable in certain complex forms of transposition of the great arteries and other perplexing anomalies for which there are no known repairs, is discussed.     

TREATMENT OF MILIARY AND MENINGEAL TUBERCULOSIS IN INFANTS AND CHILDREN

Streptomycin and combined streptomycin-promizole treatment of miliary and meningeal tuberculosis in infants and children at the Los Angeles Children''s Hospital has resulted in clear-cut arrests in seven patients, two of whom had meningitis. A much longer period of observation will be necessary before these patients may be considered cured. These results are incomparably better than the universally fatal outcome of both diseases in a large and unselected group of untreated cases which has been studied. Promizole, and possibly also para-aminosalicylic acid, should be given concurrently with streptomycin. As they are relatively harmless drugs, they should be given to ambulatory patients for a long period of time after arrest of the disease to decrease the likelihood of recurrence. If necessary, streptomycin may be given for longer than 90 days, or in second courses, since combined chemotherapy apparently delays the appearance of streptomycin-resistant strains of tubercle bacilli. The current pessimism with which many pediatricians view miliary and meningeal tuberculosis is unwarranted. Optimism will be rewarded with many more recoveries in the future.     

皮肤益生素霜在面部皮肤美容中的应用

应用皮肤益生素霜,对面部痤疮、化妆品过敏、黄褐斑共251例患者进行良好的调理。结果痤疮患者142例,治愈81例,有效45例,无效16例。化妆品过敏患者64例,治愈54例,有效9例,无效1例。黄褐斑患者43例,治愈11例,有效23例,无效9例。提示皮肤益生素霜能够起到良好的皮肤治疗和护理作用。     

A NEW SIMPLIFIED METHOD OF MAMMAPLASTY

Abnormally large breasts, which may be a factor in psychic disturbance from an esthetic point of view and which appear to be related to habitual abortion and sterility, can be reduced in size and reshaped by a simpler operative procedure than those now in use. The operation takes considerable less time than others used heretofore. It avoids the need for marking the skin beforehand as a guide to the reshaping procedure and then trying to abide by a preconceived plan, which may be difficult, and it permits the ultimate site of the nipples to be selected after the reshaping is done and even after the skin over the entire breast is completely closed.     

外科急腹症48例临床诊疗分析

目的:探讨外科急腹症的早期诊断与治疗,以便总结经验,提高治愈率,降低致残率与病死率。方法:回顾性分析48例外科急腹症诊治的临床资料。结果:急诊手术40例,经严密观察后手术8例,术后并发症11例,治愈44例,死亡4例。结论:外科急腹症的诊断应结合病史,体征及辅助检查等综合判断。对其早期确诊与及时处置和手术治疗是降低病死率的关键。     

Gastric polyposis

In a series of 48 cases of gastric polyps, 40 patients had benign lesions while the polyps in the remaining eight cases were malignant. Although the symptomatology in this series was not uniform, only one patient was entirely asymptomatic. Of the eight patients with malignant lesions, three had polyps which could well be described as small, suggesting that size may not be a reliable criterion of benignity even in a single lesion. Laboratory studies indicated that anemia, achlorhydria and occult blood in the stools are frequently associated with gastric polyps. There was no apparent correlation, however, between these phenomena and the benign or malignant nature of the lesions.X-ray examination, performed in every instance, was completely negative in six cases and inconclusive in an additional five. Gastroscopy did not reveal the presence of polyps in three of 15 cases. Malignant change was detected by cytologic examination in one case in which both roentgen and gastroscopic examination were negative. The author believes that in most cases of gastric polyps operative treatment affords the greatest degree of safety. An operative procedure of considerably less extent than total gastric resection often is feasible. However, if true polyps occur where removal can be effected only by total gastric resection, the incidence of malignant change in these lesions would seem to indicate the advisability of such a procedure unless positive contraindicating conditions are present.     

腹腔镜下输尿管切开取石术疗效探讨

目的探讨腹腔镜下输尿管切开取石术围手术期的护理方法。方法回顾分析88例输尿管结石病人行腹腔镜下切开取石术的术前、术中、术后护理。结果所有患者均得到治愈。88例95侧均取石成功。手术时间平均116min,住院时间平均5．1天,其中1例发生尿漏经治疗后治愈,无腹腔感染发生。结论腹腔镜下输尿管切开取石术是治疗输尿管结石有效、可行的微创技术,通过周密的护理。取得满意效果。     

Cigarette smoking and face lift: conservative versus wide undermining

The effects of cigarette smoking on the skin flaps of the face lift procedure are discussed. Reported elsewhere is a significant incidence of skin slough in smokers with use of wide undermining techniques. This complication is thought to be due to the vasoconstrictive effects of nicotine on the peripheral circulation. Our group has employed a conservative bilateral undermining technique in 407 face lifts. Of these, 32.4 percent were smokers and 67.6 percent were nonsmokers. No cases of skin slough were encountered. Our conservative undermining technique is briefly discussed. Among its advantages are shorter operative time, use of less local and/or general anesthesia, less intraoperative bleeding, adequate exposure for SMAS and platysmal surgery, and snugger skin closure without the risk of flap necrosis. As shown by our statistics, it is a safer procedure in smokers than the usually performed more radical procedure.     

Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps

A report of 19 cases of large spina bifida cystica defects closed with bilateral bipedicled latissimus dorsi musculocutaneous flaps is presented. This procedure offers a distinct advantage over other procedures used currently: (1) any large defect in the thoracic, lumbar, and sacral area can be repaired without tension; (2) the flaps have good blood supply; (3) they require no delay, and operative time and blood loss are minimized; and (4) excellent results have been obtained using this safe, predictable technique with a minimum of complications.     

Cryodestruction of Haemorrhoids

Thirty-seven cases of second and third degree haemorrhoids have been treated by cryosurgery. Although the number of cases treated is small and the follow-up is short, we are greatly encouraged by the early excellent results. It is a simple and effective procedure with minimal complications, and it is especially recommended for those patients who are medically unfit for general anaesthesia. The rapidity of this procedure combined with the painless operative and postoperative course enables the patient to leave hospital the next day. More cases with long-term follow-up are needed before adequate evaluation of this form of treatment can be made.     

不同术式治疗早期卵巢颗粒细胞瘤的预后分析

目的：探讨不同术式对早期卵巢颗粒细胞瘤初治患者预后的影响。方法：收集2000年1月～2008年12月我院收治的39例早期卵巢颗粒细胞瘤患者的临床资料,分析不同术式对肿瘤复发和预后的影响。结果：39例患者中,行全面分期手术者20例,其中7例仅予盆腔及腹主动脉旁淋巴结活检而未予淋巴结清扫,所有淋巴结术后病理皆提示无淋巴转移;19例行非全面分期手术。随访期间,全面分期手术组皆无复发,而非全面分期手术组4例复发,两组患者术后3年的复发率分别为0和21%,具有统计学差异（P〈0.05）;非全面分期手术组有1例患者于术后29月死亡,死亡年龄为72岁,全面分期手术组无死亡病例,两组患者的死亡率不具有统计学差异（P〉0.05）。结论：原发性卵巢颗粒细胞瘤罕有淋巴结转移,早期卵巢颗粒细胞瘤行全面分期手术对于明确肿瘤分期、治疗及预后有重要意义,而全面分期手术中行盆腔及腹主动脉旁淋巴结清扫对于肿瘤的复发意义有限,初治患者全面分期手术时可不予淋巴清扫。     

THE PROS AND CONS OF ROUTINE CIRCUMCISION

The origin of the practice of circumcision is an ancient one having a ritual significance in most cases, but the operation is done primarily for hygienic purposes amongst English-speaking people.Critical evaluation of the indication for circumcision suggests that the hygienic principles are probably overrated. If it were understood that the anatomy of the prepuce and glans has a morphological development which in most cases removes the possibility of phimosis after the third year, less emphasis would be placed on the necessity for the operation.On the other hand, the feeling exists that boys who will require circumcision because of phimosis, balanitis, etc., should not be subjected to the operation at the age when psychological trauma can result. Convention and conformity demand the continuation of the procedure in many areas. The decision to circumcise remains a matter of individual preference as prescribed in the doctor-patient relationship.     

Airway obstruction and sleep apnea in children with craniofacial anomalies

Children with severe craniofacial anomalies and breathing problems are rare, and the accumulated experience of their treatment is limited. LeFort III midface advancements have been tried by many craniofacial teams, but no consensus has yet been reached as to the effectiveness of this procedure. In this report of seven patients with craniofacial malformations and severe breathing problems, three had a LeFort II midface advancement, one had release of bilateral temporomandibular joint ankylosis, and two had tonsillectomies. Two patients without a tracheostomy suffocated, four had a long-term tracheostomy, and one was cured by a unilateral tonsillectomy. It was concluded that LeFort III midface advancement is ineffective in these types of cases without a very stable postoperative retention, and it was suggested that all patients with severe craniofacial anomalies and breathing problems, regardless of their planned subsequent treatment, should have a tracheostomy as an initial measure.     

Otoplasty: sequencing the operation for improved results

LEARNING OBJECTIVES:: After studying this article, the participant should be able to: 1. Understand the anatomy and embryology of the external ear. 2. Understand the anatomic causes of the prominent ear. 3. Understand the operative maneuvers used to shape the external ear. 4. Be able to sequence the otoplasty for consistent results. 5. Understand the possible complications of the otoplasty procedure. Correction of prominent ears is a common plastic surgical procedure. Proper execution of the surgical techniques is dependent on the surgeon's understanding of the surgical procedure. This understanding is best founded on an understanding of the historical bases for the operative steps and the execution of these operative steps in a logical fashion. This article describes the concept of sequencing the operation of otoplasty to produce predictable results combining the technical contributions from many authors. The historical, embryological, and anatomic bases for the operation are also discussed. Finally, the authors' preferred techniques are presented. Sequencing the steps in the preoperative assessment, preoperative planning, patient management, operative technique, and postoperative care will produce reproducible results for the attentive surgeon. Careful attention to the details of the operation of otoplasty will avoid many postoperative problems.     

SURGICAL TREATMENT OF MYASTHENIA GRAVIS

On the basis of statistics, total thymectomy should be considered for the treatment of myasthenia gravis if the disease is severe and response to well regulated medical management is unsatisfactory. That improvement follows the operation in many cases, particularly if symptoms are of recent development, is indicated by reports in the literature. Of two patients operated upon by the author, one whose symptoms were of short duration was benefited objectively and subjectively; the other, in whom symptoms had existed seven years, said she felt better but there was no objective evidence of improvement. Patients should be told beforehand of the operative risks involved and the uncertainty of prognosis following the procedure.     

ASPIRATION OF BREAST CYSTS

In 1,364 cases of breast cyst aspiration reported in the literature, there is no note of a missed diagnosis of carcinoma.The author carried out needle aspiration in 80 patients with a definite mass in the breast as a therapeutic or diagnostic procedure.A diagnosis must be established for every definite mass in the breast and needle aspiration is a logical diagnostic procedure. If the needle encounters a solid mass, the mass must be removed for biopsy. If the needle encounters a cyst containing fluid, the fluid should be removed completely. A biopsy specimen then should be taken from the mass if (a) the fluid is bloody, (b) the mass does not entirely disappear, or (c) the mass recurs promptly. Adherence to these rules will keep the examining physician from missing a carcinoma within the cyst.Aspiration of breast cysts is a simple and safe diagnostic and therapeutic procedure that saves the patient distress and money.     

DeloRes trial: study protocol for a randomized trial comparing two standardized surgical approaches in rectal prolapse - Delorme¿s procedure versus resection rectopexy

ABSTRACT: BACKGROUND: More than 100 surgical approaches to treat rectal prolapse have been described. These can be done through the perineum or transabdominally. Delorme's procedure is the most frequently used perineal, resection rectopexy the most commonly used abdominal procedure. Recurrences seem more common after perineal compared to abdominal techniques, but the latter may carry a higher risk of peri- and postoperative morbidity and mortality. METHODS: DeloRes is a randomized, controlled, observer-blinded multicenter trial with two parallel groups. Patients with a full-thickness rectal prolapse (third degree prolapse), considered eligible for both operative methods are included.The primary outcome is time to recurrence of full-thickness rectal prolapse during the 24 months following primary surgery. Secondary endpoints are time to and incidence of recurrence of full-thickness rectal prolapse during the 5-year follow-up, duration of surgery, morbidity, hospital stay, quality of life, constipation, and fecal incontinence.A meta-analysis was done on the basis of the available data on recurrence rates from 17 publications comprising 1,140 patients. Based on the results of a meta-analysis it is assumed that the recurrence rate after 2 years is 20% for Delorme's procedure and 5% for resection rectopexy. Considering a rate of lost to follow-up without recurrence of 30% a total of 130 patients (2 x 65 patients) was calculated as an adequate sample size to assure a power of 80% for the confirmatory analysis. DISCUSSION: The DeloRes Trial will clarify which procedure results in a smaller recurrence rate but also give information on how morbidity and functional results compare.Trial registrationGerman Clinical Trial Number DRKS00000482.     

REPAIR OF VESICO-VAGINAL FISTULA

One hundred and thirteen patients with vesico-vaginal fistula were seen at the University of California Hospital from 1932 through 1959. The most common cause of fistula was trauma associated with pelvic operation, and the operation most often involved was total abdominal hysterectomy. Malignant disease of the pelvic organs was the second most common cause, while radiation therapy and obstetrical causes were next in the order of frequency.Three fistulas healed spontaneously. Twelve bladder by-pass operations were done and 54 repairs were carried out in 46 patients. Thirty-eight patients (82.6 per cent) were cured after one or more repair operations. A variety of operative approaches were used, selected in accordance with the needs of the individual case. Bladder distention postoperatively, due to a plugged catheter, was held responsible for failure of the repair in three cases, and this complication was considered preventable.Close attention to surgical technique, the recognition of bladder injury, and proper repair at the time of operation are prime factors in the prevention of vesico-vaginal fistula.