Biomedical subjects
G Berci
Publications and source records attributed to G Berci.
Microimaging.
Recent technological advances in optics, imaging, and illumination have brought forth a new generation of miniature laparoscopes suitable for emergency laparoscopy. A simple comparative analysis was conducted to determine which optic would be most suitable in an emergent environment. Animal experiments were designed to emulate a videolaparoscopic procedure. Six telescopes were visually assessed as to sharpness, depth of field, brightness and displayed image size on the TV monitor. A videotape record was obtained. Two telescopes were perceived as clearly superior in the field. When they meet image specification, miniature laparoscopes can be useful in the emergency setting.
Individual assessment of visual perception by surgeons observing the same laparoscopic organs with various imaging systems.
Laparoscopic surgery necessitates that operations be performed via a television screen; therefore, image quality is crucial in determining the final outcome. Electronic imaging systems are constantly undergoing revisions and incorporating new ideas. Recently, we have been confronted with a variety of systems, and we, as operators, have no idea what the differences are between the old and the newer systems. As clinicians, we have no electronic yardstick available to compare the options presented or to check the specifications. This study examines critical aspects of image perception. General surgeons, gynecologists, operating-room nurses, as well as allied health personnel all experienced in laparoscopic surgery participated as test subjects. A blinded study was performed in which various camera systems (single chip, three-chip, digitized and nondigitized) were displayed in random fashion. Porcine abdominal areas were displayed using the various imaging units. Participants graded image perception based on the following characteristics: sharpness, color, contrast, and depth of field. The audience were blinded to the types, brand, and number of cameras utilized. A significant preference was shown for digitized systems (P < 0.0001). Also, digitized single-chip cameras scored higher than three-chip cameras (P < 0.05). We propose thorough testing by surgeons and nursing personnel before deciding what type of equipment to purchase.
Continuing hazards of the learning curve in laparoscopic cholecystectomy.
Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy (LC). In open cholecystectomy (OC) the reported incidence of injury is less than 0.2 per cent. In LC, the aggregate reported experience, in many thousands of cases, is three or four times this number. Although "the learning curve" has been considered the principal factor in the heightened incidence of this complication with LC, there are hazards inherent in this new surgical modality that may never allow elimination of the increased risk of bile duct injury. As a sequel to an earlier report of 1200 cases of OC before the laparoscopic era from a single institution, this report deals with the next 2427 consecutive cases of LC from the same institution. In the first 1284 cases of LC, there were seven bile duct injuries (0.58%); in the ensuing 1143 cases there were six bile duct injuries (0.50%). The overall incidence nationwide is even higher, as evidenced by widespread reports of repair of bile duct injuries referred to major tertiary care centers. Routine operative cholangiography is of the utmost importance in the early recognition and immediate repair of ductal injuries. In 12 of the 13 cases reported here, early recognition and repair during the primary surgery resulted in a successful outcome.
An analysis of the problem of biliary injury during laparoscopic cholecystectomy.
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Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries.
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Static cholangiography vs digital fluoroscopy. Intraoperative cholangiography: benefit and cost ratio.
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Laparoscopic management of common bile duct stones.
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Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons.
Laparoscopic common bile duct exploration (CBDE) was the subject of a multi-institutional study on 226 patients from 19 major hospital centers. Female patients predominated (2.3:1); the average age was 54; 75% of cases were chronic, and the remainder were acute. Although 97% had preoperative ultrasonograms, only 12% showed a stone in the dilated common bile duct. The alkaline phosphatase was elevated in 41% and the serum bilirubin in 28% of cases. Preoperative endoscopic retrograde cholangiography with sphincterotomy (ERC-ES) was performed in 8.5%; there was a successful stone extraction in less than half the cases. Cholangiography was performed in 99.5%, and in 94% of those cases, stones were found. In 83% of cases, stones were removed through the transcystic approach, and in 17% removal was throughout the CBD. In the majority of cases, the choledochoscope and wire basket (34%), irrigation (33%), or a combination of both was employed. In the transcystic group, 5% were converted to open procedures due to technical difficulty, as contrasted with the trans-CBD route, where the conversion rate was 19%. There were two ductal injuries. Minor complications occurred in 5.7% within 24 h; there was one death (0.4%). Within 30 days, the morbidity rate was 7% and there were no deaths. Retained stones were discovered in 2.6% of cases. Laparoscopic CBDE is a feasible approach for CBD stones which permits a definitive procedure in one stage, without pre- or postoperative ES. It is a skill which should be mastered by the biliary surgeon. Further improvement in instrumentation and technique should make the laparoscopic approach not only comparable but preferable to the standard open choledocholithotomy.
Complications of laparoscopic surgery.
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Maintaining a clear view in laparoscopic surgery.
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SAGES presidential address. Society of American Gastrointestinal Endoscopic Surgeons.
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Training in laparoscopic cholecystectomy. Quantifying the learning curve.
There is no clear consensus on the best way to train general surgeons to perform laparoscopic cholecystectomy (LC). We attempted to quantify the "learning curve" for 86 surgeons attending eight consecutive 3-day, three-pig courses in LC. Each step of the operation was scored by the instructor for successful performance: Uncomplicated pneumoperitoneum (p), cystic duct and artery dissection (cd), artery and duct clipping (cc), operative cholangiography (oc), gallbladder dissection without holes (gd), liver bed hemostasis (h), gallbladder removal in one piece (i), and no abdominal organ injury (in). As well, operative time, method of dissection, and contact Nd: YAG or electrocautery were recorded. The percentage of students successfully completing each task for the first and third pigs on which they acted as surgeon was as follows: [table: see text] The operative time for the first and third pigs was 1.3 +/- 0.56 and 0.70 +/- 0.34 (mean +/- SD) h, respectively (P < 0.01). When students were trained with the contact Nd: YAG laser there was more blood loss than with electrosurgery (P < 0.001). Statistically significant improvement could only be demonstrated in the most difficult task, gallbladder dissection without perforation, but that task had not been mastered by the end of 3 days. The flat portion of the laparoscopic cholecystectomy "training curve" had not been reached by the end of the program.
Multifunctional laparoscopic surgical instruments.
A miniature hook scissors was developed which facilitates the incision of the cystic duct and other important structures because of the characteristics. The organ in question can be hooked first before cutting, and with slight movements, the cut can be determined. Unnecessary transsection can be avoided. Simultaneous irrigation helps in case of oozing. A miniature alligator forceps can serve as a peanut holder for blunt dissection and can be of great help in case of gallbladder wall perforations in grasping the edges of the hole with great precision. After the open endo loop is placed, part of the organ in question is tented, to help to place the loop underneath with ease. Because of the teeth appropriate grasping of oedematous or thin walls is secured.
Analysis of surgical movements during suturing in laparoscopy.
Laparoscopic suturing is now recognized as a necessary component of minimally invasive surgery. Until recently it has been avoided due to the lack of proper instrumentation and systematic technique. The principles of magnified surgery are discussed as they apply to the laparoscopic field, with emphasis on visual perception, economy of motion, choreography of movements, and "flawless technique". The principles and techniques of needle loading, handling, and driving are presented, as are the series of movements involved in tying an intracorporeal square-slip knot.
Value of early cholescintigraphy in detection of biliary complications after laparoscopic cholecystectomy.
Cholescintigraphy using technetium-99m disofenin tracer is accepted as a routine component of preoperative evaluation of the biliary tract in selected patients but is not used regularly in postoperative management. This is a retrospective analysis of the utility of the nuclide scan in 27 patients after laparoscopic cholecystectomy (LC). Most patients had vague postoperative symptoms such as nausea, pain, and low grade fever. Two patients developed jaundice. Seven of the 27 patients had biliary leaks, and two had common bile duct obstructions. We conclude that cholescintigraphy is a sensitive noninvasive test for the evaluation of biliary complications after LC and is a pivotal component of an algorithmic approach to postoperative complications. Because of the subtle clinical findings and the potential for delayed diagnosis of biliary complications after LC, early performance of this test will minimize patient morbidity.
The future of surgical endoscopy.
The first great discoveries in endoscopy were made more than 100 years ago, but it is only recently that its potential has been appreciated by the majority of surgeons. Impelled by technical breakthroughs in optics, video, and instrumentation, endoscopic surgical procedures such as laparoscopic cholecystectomy have transformed the way surgeons and nurses perform their jobs in the operating room. As the dust settles after the initial frenzy of training courses, dizzying numbers of fresh procedures and ever-spiralling costs in high technology, conscientious appraisal of new methods ensuring their safety, efficacy, and cost-effectiveness must be accomplished. Perioperative nurses are singularly well placed to share in this process with surgeons.
The role of ERCP and therapeutic biliary endoscopy in laparoscopic cholecystectomy.
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