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Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have pro-spectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL ( P = 0.004), whereas the sEBL was significantly less than the MBL ( P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.

Surgical site infections (SSIs) represent a significant source of preventable patient morbidity and hospital expense. Our objective was to assess the role of postoperative incisional alcohol cleansing in decreasing the rates of SSI as compared with standard care (control). Patients undergoing clean-contaminated abdominal operations at a single center were included. Prospectively collected data on control patients were compared with patients treated with daily postoperative alcohol-based surgical site cleansing (70% isopropyl alcohol) for the primary outcome of an SSI within the first 30 postoperative days. A total of 93 patients were included, 56 managed with standard care and 37 managed with the addition of daily alcohol cleansing. A significantly lower rate of SSI in the group managed with daily alcohol cleansing was observed (13% vs 32%, P = 0.04). This study suggests a role for adding daily incisional alcohol cleansing to further reduce the rate of SSIs.

Objective Endoscopic vascular anastomosis of abdominal aortic aneurysms is rarely performed and requires standardization. Here, we examined the impact of the surgeon's experience of abdominal aortic aneurysm surgery on the learning curve for robot-assisted endoscopic vascular anastomosis. Methods Three vascular surgeons with more than 10 years’ experience (group A), three vascular surgeons with less than 10 years’ experience (group B), and three medical students with no experience (group C) of performing vascular surgery used the da Vinci surgical system to anastomose 8-mm–diameter vascular prostheses in an end-to-end manner with continuous 5–0 Prolene sutures. The procedure was performed five times by each participant. Outcomes were anastomosis time, number of actions, visual score, and pressure test. Snapping of the prolene thread was recorded as a procedural failure. Results Procedural failure occurred only in group C (3/15 trials, 20%; P < 0.0001). Learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions. Between trials 1 and 5, learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions but were not apparent for leakage or visual score in any group. Visual score and leakage were not significantly different among the three groups in each trial ( P = 0.10 and P = 0.45, respectively). Conclusions By using the da Vinci surgical system, experienced vascular surgeons and surgically naive students showed marked improvements in vascular anastomosis techniques with a short period of training.

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations’ characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21–87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1–13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.

Background Patients with previous history of abdominal operations are sometimes excluded from consideration for peritoneal dialysis because of concerns for increased risk of complications during the implantation procedure and inadequate dialysis due to reduced peritoneal surface area. Employing a laparoscopic approach, we compared the outcome of peritoneal dialysis catheters in 2 groups of patients with and without intra-abdominal adhesions. Methods All data in this report were recorded prospectively. Revision-free and overall survival of catheters, the incidence of mechanical and infectious complication, and surgical revision rates were compared between the 2 groups. Results In 217 successful catheter implantations, there was a history of previous abdominal surgery in 42.9% of procedures; only 26.9% of them had intraperitoneal adhesions; 2.8% of patients without history of previous abdominal surgery had intraperitoneal adhesions. There were no significant differences between the 2 groups for 1- and 2-year revision-free and overall catheter survival, mechanical dysfunction, infectious complications, or surgical revision rates. Conclusion History of previous abdominal surgery should not be used to judge the eligibility of patients for peritoneal dialysis. Laparoscopic placement is the best way to ensure optimal catheter outcomes equivalent to patients without previous abdominal surgery.

Among the surgical procedures with abdominal approach (Burch colposuspension, Marshall-Marchetti-Krantz operation, Richardson paravaginal repair) used to correct genuine stress incontinence (GSI), the Burch colposuspension is both easy to perform and very effective. The purpose of the operation is to reposition the cervicourethral complex in a fixed retropubic space. Since anterior replacement of the vaginal axis may cause iatrogenic enterocele or increase a posterior cystocele or a previous rectocele, other complementary operations (Douglas obliteration, anterior or posterior vaginal repair) are necessary. The authors report that in 256 patients with type I and II genuine stress incontinence, the recovery rate after Burch colposuspension associated with gynecological procedures has been 81.25% in a 1 to 5-year follow-up.

Abdominal operations were required in 21 patients on intermittent peritoneal dialysis (IPD) -13 elective, eight emergency. There was one death in the elective group (inguinal herniorrhaphy) and four deaths in the emergency group (three spontaneous colonic perforations and one strangulated ventral hernia). Wound complications occurred in seven patients. Wounds require secure, watertight closure to prevent dialysis leak. In elective abdominal surgery, IPD should be carried out shortly before operation to delay dialysis for a few days after operation and also to decrease platelet dysfunction. Hernias should be repaired electively. Constipation should be avoided. Preoperative transfusion for anemia is generally unnecessary. Drains should be avoided or removed before resumption of IPD. Postoperative IPD should be done with one-liter exchanges. In certain instances, transfer to hemodialysis is indicated.

Peritoneal sclerosis occurred in two patients treated by continuous ambulatory peritoneal dialysis (CAPD) using only lactate-buffered dialysate. Both patients had recurrent peritonitis and the second patient had multiple, minor abdominal operations. Patients receiving lactate-buffered CAPD are not immune from peritoneal sclerosis. Recurrent peritonitis and repeated abdominal surgery might be important causative factors.

ConclusionsThese observations provide additional evidence that there is a post-operative embarrassment of respiration following abdominal operations and that it is the diaphragmatic component that is primarily affected.Inasmuch as post-operative pulmonary complicatioils usually occur in the lower lobes and most commonly follow operations on the abdomen, it is probably more than a coincidence that abdominal operations result in decreased diaphragmatic excursions with the bitendant diminution of ventilation of the lower lobes of the lungs.

Intercostal nerve blocks with 0·5 per cent bupivicaine were used for post operative pain relief in 100 patients having upper abdominal operations. The blocks were very effective in 86 patients and had an average duration of 11 hours. Two asymptomatic pneumothoraces occurred.