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A video camera has difficulty in gaining access for obesity operations. A 7-ft aluminum arm (boom) has been mounted on a sturdy tripod. A camera at one end of the boom enables easy direct videotaping, without interfering with the operating table

We investigated, in retrospect, if there were differences in the frequency and types of abdominal surgery between newly diagnosed female fibromyalgia (n = 80) and rheumatoid arthritis (n = 47) patients performed before the formal diagnosis. There was no difference in the total number of abdominal operations between both groups. In the rheumatoid arthritis group more cholecystectomies (p = 0.01) were performed, probably due to the older age of these patients (58.5 vs 48.5 years). However, in the fibromyalgia group there were more hysterectomies (p = 0.04) and appendectomies (p = 0.05) than in the rheumatoid arthritis group.

In 1908, Sir Arbuthnot Lane [30] published the results of the first series of abdominal operations for the treatment of severe chronic constipation. He believed that chronic constipation caused “autointoxication” and advocated colectomy in these patients. Since then, surgery for chronic constipation has remained an issue of controversy.

As laparoscopic surgery evolves, a growing number of different abdominal operations can now be performed. This necessitates the use of multiple large trocars. Herniation through the fascial defect created by trocar entry in laparoscopic interventions has been reported at a rate of 1-6%. We describe a simple closure technique for fascial defects at trocar sites after laparoscopic surgery. To facilitate the closure of the fascial defects ofor = 10 mm trocar entry sites, the surgeon places the upper end of a dissecting forceps through the fascial defect and tilts it so that the abdominal of the peritoneum comes into contact with its flat surface. The assistant retracts the skin and subcutaneous tissue and the "J" needle with the appropriate suture material is then used to take a stitch through the fascia under direct vision. The sharp end of the needle is prevented from coming into contact with any deeper structure as it slides on the flat surface of the dissecting forceps. The stitch is then pulled up to lift the edge of the fascia and the needle is passed from the opposite edge of the fascia in the same manner and then the suture is ligated. The aforementioned technique is easy to perform and facilitates the closure of the fascial defect at trocar sites, and there is no extra cost for the procedure.

Postoperative adhesions are the most common cause of intestinal obstruction and have a prevalence of 20%–48% [13]. Nearly 1% of all abdominal operations performed are due to this condition [9]. Many attempts have been made to prevent the postoperative formation of adhesions, but the value of the different procedures is questionable. Long intestinal tubes are used in the surgical therapy of small intestinal obstruction for two different indications. First, endoscopically placed long intestinal tubes have the capability to decompress a distended bowel and break through the pathophysiologic cascade of ileus (Fig. 1). Second, long intestinal tubes can be used for intraluminal stenting after adhesiolysis to prevent recurrent obstruction.

Peritoneal adhesions are abnormal fibrous connections between adjacent peritoneal surfaces. They are the commonest cause of small intestinal obstruction in developed countries [31, 45], a prominent reason for female infertility and a troublesome cause of abdominal or pelvic pain. When encountered by the surgeon, peritoneal adhesions make abdominal operations more difficult, hazardous and time-consuming.

One hundred patients undergoing abdominal surgery were included in this prospective study. The role of local application of Betadine, use of synthetic sutures, and use of low pressure subcutaneous suction drainage were evaluated in preventing post-operative wound infection. The infection rate was 15 per cent with Betadine, 15.4 per cent with prolene, 20 per cent with subcutaneous suction drainage and 30.8 per cent in the control group.

Mesenteric visceral infarction occurring after laparoscopic procedures in the upper abdomen may be a direct result of physiologic changes induced by carbon dioxide pneumoperitoneum and other technical elements with these procedures. The reported case is characteristic of a seemingly successful operative result interrupted by this devastating complication.

Colon smooth muscle electrical control (ECA) and response activities (ERA) were recorded for up to 4 wk postoperatively for 48 patients after major abdominal operations. Bipolar electrodes were implanted into right and left colon circular muscle and exteriorized through the flanks, and signals were tape recorded for 2-24 h daily beginning on the 1st postoperative day. A computer program was used for data reduction and analysis. Recorded signals were digitized and filtered. The ECA frequency components were identified by fast Fourier transformation, and their relative tenancy in low, mid, and high frequency ranges was determined. Short and long ERA burst duration and frequency and number and velocity of propagating long ERA bursts were determined. ECA was omnipresent and exhibited a downshift of the dominant frequency from the mid to the low range as recovery from postoperative ileus progressed. Concurrently, first in the right and then in the left colon, the frequency of long ERA bursts increased, followed by the appearance of propagating long ERA. After the 6th postoperative day, no further significant changes in parameters of colon electrical activity occurred with time.

To define the risk of complications in cirrhotic patients with asymptomatic cholelithiasis and the possible benefit of incidental cholecystectomy during abdominal operations in these patients, a retrospective cohort of cirrhotic patients who had asymptomatic cholelithiasis and underwent abdominal operations for portal hypertension was analyzed. Of 338 patients operated on during the last 15 years, 34 patients were found with asymptomatic cholelithiasis, all of whom had long-term follow-up. At a mean follow-up of 70.5 +/- 8.6 months (SEM), 28 patients remained asymptomatic (82%), 6 patients have developed symptoms (18%), (4 patients had acute cholecystitis and 2 chronic cholecystitis), and 3 of these patients (8.8%) died due to complications of acute cholecystitis. The results suggest that the risk for the development of complications is low but that the mortality associated with acute episodes of cholecystitis is high. Incidental cholecystectomy is not justified in cirrhotic patients with asymptomatic cholelithiasis, but close follow-up with early elective operation when symptoms supervene should be recommended.

Intestinal ischemia is associated with derangement of gastrointestinal motility. Uncontrolled clinical observations that bupivacaine injected into the epidural space causes faster recovery of bowel motility after various abdominal operations led us to assess the hypothesis that epidural anesthesia can hasten the recovery of gastrointestinal motility in the immediate postischemic period.Gut motility studies were performed in rats in which epidural anesthesia and intestinal ischemia could be initiated without the need to provoke surgical trauma. Epidural lidocaine was compared to epidural saline in their effect on intestinal motility after a 30-min period of bowel ischemia.Total ischemia to the small bowel resulted in pronounced postischemic adynamic ileus as evidenced by only 0.7% of the total length of the small bowel filled with a marker meal at the end of the study period (transit index) compared with 84.4% in the control group. Lidocaine epidural anesthesia caused significantly more rapid resolution of the adynamic ileus (60.3% of the bowel filled with the marker meal vs. 30.9% in the controls in which saline was injected).Epidural lidocaine compared to epidural saline hastens the recovery of gastrointestinal motility in rats after a 30-min period of bowel ischemia. This effect may be elicited by attenuation of sympathetic efferent inhibitory pathways or by vasodilatation caused by the sympathetic block. These results suggest that lidocaine epidural block not only alleviates pain in situations of ischemic injury to the bowel but may also hasten the recovery from postischemic paralytic ileus.

Appendicitis remains the most common condition leading to emergency abdominal operations in children and adolescents. We present a case of foreign bodies in the appendix causing obstruction and perforation of the appendicular tip by a nail.

Objective and quantitative intraoperative methods of bowel viability assessment are essential in gastrointestinal surgery. Exact determination of the borderline of the viable bowel with the help of an objective test could result in a decrease of postoperative ischemic complications. An accurate, reproducible and cost effective method is desirable in every operating theater dealing with abdominal operations. Numerous techniques assessing various parameters of intestinal viability are described by the studies. However, there is no consensus about their clinical use. To evaluate the available methods, a systematic search of the English literature was performed. Virtues and drawbacks of the techniques and possibilities of clinical application are reviewed. Valuable parameters related to postoperative intestinal anastomotic or stoma complications are analyzed. Important issues in the measurement and interpretation of bowel viability are discussed. To date, only a few methods are applicable in surgical practice. Further studies are needed to determine the limiting values of intestinal tissue oxygenation and flow indicative of ischemic complications and to standardize the methods.

Bezoars are retained concretions of undigested animal or vegetable material that can produce gastrointestinal obstruction, ulceration, and bleeding. Therapeutic options for gastric bezoars include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic disruption and removal, and surgical removal. Multiple large gastric bezoars generally require conventional surgical management through an upper abdominal incision. With the recent improvement of laparoscopy, a lot of portions of abdominal operations have been performed laparoscopically. We successfully removed multiple large gastric phytobezoars in a 52-year-old female completely through laparoscopy. This supported the feasibility of laparoscopic surgery for patients with gastric bezoars.

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation.

Reintubation following failed extubation is an independent predictor of prolonged ICU stay, morbidity and mortality. Extubation criteria at the end of surgical procedures are similar to those applied to critically ill patients in mechanical ventilation.

WILLY MEYER (1858-1932) was born in Minden, Germany, and received his medical education at the universities of Bonn and Erlangen. He emigrated to the United States in 1884 and immediately began to practice medicine and surgery in New York City. From 1886 to 1893, Meyer served on the clinical surgery faculty of the Woman's Medical College, and during those years he was also on the staff of the New York Skin and Cancer Hospital, the German Hospital (now the Lenox Hill Hospital), and the Post-Graduate Hospital. Meyer made many seminal contributions to clinical surgery, including the first published description of Freidrich Trendelenburg's (1844-1924) elevated pelvic position as an aid to the performance of certain pelvic and abdominal operations (1884). Meyer also helped introduce into the United States the concept of cystoscopy (1887) and the catheterization of the male ureters with the aid of the electric cystoscope (1896). An early advocate

The 10th edition of this classical surgical text has much to commend it. As in previous editions, this excellent text is dedicated to providing general surgeons and surgical trainees a concise but detailed overview of the operative and nonoperative components of abdominal surgery. SinceMaingot's Abdominal Operationshas a wide readership and has enjoyed considerable success in the past, and there is a tendency not to tamper with success, I expected the 10th edition to largely resemble the previous edition, which was published in 1990. Nothing could be further from the truth. The new edition is more than a major revision of a classical text; in many ways it is a de novo text, with new chapters and new authors. In comparing the 10th to the ninth edition, I found that only 18 of the 81 chapters had the same contributors, while 20 chapters were new, and the remaining 43

To the Editor. —In introducing their excellent review on exploratory celiotomy for patients with truncal stab wounds, Sirinek and associates 1 note, "Introduction of the principle of mandatory exploration for all penetrating abdominal wounds during World War II resulted in markedly improved morbidity and mortality rates." Although it may be a matter of diction, I believe we should date the introduction of the principle of mandatory exploration of penetrating abdominal war wounds to World War I when the British surgeon Cuthbert Wallace proclaimed, "No man shot in the belly would be left to lie in a hospital bed in a civilian hospital.... Abdominal surgery, to be successful, must be done at once." 2 Under Wallace's leadership, British surgeons near the front were operating on abdominal wounds with success by the summer of 1915. For 3520 abdominal operations performed from July 15 to September 19, 1917, the operative mortality was 53%

A prospective study was carried out to determine the possible role of exogenous and endogenous bacteria in the development of postoperative complications in patients in whom drainage was routinely employed after cholecystectomy. In 100 patients undergoing cholecystectomy because of cholelithiasis, cultures were made of specimens taken from the bile during operation and from the drains. Bile cultures were positive in thirty-eight patients. Drain cultures were positive in thirty-five patients, with most of the bacteria cultured being from an exogenous source (in most cases staphylococcus). The rate of postoperative complications was found to be significantly higher in the group with positive bile cultures (of endogenous origin) than in the group with positive drain cultures (of exogenous origin) or sterile cultures. In the patients with positive bile cultures, the rate of wound infection was 31 per cent, whereas in those with positive drain cultures it was 5.7 per cent, and in those with sterile drains only 4 per cent. These findings indicate that if the bile is not infected, the risk of wound infection is considerably reduced and that the bacteria of exogenous source do not play a prominent role in the development of postoperative complications. In consideration of this as well as the fact that the use of a drain may obviate the need for reexploration in patients in whom there is postoperative leakage of bile or blood, routine drainage should not be rejected categorically in “clean” abdominal operations.

Mechanical suturing procedures on the bowel, lung, bronchi and pulmonary vessels have been used on 264 occasions in 180 thoracic and abdominal operations. The instruments proved simple to use and produced reliable good quality closures, for the most part without manual reinforcement. There were 2 technical failures, one ending fatally, after colo-colostomy. Two minor postoperative suture leaks were encountered in 122 operations on the alimentary tract, but no leakage or other problem has arisen in 58 pulmonary cases. The staple-suturing methods described are safe and straightforward, and it is believed that they represent a significant advance in the techniques of thoracic and abdominal surgery, which can usefully be applied in many situations.

An overview of surgery of the alimentary tract is presented in three parts. The first part is designed to give historical perspective, showing the relatively recent development of surgery of the alimentary tract compared with surgery of other systems. Three particularly important reasons for its slow development are medicolegal constraints, lack of educational materials and a high incidence of illiteracy among surgeons. Lessons to be learned include the following: (1) inappropriate legal constraints stifle progress; (2) mechanisms for prompt distribution of information are critical for rapid and steady progress; and (3) the distribution of knowledge does not insure its proper use. The second part on the present status of alimentary tract surgery discusses the development of specialty societies and particularly the Society for Surgery of the Alimentary Tract, noting that programs of this society have shown an increased percentage of papers devoted to animal and clinical experiments over the years. In the third section on the future of alimentary tract surgery, it is observed that among men in this country there are more abdominal operations per 1,000 persons than any other type of operation, despite the rapid increase in cardiovascular surgery and operations involving other organ systems. Presentations by previous presidents of the society have pointed out many challenging and fascinating areas of study. Thus for our generation and future generations of surgeons, the study and treatment of gastrointestinal disease makes surgery of the alimentary tract an exciting and challenging arena.

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.

Charles Mayo was born in Rochester, Minnesota, on July 19, 1865, the son of William Worrall Mayo, a native of England and a general practitioner of medicine who had settled in the territory of Minnesota in 1855. The young boy accompanied his father and elder brother, William J. Mayo, on innumerable trips in both the village and the country as the father traveled to his patients. On several occasions he administered ether to the patients before he had earned his diploma in medicine. Charles Mayo studied in the public schools of Rochester, and received the degree of Doctor of Medicine from Northwestern University in 1888. When Mayo had been home for about a year, assisting his father and elder brother in their practice of general medicine, the sisters of St. Francis founded St. Mary’s Hospital in Rochester. Charles was one of three on the staff at the new hospital, the other two being his father and his elder brother. In later years, the elder brother recalled, “Charlie soon had me driven to cover by being a better surgeon, and I began to specialize in abdominal work and in operations on the ureters and kidneys.” He could master a difficult situation with exceptional speed, and he had a facility in a variety of challenging surgical problems which soon found him performing such dissimilar procedures as excision of a knee joint, sectioning of the gasserian ganglion, and hysterectomy. He also acquired a high degree of skill in operations on the eye, head, and neck, while his brother concentrated on abdominal operations. He devoted himself to the very extensive practice which he and his brother carried on together, after their father retired from active practice around 1890. The two brothers enlisted the aid of a third physician in 1892, another in 1901, and many others as the practice founded by their father in 1863 became well known in southern Minnesota, and then throughout the state. By 1903 the name Mayo Clinic was known not only to persons who sought the services of the brothers and their associates, but by other physicians outside the small group of practitioners in Rochester. In 1915, Charles and his brother established the Mayo Foundation for Medical Education and Research as a part of the Graduate School of the University of Minnesota, with fellowships in various specialities. The Mayos became famous teachers and were regarded with profound affection and respect by the hundreds of young surgeons who worked with them. This classic paper gives a fascinating perspective of the state of colon and rectal surgery at the turn of the century. In it Mayo suggests the advisability of the synchronous combined approach “if the surgeon has a good assistant.” He is believed to be the first to recommend this maneuver. Honors of every description were conferred upon Charles Mayo, as they were upon his elder brother. He was elected president of the Western Surgical Association, the Society of Clinical Surgery, the Clinical Congress of Surgeons of North America, the American Medical Association, the American College of Surgeons, and the American Surgical Association. He died in Chicago, where he had contracted penumonia during a visit, on May 26, 1939, at the age of 73. The death of his brother followed two months later.

Thirteen patients were studied during two hours of anaesthesia for abdmonial operations and for an hour post-operatively. Serial venous blood samples were taken for determination of plasma total and ionized calcium, acid-base variables, Na, K, Mg, PO4 total proteins and parathyroid hormone. One group of patients received 5 per cent dextrose/water and the other 5 per cent dextrose in Ringer's solution, at 250 ml per hour. Total and ionized calcium levels decreased toward the end of operation and an hour later, associated with respiratory alkalosis. Parathyroid hormone increased at the end of operation, as an effect of the decreased ionized calcium. The general effect was mild haemodilution with all the other electrolytes decreasing, as did total protein concentration.

A retrospective study has been conducted to find out the effects of preceding abdominal operations on the validity of laparoscopic examinations. The study included 1658 laparoscopies performed at the Robert Rössle Institute from January 1, 1975, to June 30,1977. 467 patients had previously undergone one or several operations; in 124 patients adhesions had been started while the patient had not undergone any laparotomy at all. In the judgement of essential abdominal organs there are no differences between patients with and without adhesions, who had not undergone any operations previously. Even after laparotomies of the epigastrium, satisfactory judgement of the organs is possible. Since the result of laparoscopy is decisive for further therapeutical measures, it should be carried out also after surgical interventions, clear indication and sufficient skill of the examiner provided.

A composite statistical analysis was made of the results from four trials comprising patients undergoing upper abdominal operations. It revealed a marked correlation between the neuroticism score as measured by a personality inventory before operation and the percentage vital capacity impairment found after operation. Neuroticism correlated also with pain as measured by a visual analogue scale. The vital capacity impairment and subjective pain readings were interrelated and both neuroticism and vital capacity impairment were related to the chest complication rate. Personality assessment before operation can identify one group of patients who will have marked pain and limitation of vital capacity after operation.

An open evaluation of relief from severe pain following major abdominal operations was carried out on at least ten patients, who had given written consent, with 0.1 to 0.4 mg doses of buprenorphine hydrochloride administered intramuscularly. Statistical analysis of the data showed that 0.3 mg of this compound provided quite satisfactory relief from pain for up to six hours. Seven more consenting patients were given buprenorphine hydrochloride 0.5 to 0.6 mg, but they did not receive much greater or longer pain relief than those receiving 0.3 to 0.4 mg. However, the latter patients were younger and heavier. It was concluded that buprenorphine hydrochloride 0.2 to 0.4 mg provided relief of severe pain probably as well as is observed with morphine 10 mg for the average-size patient, but the duration of pain relief with the new compound is substantially longer than with other strong analgesics previously tested. The only common side effect noted was drowsiness, which was observed during the analgesic action of the compound. No appreciable alterations were seen in the respiration, pulse rate and blood pressure. On the basis of these tests, buprenorphine hydrochloride appears to be a satisfactory analgesic for severe postoperative pain, and it deserves extensive study.