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11/78. Technical considerations for late removal of aortic endografts.

    INTRODUCTION: The endovascular repair of abdominal aortic aneurysms has become increasingly common during the past decade. Despite aggressive attempts to treat endoleak and graft failure with endovascular salvage procedures, some grafts necessitate surgical removal. We reviewed our experience with late endograft explantation in an effort to identify technical maneuvers critical for success. methods: Of 110 patients treated with aortic abdominal endografts at the University of Rochester Medical Center between August 1997 and June 2001, five (4.5%) needed late graft removal. medical records, radiographic files, and case report forms were retrospectively reviewed. RESULTS: One Talent (Medtronic AVE, Santa rosa, Calif) and four Vanguard (boston Scientific, Natick, Mass) grafts were removed at a mean of 32.7 months (range, 18 to 44 months) after implantation. One patient underwent conversion for rupture, three for endoleaks (one each with types I, II, and III), and one for stent separation from the graft material without endoleak or aneurysm expansion. Three cases were approached via the midline, one through a bilateral subcostal incision, and one through a retroperitoneal incision. Supraceliac aortic control was used in all patients. Removal of two of the Vanguard grafts necessitated extension of the aortotomy above the level of the renal orifices. One perioperative death occurred. The mean operative blood loss was 4700 mL (range, 1850 to 9000 mL), and length of stay was 19.8 days (range, 7 to 42 days). CONCLUSION: The morbidity and mortality rates associated with late removal of endografts are significant. Removal of Vanguard devices can necessitate extension of the aortotomy above the renal arteries. We believe that control of the aorta well above the proximal fixation site is the key to removal and that continuous aortic exposure via retroperitoneal exposure is the best option in this situation.
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12/78. Vascular and bowel complications during retroperitoneal laparoscopic surgery.

    PURPOSE: We report on vascular and bowel complications during major retroperitoneal laparoscopic renal and adrenal surgery. MATERIALS AND methods: A total of 404 patients underwent retroperitoneoscopy for various renal and adrenal pathology between July 1997 and February 2001. The occurrence of intraoperative vascular and bowel injuries, specific intraoperative circumstances, management techniques and outcomes were evaluated. RESULTS: There were 7 vascular injuries (1.7%) and 1 bowel injury (0.25%), which involved the right adrenal vein (2), left renal vein (2), right renal vein (1), right renal artery (1), inferior vena cava (1) and a superficial, small serosal injury to the duodenum (1). Of these 8 cases 5 (63%) had been treated prior with major open intra-abdominal surgery. Average blood loss for patients with vascular injuries was 1,186 cc (range 300 to 3,000). Of the 8 cases 1 was converted to open surgery and in another 2 cases the vascular injury was controlled through the extraction incision, which had already been created. Retroperitoneoscopic control and repair without open conversion were possible in each of the most recent 5 cases. Of the 404 cases open conversion has not been necessary for control of vascular or bowel complications in the most recent 200 cases, demonstrating the impact of the learning curve. CONCLUSIONS: During major renal and adrenal retroperitoneoscopic surgery our incidence of vascular and bowel injuries was 1.7% and 0.25%, respectively. With experience inadvertent vascular and bowel injuries can be efficaciously controlled retroperitoneoscopically despite the somewhat small operative field available.
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13/78. Postoperative extracorporeal membrane oxygenation for severe intraoperative SIRS 10 h after multiple trauma.

    A 34-yr-old male suffered multiple trauma in a road traffic accident. He required right thoracotomy and laparotomy to control exanguinating haemorrhage, and received 93 u blood and blood products. Intraoperatively, he developed severe systemic inflammatory response syndrome (SIRS) with coagulopathy and respiratory failure. At the end of the procedure, the mean arterial pressure (MAP) was 40 mm Hg, arterial blood gas analysis showed a pH of 6.9, Pa(CO(2)) 12 kPa, and Pa(O(2)) 4.5 kPa, and his core temperature was 29 degrees C. There was established disseminated intravascular coagulation. The decision was made to stabilize the patient on veno-venous extracorporeal membrane oxygenation (ECMO) only 10 h after the accident, in spite of the high risk of haemorrhage. The patient was stabilized within 60 min and transferred to the intensive care unit. He was weaned off ECMO after 51 h. He had no haemorrhagic complications, spent 3 weeks in the intensive care unit, and has made a good recovery.
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keywords = haemorrhage
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14/78. Emergency pelvic packing to control intraoperative bleeding after a Piver type-3 procedure. An unusual way to control gynaecological hemorrhage.

    We report a case of gynaecologic haemorrhage after a Piver type-3 procedure treated by a packing technique. The postoperative course was uneventful and the packs were removed after six days. Intra-abdominal packing should be familiar to both obstetricians and gynecologists because when any other attempt to provide hemostasis fails, it can be the last successful way to control a life-threatening haemorrhage.
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15/78. Orbital complications in endoscopic sinus surgery using powered instrumentation.

    OBJECTIVES/HYPOTHESIS: Powered dissection is increasingly used in endoscopic sinus surgery. Although it has certain clear advantages over conventional instrumentation, powered dissection also presents special liabilities. The objectives of the report are to highlight the special dangers of powered instrumentation near the orbit, to suggest techniques that might minimize these risks, and to review the management of orbital injuries. STUDY DESIGN: Case series. methods: A retrospective review was performed of patients who were referred to our institution with orbital injury complicating endoscopic sinus surgery in which powered instrumentation had been used. Patient demographics, status as revision or primary surgery, degree of intraoperative blood loss, indications for surgery, intraoperative findings, the complication sustained, time of recognition of the complication, immediate and delayed treatment, and clinical course were obtained from the clinical records. RESULTS: Three patients had medial rectus muscle injuries. In addition to the medial rectus injury, one patient also had blindness, probably from an orbital hemorrhage. One patient underwent orbital exploration in an unsuccessful attempt to reattach the ends of the medial rectus muscle. One patient had continuing diplopia, but declined orbital exploration or strabismus surgery. CONCLUSIONS: Intraoperative orbital complications that might be of minor consequence with conventional instrumentation can have dramatic sequelae when powered dissection is used. Special care must be exercised in using powered instrumentation.
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16/78. Acute intraoperative cerebral oedema: are current therapies evidence based?

    Acute intraoperative ischaemic cerebral oedema following torrential haemorrhage from the left intracranial internal carotid artery occurred during resection of a recurrent middle cranial fossa meningioma. A series of immediate anaesthetic interventions was effective in reducing brain oedema, allowed for surgical haemostasis, and resulted in no permanent sequelae to patient outcome. A review of the literature indicates that direct evidence for the efficacy of extremely early interventions as described in this case report is lacking and must be extrapolated from other brain injury models.
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keywords = haemorrhage
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17/78. Hypocalcaemia during surgery for ruptured De Bakey type III thoracoabdominal aneurysm. A case report.

    A case of a leaking De Bakey type III thoraco-abdominal aneurysm is reported. The ischaemic liver resulting from prolonged aortic cross-clamping, extensive blood loss, citrated homologous blood replacement and low calcium levels is discussed. It is suggested that during aortic clamping the ischaemic liver cannot metabolise the excess citrate in homologous blood and recommend that homologous blood is avoided during this period--crystalloids and heparinised blood being used instead of citrated blood.
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18/78. Necrotizing crepitant cellulitis of the abdominal wall following a caesarean section and subsequent hysterectomy.

    A case report of necrotizing crepitant cellulitis of abdominal wall following caesarean section is presented. Because of intense haemorrhage it was namely necessary to perform additional hysterectomy and bilateral hypogastric artery ligation. Serious wound infection and sepsis were successfully treated by administration of antibiotics and repeated deep incisions.
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ranking = 0.17868863224257
keywords = haemorrhage
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19/78. Unexpected surgical difficulties leading to hemorrhage and gas embolus during laparoscopic donor nephrectomy: a case report.

    PURPOSE: To report the case of a laparoscopic donor nephrectomy in which the preoperative evaluation of the patient gave no indication of the surgical difficulties that were encountered intraoperatively, resulting in substantial bleeding, a suspected gas embolism, and emergency conversion of the procedure from laparoscopic to open donor nephrectomy. CLINICAL FEATURES: A 59-yr-old man - height: 175 cm, weight: 85.5 kg, American Society of Anesthesiologists physical status I - presented as kidney donor for laparoscopic donor nephrectomy. He was healthy, on no medication, and had no previous abdominal surgery or diseases of the urinary tract. The preoperative computed tomography (CT) scan evaluation of his kidneys confirmed this by reporting a normal bilateral renal and renal vascular anatomy. In contradiction to the preoperative CT scan findings, the surgeon discovered abnormalities in the operative field. This included extensive scarring surrounding the left kidney, adenopathy near the right hilum, and a large branch lumbar vein entering the renal vein. The large branch lumbar vein was clipped but the clips dislodged, causing significant blood loss, and a suspected gas embolus. The procedure was converted to an emergency open donor nephrectomy. Postoperatively the patient made a full recovery. CONCLUSION: Laparoscopic donor nephrectomies, though usually performed on healthy individuals, have their pitfalls, and complications during this procedure can be sudden and serious. As shown in this case, although CT scan results are regarded as reliable, they can be misleading. As an anesthetic precaution for possible gas emboli during laparoscopic procedures, nitrous oxide should be avoided and the patient be ventilated with 100% oxygen.
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20/78. Inversion of the uterus at caesarean section.

    INTRODUCTION: Inversion of the uterus through the uterine incision during caesarean section is a rare event. Therapy is usually simple and maternal morbidity is low when re-inversion of the uterus can be accomplished immediately. In cases of prolonged uterine inversion thereof, haemodynamic instability and shock, often out of proportion to the degree of blood loss, have been reported as serious sequelae. CASE REPORT: We describe such a case with a prolonged inversion to re-inversion interval where the patient suffered an intraoperative cardiovascular arrest during unrepositioned uterine inversion. Reposition of the uterus led to an immediate return of the patient's vital signs and improvement of her haemodynamic status. DISCUSSION: The mechanisms of haemodynamic instability and the technical aspects of manual reduction of the inverted, heavily contracted uterus during caesarean section are discussed.
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