The change from traditional open, large incision surgery to minimally invasive techniques is likely to be recorded as the most significant advance in the surgical art of the last part of the 20th century. Key to this trend is laparoscopy. Looking into the abdomen (the true meaning of the term laparoscopy), and operating with instruments through very small openings, allows surgery to be performed with far less postoperative discomfort and often faster recovery. Originally devised at the turn of the twentieth century, and utilized commonly by gynecologists before its widespread use in general surgery, the development of high-resolution microchip video cameras and specialized instruments has truly revolutionized intraabdominal surgery.

In order to visualize the organs and disease inside the abdomen, a space has to be created through which one can see the contents. This usually is accomplished by insufflating gas, usually carbon dioxide, and stretching forward the abdominal wall (similar to the stretching that occurs in pregnancy).

Basic Laparoscopic Techniques:

The first step in all laparoscopic procedures is accessing the abdomen — allowing the insertion of the first trochar. This can be accomplished in either of two ways:

· The closed technique, in which a special retractable tip blunt ended needle (Veress needle) is inserted into the abdomen, usually through or just below the umbilicus (belly button), the gas is insufflated, and then an operating trochar is inserted after the abdomen is distended and a space created between the wall and the underlying organs.

· The open technique, in which a small incision is made, and the trochar tube introduced into the abdomen in a technique similar to that used in open surgery, only with a much smaller incision. Again this initial step usually is through or just below the umbilicus, where the abdominal wall is the thinnest.

Neither method has proven to be better than the other; many surgeons use both techniques, choosing which to utilize on a case by case basis.

By far the most dangerous step(s) are inserting the initial trochar (and/or Veress needle, if used). After all, one basically is trying to make a small “stab wound” into the abdomen without damaging any of the abdominal organs or blood vessels. Then, one or more additional operating trochars, of varying sizes, commonly are inserted. These secondary trochars are inserted while looking into the abdomen directly, making their placement inherently safer than the initial access.

Once the trochars are placed, the various instruments needed for a specific procedure are introduced through the trochars. Additional trochars may be placed during the course of a procedure as circumstances dictate. The opposing angles required to manipulate instruments at the ends of relatively long, thin tubes often results in the sites chosen for the small incisions used in laparoscopy being placed some distance away from the actual location of the disease.

Complications:

Risks are inherent in any surgical procedure, and laparoscopy is no exception. Each individual operation, such as cholecystectomy (gall bladder removal), appendectomy, tubal ligation, etc. has complications specifically related to the procedure. This section will deal with complications related to laparoscopy in general.

Perhaps the most worrisome problem is injury to an underlying organ or blood vessel while achieving access to the abdomen, most commonly while inserting the initial trochar and/or the Veress needle. Manufacturers have devised trochars with spring-loaded, retractable blades that cover the sharp tip almost instantly upon entering the abdomen, but injury is possible nonetheless. Most trochar injuries occur while inserting the first tube, which usually cannot be visualized upon entering the abdomen. Making the initial access away from sites of previous surgical procedures (scars), where adhesions are likely to be present and internal organs stuck to the abdominal lining, may reduce the chance of injury. Some surgeons feel that the open technique lessens the chance of injury; others feel the Veress needle is safe when used properly. The surgeon’s experience and knowledge of his or her specific patient are most valuable. Some ingenuity in choosing the site for initial trochar placement may be necessary.

Complications can occur in establishing or maintaining the gas under pressure in the abdomen (pneumoperitoneum). If the abdominal pressure becomes too high, it may impair circulation or respiration. A dreaded complication of laparoscopy is the entrance of the gas into a vein, usually the result of inadvertently placing the Veress needle or a trochar directly into a major vessel. Starting the insufflation with a slow rate of flow until one is sure of proper placement helps avoid this problem.

Cautery and other energy sources are used during laparoscopy to cut tissues, stop bleeding, etc. Such energy sources can stray, and cause injury to organs away from the operative site. Often these injuries are not seen during the procedure, only becoming apparent later.

Laparoscopy allows only a two-dimensional view of the abdominal contents, and relies on the surgical team’s sense of vision. Depth perception is limited. One cannot usually feel the structures inside the abdomen and evaluate them directly.

Most laparoscopic procedures are well tolerated, quite safe, and many major operations that formerly required several days of hospitalization for recovery can now be done on an outpatient basis or with just a brief one or two day hospitalization. People should recover quickly and promptly after laparoscopic procedures. Complications are sometimes difficult to appreciate and evaluate. Patients and surgeons alike need be aware that if things do not seemingly “sail” smoothly after laparoscopy, there may be a hidden problem. Prompt identification and treatment of the problem is essential. Excessive pain following laparoscopy is a significant “red flag” that a complication may be occurring. It is a grave mistake for a surgeon to disregard patient complaints after laparoscopy.

Instrumentation for laparoscopy:

- The laparoscope – a rod filled with fiberoptic fibers that transmit light and images without distortion. Sizes range from 10 mm in diameter down to 2 mm, and there are several different angles for viewing – most commonly a straight-on (O degree) ‘scope is used. The laparoscope has a lens on the outer end, through which the surgeon looked directly before the advances in video camera technology occurred. Today, a video camera is attached, and the surgeon and his assistants view the operation on high-resolution video monitors.

· A high intensity light source, transmitted by fiberoptic cable, to supply the light necessary to see inside the abdomen.

· An automatic insufflator – the device to pump (insufflate) gas into the abdomen under pressure and maintain steady distension of the abdominal wall so that a field of view is possible (pneumoperitoneum). By far, the most common insufflating gas is carbon dioxide. Its advantage is that it is inert and non-explosive, permitting cautery and other electrical equipment to be used safely inside the abdomen; its disadvantage is that it is irritating to the abdominal lining, and therefore general anesthesia is required for most laparoscopic procedures.

· The video camera, which either attaches to, or in some instances, is an integral part of, the laparoscope. The high resolution available with today’s technology is phenomenal.

· A recording device, usually a printer of video images, to document important findings. Videotape sometimes also is used.

· Trochars: Different size tubes, commonly ranging from 2 to 12 mm in inner diameter, with valves on their outer ends, through which the instruments used during the procedure are inserted and removed, while maintaining the pneumoperioneum for visualization

· Various instruments used by the surgeon – these are similar to instruments used in open surgery, only they are made to operate at the tips of long rods, permitting their introduction through the various sized trochars. They include scissors, graspers, retractors, cautery devices, stapling devices, clip appliers, needle holders and sutures, suction and irrigating systems, and other technology. In addition, instruments inserted into the uterus allow the organ to be manipulated, increasing access to the uterus, Fallopian tubes, and ovaries during gynecological procedures.

· Energy sources – most commonly electrocautery, occasionally lasers, and yes, even water, injected under pressure to separate tissues.

· The operating table itself, which by electrical manipulation can be moved into a variety of positions, helping the surgeon by allowing gravity to drop covering organs out of the way.

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Thoracoscopic surgery of the chest was first described in terms of its original concept in 1922 by Dr. Jacobaeus. He was far ahead of his time in terms of originality of thought and almost 50 years ahead of the technology needed to make this exciting new diagnostic and therapeutic tool available for clinical use. In 1970, Dr. Joe Miller, Jr., at the Emory Clinic, began to match changes in technology with clinical applications and the field of thoracoscopic surgery was born. My first experience did not come until the early 1990 ties when thoracoscopy emerged from lab use and was available for every day practice.

The thoracoscope consists of a slender fiberoptic tube than can be inserted into a 1/2 inch incision in the chest. The image is then combined with a tiny telescopic lens, a powerful light source, and a small video camera and is projected onto a TV screen. The surgeon can literally see into the chest.

Then using graspers, endoscopic scissors, and endostaples, the surgeon can perform a whole host of procedures. The revolutionary changes this technique has brought to thoracic surgery mark a milestone in the evolution of surgical technology. Thoracoscopy offers many patients marked advantages over standard open procedures. First, it gets the patient home from the hospital in 36 to 48 hours after the procedure. Second, recovery time from surgery and the level of pain experienced by the patient is markedly reduced. Lastly, the small incisions used are better tolerated than the old larger open thoracotomy incisions.

The most familiar use of thoracoscopy is to diagnose disease within the chest wall. In this case, small pinch biopsies of the pleura, the membrane surrounding the lung, the chest wall, the lung, and the pericardium surrounding the heart can be obtained. In addition, the mediastinum or, the area between the two lungs, can be readily visualized and lymph nodes biopsied. In patients with fluid collections around the lung called pleural effusions, samples can be obtained for culture studies and cells for cytological examination.

Patients with asbestos exposure who may have concerns about pleural tumors called mesotheliomas are usually good candidates for this technique. Other patients with abnormal chest x-rays and pulmonary nodules within the lung may benefit from small wedge resections made with the help of an endostapling device. Often, the lesions removed can be determined to be a benign tumor such as sarcoid or a malignant cancer of the lung. Using the wedge technique, small to moderate sized masses can be completely removed and sent to pathology for examination under the microscope.

A second common use for thoracoscopy is therapeutic. A number of topics fall into this grouping. Treatment of pleural disease, removal of pus collections call empyemas and lysis of adhesions from entrapped lungs are but a few indications. Other applications of this new technique involve removal of blebs or weak areas on the surface of the lung, staging of lung cancers and resections of metastatic disease from other areas of the body. In terms of the heart and the pericardium, pericardial effusions can be drained and cardiac tamponade relieved.

In my own practice I have operated on a series of patients with excessive sweating called hyperhidrosis, Raynaud’s disease and reflex sympathetic dystrophy. In these cases, the sympathetic chain of nerves passing on the inside of the chest wall can be resected and sweating and pain reduced to symptomatic arms, hands and fingers. Another group of patients with esophageal conditions such as acid reflux disease and benign tumors of the esophageal wall can be helped.

This is but a quick review of a revolutionary new technique available to the thoracic surgeon to diagnose and treat a wide variety of conditions found in the chest. More indications seem to come along each year all to the patient’s benefit.

Recommendations:

1) If you have an abnormal chest x-ray and are told that a mass, nodule, lymph node or fluid collection is present, a test called a CT scan of the chest is usually recommended to better define or isolate the abnormality.

2) A second test called a bronchoscopy may then be indicated. This test involves using a small tube with a light on the end to look down the airways in hopes of seeing the lesion and possibly getting a biopsy.

3) A third test called a CT directed needle biopsy may then aspirate cells from the mass or collect fluid samples.

4) Finally, you may be referred to a thoracic surgeon for the new thoracoscopy procedure. Hopefully, this single test may be used to both make the diagnosis and effect the removal of the abnormal area. If all else fails, the old open thoracotomy can be held in reserve to allow a hands on approach to the problem. Good Luck and I hope you benefit from the new fiberoptic technology.

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When a lump is found in a woman’s breast, and it is not a fluid-filled cyst, it usually requires removal, both for diagnosis to see whether or not it might be a cancer, and for treatment. Surgery to remove or biopsy breast lesions is relative simple, not usually associated with great pain, and almost always done as an out-patient procedure, often under local anesthesia.

If one can feel the lump, the surgery usually involves its complete removal (excisional biopsy). A relatively small incision is made, taking into consideration the location of the scar, not only for reasons of appearance, but also for potential future treatment. When a lump is quite large, and suspicious for cancer, only a small portion may be taken (incisional biopsy) to establish the diagnosis and provide information necessary to start treatment. As with other less invasive methods of the detection, such as fine needle aspiration or core needle biopsy, only a positive study is definitive; if negative, one must remove the lesion in total for complete biopsy.

When a lump cannot be felt, the surgeon has to turn to the radiologist for help in “localizing” the mass – in other words, pointing out where a lump too small to feel, yet one that might be an early cancer, is located. The most common method used is needle localization biopsy: using the mammogram as a guide, the radiologist inserts a special needle and then a wire into the lesion, and “marks the spot” for the surgeon, who subsequently traces the wire in the breast, finds the area in question, and removes it. It then is sent for evaluation by the pathologist, often with additional guidance from the radiologist as to where to look.

Other methods to evaluate mammogram-detected lesions include fine needle aspiration for cytologic analysis of the area in question, and the use of X-ray guided “stereotactic” biopsy devices. Two such instruments are commonly used – the mammotome, which takes a small core needle biopsy, and the Advance Breast Biopsy Instrument (ABBI), which often can totally remove a suspicious area. A more recent development, and still experimental method, is to identify the milk duct supplying the area, and then inserting a very fine catheter (tube) into that duct, introducing some sterile fluid to irrigate the duct, thus obtaining cells from the area to examine microscopically.

There are some uncertainties in the evaluation of breast lumps. First, not all pathologists will diagnose the same lesion identically. While there is some standardization, one must realize than no person can look at each and every cell in a breast biopsy, and there are honest differences of opinion. Recent advances in pathology allow the detection of cancer in minute microscopic quantities, diagnosing lesions we never knew of previously. It now is quite common to find cancers that have not yet gained the ability to metastasize (spread to other areas), or even lesions that have not yet changed sufficiently from normal to be called cancer. These early cancers, called carcinoma in-situ, need treatment, and often serve as a warning for the future development of cancer elsewhere in the same or the other breast. This allows true measures of prevention occasionally to be instituted.

Francis C. Evans, MD, FACS

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The word carotid is derived from the Greek term karotide or karos meaning to stupefy or plunge into deep sleep. The term was applied to the arteries of the neck because compression of these vessels during combat produced stupor or sleep. The 31st metope from the south side of the Parthenon in Athens demonstrates that the ancient Greeks were aware of the significance of the carotid artery.

Over the centuries since the early Greeks, many noted surgeons have advanced the science of carotid artery surgery. The first carotid endarterectomy, or cleaning out of the cholesterol plague in the wall of the artery, was performed in 1953, by Dr. Michael DeBakey. Today, it ranks as the most frequently performed peripheral vascular surgical procedure in the United States.

Cerebrovascular disease is the third leading cause of death in the western world, accounting for 9% of all deaths in the United States. About 450,000 new strokes occur each year in this country, and nearly 75% result from thromboembolic (blood clot) disease. Two major prospective studies were mounted in the 1980s to evaluate the role of surgery in the treatment of symptomatic carotid artery disease. These trials were designed to test surgery against conventional medical therapy.

Conventional medical therapy was defined as control and treatment of those risk factors thought to be of importance in the pathogenesis of atherosclerosis, or plaques, of the carotid artery and their contribution to the development of ischemic cerebrovascular events.(Strokes, TIA’s). The drug aspirin was used in both studies. Given the results of these two trials, it is certain now that carotid surgery is more effective than conventional therapy in symptomatic patients with stenosis, or narrowing of the artery in the range of 70% to 99%. It also appears that the gradient of risk increases as the degree of stenosis increases; that is, stenosis of 90% to 99% is more dangerous than is stenosis of 70% to 79%.

In the NASCET study, the combined morbidity and mortality rate during surgery and postoperatively was 2.1%. The surgical mortality rate was 0.6%. The medically treated patients had a stroke rate of 3.3% and a mortality rate of 0.3% for the first 30 days. For the patient that had surgery, the cumulative risk of stroke at 2 years was 9%. For the medically treated patients, the cumulative risk of stroke was 26%. This represented a risk reduction of 17% when patients were treated with surgery. For major or fatal stroke, the risk for the surgically treated patients was 2.5% compared to 13.1% for the medically treated patients. This represents an absolute risk reduction of 10.6%.

Both studies came to the conclusion that patients with greater than 70% stenosis had a significantly reduced stroke rate if they were offered surgery instead of relying on medical therapy. Given the results of these two studies, it is certain now that carotid surgery is more effective than medical therapy for symptomatic stenosis greater than 70%.

Asymptomatic patients are a different sunset based on population studies. A recently published trial on asymptomatic carotid stenosis reported that 50% of patients had a stroke without any warning symptoms. A bruit, or a noise, can occur in the carotid artery with stenosis as minimal as 20 to 30%. It is therefore important that physicians listen to the neck of patients to see if a noise can be heard in the artery as part of a routine physical exam. With patients with stenosis of less than 50%, the annual rate of stoke is minimal. As the area of reducing stenosis increases from 50% to 70%, and then to greater than 75%, the incidence of symptoms called TIA’s or transient ischemic attacks increases significantly. A 75% stenosis is a threshold lesion for considering surgical intervention in asymptomatic patients.

The most common clinical situation is the patient referred by his family doctor with a cervical bruit or noise in the carotid artery who either has no symptoms or intermittent episodes of nonspecific symptoms such as dizziness, visual changes or lightheadedness. These patients should undergo a carotid ultrasound test. If the results show a greater than 75% stenosis, a digital subtraction angiogram in which dye is put in the artery and a cine x ray test performed should be considered. Patients with significant peripheral vascular disease have significant carotid disease in 33% of patients, 6.8% of patients with coronary artery disease, and 5.9% with significant risk factors.

Current recommendations:

1. Patients with significant stenosis as outlined above by Doppler exam or angiography should be considered for surgery. Patients with significant coronary artery disease should be further evaluated by dobutamine echocardiogram and EKG.

2. The procedure is called carotid endarterectomy and is usually performed with the patient awake under cervical neck block or general anesthesia. The surgery takes 30 to 40 minutes to complete and the patient is released from the hospital the next day.

3. The expected mortality rate for surgery is small and the comorbid complication rate is small.

4. If severe stenosis is found on both sides of the neck, the most severe side is usually operated on first and the opposite side a month later.
Most patients are back to work in 10 to 12 days with only a small incision on their neck to show their friends.

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The advances in surgery at the end of the nineteenth century, and the subsequent improvements in medical care throughout the twentieth century, have made what once was an often-fatal illness a disease that usually can be cured rather easily. Today, appendicitis is a very, very rare cause of death.

While on rare occasion appendicitis may subside spontaneously, the treatment almost universally is surgical – an appendectomy – removing the appendix. If the disease is diagnosed promptly, and the appendix removed before it ruptures, the usual hospital stay is brief and patients are back to full activities within a week to ten days. However, if the appendix ruptures and peritonitis (inflammation of the abdominal cavity), abscess, or other complications develop, the illness may be quite prolonged.

Virtually every surgeon, emergency room physician, primary care doctor, etc., has “missed” the diagnosis of appendicitis at some time during his or her career. This is not necessarily below the standard of care; detecting appendicitis is often a quite challenging problem. Even with today’s improved diagnostic acumen, the number of instances when appendicitis is not promptly diagnosed, leading to rupture, peritonitis, abscess, etc., is decreasing, there still are occasions when appendicitis confuses patient and physician alike. The body’s natural defenses “wall off” an inflamed organ, and indeed pain and other symptoms often will improve transiently.

It thus is important that a patient who presents with abdominal pain and is felt not likely to have appendicitis be advised to follow-up promptly if symptoms do not completely resolve. It likewise is important for emergency room and other physicians to have a great degree of suspicion when a patient returns with the same or similar complaints. Common diseases present in somewhat unusual fashion far more often than do rare problems.

Diagnosing Acute Appendicitis

Appendicitis classically presents with the sudden development of severe, steady abdominal pain. The discomfort starts about the umbilicus, and then migrates to the right lower abdomen. Nausea and/or vomiting follow. The bowels stop functioning, and appetite is lost. The white blood cell count and temperature rise. Secondary signs of infection – generalized toxicity – worsen as the disease progresses.Although this “classic presentation” is most common, the symptoms vary idely, ranging from someone who suddenly becomes deathly ill to a discomfort that seems insignificant until it has gone on for several days. Not everyone has the migrating pain; not everyone is nauseated or vomits; some people continue to eat without problems. Bowel movements may continue, or there may even be diarrhea. In some, the white count remains normal.

Typical findings upon physical examination include tenderness in the right lower abdomen, often with some spasm of the muscles in the abdominal wall in the area. Bowel sounds often are quiet; there may be “rebound” or “percussion” tenderness: in other words, jiggling the abdomen aggravates the pain. Patients often complain that while driving to the emergency room or doctor’s office oing over a bump aggravates the discomfort.

With the key to treatment of appendicitis being early diagnosis, it remains an art for the surgeon, in particular, and other physicians to try to distinguish appendicitis from other causes of abdominal pain, nausea, vomiting, etc. Clinical acumen remains the number one diagnostic tool. Because of the fear of “missing” the diagnosis and possibly allowing the appendix to rupture, it was widely accepted for many years that one would operate in uncertain instances, accepting that the appendix might be normal in as high as twenty percent of operations. Recent advances have reduced this rate of negative exploration, but there always will be uncertainty; operation often is the safest and most onservative option.

Through the years physicians have tried to improve diagnostic accuracy using various X-ray and other imaging studies. Plain X-rays of the abdomen are usually unproductive. In the 1980’s, ultrasonography was advocated to help make the diagnosis; unfortunately, it is not very accurate, but remains quite helpful in young women in trying to distinguish gynecological problems from appendicitis. If the appendix is visible on ultrasonography, the patient likely has appendicitis, but most diseased appendices are not identified.

Computerized axial tomography, or CT Scanning, has become the most widely used and important imaging technique to help identify patients with acute ppendicitis, perhaps to the point where it is overutlilized. [It is this surgeon’s opinion that in the classic presentation of appendicitis, especially in an otherwise healthy young male, there is little need for fancy imaging studies; one can proceed promptly to operation without the expense of additional studies.] CT scanning typically will identify an inflamed appendix. The radiologist often will describe the “dirty fat” of inflammation about the organ. The CT may identify other problems, and thus help in the differential diagnosis. Accuracy rates in diagnosing appendicitis of as high as 98 % have been reported.

Confusion in the diagnosis (and the majority of the cases in which the surgeon finds a normal appendix) is most common in young, menstruating women. iseases of the ovaries, Fallopian tubes, and uterus are actually more common than appendicitis. Problems such as a ruptured or twisted ovarian cysts, ectopic pregnancies, and pelvic infections can mimic appendicitis exactly. In addition to the imaging studies, the laparoscope has been particularly beneficial in this setting. It readily allows visualization of the pelvic organs and appendix through small incisions, permitting accurate diagnosis and treatment of the problem identified.

Surgical Treatment

Appendectomy was first performed in the late 1800’s. There is little controversy concerning the techniques used in open surgery. Usually a small incision is made in the right lower abdomen, the muscles of the abdominal wall stretched apart, the abdominal cavity entered and the appendix removed.
With the development of minimally invasive surgery, it has become increasingly attractive to remove the appendix using laparoscopic techniques. However, unlike cholecystectomy (gall bladder removal), in which there was a dramatic decrease in postoperative pain and hospital stay with the development of the laparoscopic approach, a dramatic shift in recovery time has not occurred with laparoscopic appendectomy. The reason likely is that the diseases are different. When removed, the appendix typically is acutely inflamed and infected, and antibiotics and other treatment are needed to resolve the infection. Antibiotic therapy is usually initiated before surgery and is required postoperatively for a varying time, depending on the degree of infection.

Laparoscopic appendectomy does seem to have some advantages, and increasing numbers of appendectomies are being done laparoscopically. Wound infection rates may be a bit lower, and time to return to work averages a day or two sooner. Some studies, however, suggest a higher rate of late intra-abdominal infections with laparoscopic surgery as compared to traditional open techniques.

Not all appendicices can be removed laparoscopically. What has become clear is that the decision to attempt laparoscopic vs. open removal has to be made on a case-by-case basis. Often it may involve an initial laparoscopic step for diagnosis and then making a conventional incision (perhaps a bit smaller since the location of the appendix may be pin-pointed) for appendix removal.

The appendix is sometimes removed incidentally during an operation for another problem. While this has decreased in popularity among general surgeons and gynecologists, it is important for patients undergoing abdominal operations to know whether or not the appendix was removed. When the operation is done for suspected appendicitis, and then the appendix is found to be normal, and no alternative disease or contradiction to appendectomy is identified, it is usual practice to remove the appendix to avoid future confusion. Thus every patient needs to know the surgical findings and the operation accomplished, as well as the pathologist’s report—does it confirm the surgeon’s diagnosis of acute appendicitis? It is quite acceptable to remove a normal appendix; it is not acceptable for the patient not to know the full nature of the illness.

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The long muscles of the extremities are wrapped in sheaths of tissue called fascia. Also enclosed are the nerves and blood vessels, which serve these muscles. This fascia is fairly unyielding and sturdy, helping to give the muscle its linear characteristic and contributing to its strength. This community of muscle, nerves and blood vessels enclosed within a sturdy fascia wall is referred to as a Compartment.

Yet, because of this limited noncompliant fascia surrounding the muscle compartment, there is little opportunity for an elevation of the internal pressure, from such things as bleeding or edema, to be accommodated. When trauma, either from injury or from overuse occurs then the muscle may swell and the pressure in this Compartment becomes elevated.

Once the tissue pressure rises above the arterial perfusion pressure, the flow of oxygen and blood will cease and tissue hypoxia will ensue. Ischemia is followed by reperfusion, capillary leakage from the ischemic tissue, and this increase in tissue edema causes a decrease in tissue perfusion, by increasing tissue pressure, resulting in nerve and muscle damage. This, if not alleviated within 6 hrs. of onset, will result in necrosis of tissue, possible permanent tissue impairment, contractures, rhabdomyolysis, and even loss of limb, kidney failure and death.

The elevation of pressure in these muscle compartments along with the damage which develops, is referred to as COMPARTMENT SYNDROME.

Sometimes the syndrome is recurrent, as with exercise, but spontaneously abates with rest. Often it is irreversible, and must be attended to quickly.

Compartment Syndrome is found wherever there are compartments-hand, forearm, upper arms, abdomen, buttocks, and entire lower extremity

ETIOLOGY

Common causes of Compartment Syndrome are:

Long Bone fractures- especially fractures of the tibia, or the forearm. Also, after intramedullary nailing, in the thigh or upper arm. The presence of fracture blisters may encourage the formation of this syndrome.
Vascular injury – (inadvertent arterial puncture, extravagated caustic medication or contrast, repetitive juxtaposition venous sticks, etc.)
Crush Injuries
Vigorous muscular exercise-as by running, or from seizures or tetany.
Burns
Envenomation
Hemorrhage
Nephrotic Syndrome
Limb immobility under pressure-(Saturday Night Palsy).
High velocity injuries
Excessive external pressure as from Casts,external pressure suits ( MAST).. (These diminish the compartment size causing elevation of the pressure).

Certain operating room positioning of the patient, such as hip or knee flexion, leg elevation, compression bandaging, or prolonged use of a tourniquet can lead to this condition. All of these conditions, with the exception of increased external pressure, will cause increase fluid or blood to accumulate and an elevation of the internal pressure, putting the perfusion into that area at risk.
Individuals, who are on anticoagulations, are especially susceptible to internal bleeding with associated elevation of compartment pressure, when exposed to a simple venapuncture, inartfully done, or to a minor injury.

DIAGNOSIS

Since irreversible tissue damage can occur within 6 hours, it is incumbent for the Physician to maintain a high index of suspicion in situations where Compartment Syndrome is known to occur. Signs and symptoms often appear to be excessive when compared to the observed physical abnormality, but must be recognized before damage occurs. They are:

Pain- often severe, characterized as burning or tightness. This pain occurs even with rest.
Paresthesias-numbness and tingling
Strength- often diminished and almost paralyzed.
Flexibility of extremity parts- the earliest clues are often pain with active flexion, and, especially, pain with passive stretching movements.
Swelling- the area of the limb will become tense and hard. Comparing limb sized will help.
Chronic exertional compartment syndrome most often occurs in the anterior or the lateral lower extremity compartment.

LABORATORY DIAGNOSIS

The usual tests such as an SMA-16, and a CBC with differential are helpful towards indicating etiology. The interrogation of a dark urine, which is positive for blood, but reveals few red blood cells will direct one to checking a serum and urine myoglobin and CPK, to rule out muscle damage (rhabdomyolysis). A Prothombin time and a PTT are helpful. X-rays to check for bone damage and Ultrasound exam for venous competency to rule out DVT, or to assess accumulation of large quantities of fluid or blood are helpful.

But once suspected, Compartment Syndrome is best identified by measuring the tissue pressure, within the suspected compartment, by tonometers. It’s imperative to make sure that the tissue measured it within the right area and not in. If the intracompartmental pressure is greater than 30 mm of Hg., intervention is required. The capillary perfusion pressure is presumed to have been overwhelmed and for the capillaries to have shut down. Some authorities allow a compartment pressure o up to 70 mm of Hg, before recommending acute surgical fasciotomy.

A, supposedly more definitive measurement, is the delta p pressure. This is a measurement of the perfusion pressure as determined from the diastolic BP minus the Intracompartmental pressure. If the delta p pressure is less then 30 mm of Hg, a fasciotomy is indicated. This has been helpful in cases where the compartment pressure was as high as 40 mm of Hg, but if the delta p pressure was greater than 30 mm of Hg, the surgery was withheld with no loss of tissue. Conversely, if the compartment pressure was less than 30 mm of Hg and the delta p pressure was less than 30 mm of Hg, surgery was done and was felt to have been the right choice. Thallium stress testing, which is noninvasive, may be a more physiologic measurement.

TREATMENT

Fasciotomy has been the treatment of choice in this condition. Even the sequelae from prophylactic fasciotomy is less then the damage acquired from delay in treatment of Compartment Syndrome. Fasciotomy consists of . It carries the disadvantage of presenting an open wound, which is subject to infection, as well as prolonging the hospital stay of the patient.
Mannitol infusions, to try and osmotically lure the intracompartmental fluid back into the blood stream in order to lessen the intracompartmental pressure is receiving some recent recognition of success. Hyperbaric Oxygenation has, also, been recognized as a fairly successful remedy for this condition.

References:

Orthop Nurs. 2001 May-Jun; 20 (3): 15-23;
Postgrad Med. 1999 Mar; 105 (3): 159-62, 165, 168.
Hosp Med. 2003 May, 64 (5): 296-8, Review
J. Orthop Trauma 2003. May, 17 (5):382-6
J. Vasc Surg. 2003 May; 37 (5): 1103-5
World J. Surg 2003 May 13
Int. Care Med. 2003 June; 29 (6): 1032

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Most patients learn of their need for coronary artery surgery after they present to the ER complaining of chest pain, shortness of breath or pain radiating to their jaw or down the left arm. Other patients notice a pressure-like sensation often described as an elephant standing on their chest. An EKG is usually requested and this study may show the general area of the heart which is at risk.

The muscle in this area of the heart may show characteristic electrical changes that alert the physician to possible heart damage. If the patient is thought to have an acute heart attack or MI, thrombolytic therapy or clot buster drugs may be given in the ER to dissolve blood clots in the coronary arteries. Once stabilized, the patient is usually scheduled by the cardiologist for a cardiac catheterization.

Cardiac caths are routine x-ray studies during which a small amount of dye is placed in the coronary arteries to search for blockages. If the blockages cannot be handled by balloon angioplasty or stents or atherectomy techniques, then surgery is recommended to bypass the blocked arteries. The patient also may undergo an echocardiogram prior to surgery and following surgery to determine the overall contractility of the heart muscle.
Since the early 1960ties, the operation to bypass blocked arteries in the heart has been called coronary artery bypass grafting or C. A. B. G. In recent years, cardiologists have been able to balloon open or angioplasty many blockages in the main coronary arteries and, on some occasions, an atherectomy technique has been available to actually cut away the plaque in these arteries. Despite all of these technical improvements, coronary artery bypass surgery still remains the most frequently performed cardiac surgery in the United States.

Saphenous veins from the legs and internal mammary arteries from the chest are usually used as grafts. In 1980, Loop and associates at the Cleveland Clinic reported a series of 646 patients who were restudied 48 months after their surgery. They noted that 81% of vein grafts harvested from the legs remained open or patent at that time interval. The patency of internal mammary artery grafts for the same period was 95%. The internal mammary artery is a small artery which is detached from beneath the breast bone and can be used to bypass some of the blocked vessels found on the surface of the heart.
In 2000, some 20 years later, the patency rate for vein grafts has improved to about 89% at one year and internal mammary artery graft s remain open 97% of the time. The reason for the superior long-term results of internal mammary artery bypass grafts is because the artery is mobilized for grafting along with the small arteries and veins which feed it, the chest wall fat and muscle.

This technique maintains the homeostasis of the artery and its endothelium or inner lining remains intact. Free grafts such as saphenous vein grafts or radial artery grafts do not have this pedicle and are subject to ischemia or sloughing of their endothelial linings. Unfortunately, endothelial damage can lead to stricture or occlusion of the artery or accelerated atherosclerosis. The point being that internal mammary bypass provides the best conduit to supply blood to the heart and this seems to hold up over time better than any other type of material. Plastic grafts, while often used in peripheral vascular surgery, do not stay open because of the small sizes need for coronary bypass surgery.
Now for the bad news. There are several disadvantages that limit internal mammary artery grafting. One is the technical problem of mobilizing the artery. Secondly, there are only two internal mammary arteries and their length is often not sufficient to reach the back wall of the heart well. A third problem is that flow through the internal mammary artery must be equivalent to the flow in the artery to be grafted.

In other words you must have a pretty good size match for this technique to work and the bypass to stay open. In diabetic patients or patients with severe emphysema or fragile breast bones, the artery may be of poor quality and not suitable for grafting purposes.

Recommendations:
1) If you have chest pain which is new in onset, or a pressure sensation often accompanied by sweating and the feeling that something is wrong go to the nearest ER.
2) If your EKG suggests an acute MI, you may be told that you need a clot buster like t-PA to dissolve blood clots.
3) The next step in your workup may well be a trip to the cath lab to discover the exact location of blockages in the coronary arteries of your heart.
3) If your cath films shows several blockages, coronary artery bypass may be your best chance for recovery of most of your cardiac muscle function.

4) Lastly, saphenous vein grafts or internal mammary grafts should give you a new lease on life, but you will most probably have to change your lifestyle in the future to avoid another trip to the OR in 10 years.

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