Correspondence 8. 9.
Stubblefield PG. Intraovarian abscess treated with laparoscopic aspiration and povidone-iodine lavage. A case report. .I Reprod Med 1991; 36: 407-9. Rhodeheaver G , Bellami W, Kody M. Bactericidal activity and toxicity of iodine-containing solutions. Arch Surg 1982; 117: 181-6.
Sir We were interested to read the Case Report by Whiston et al. ( B r J Surg 1991; 78: 1325) of tension pneumothorax during laparoscopic cholecystectomy. We recently noted a large, right-sided pneumothorax developing at the end of the procedure on a 53-year-old woman. Pneumoperitoneum was achieved using carbon dioxide via a variable flow pressure-controlled insufflator. In recovery the patient's oxygen saturation (measured by continuous transcutaneous oxygen saturation monitoring) had dropped to 48 per cent. Clinical examination revealed a right-sided pneumothorax, confirmed on chest radiography. While preparations were being made to insert a chest drain, the oxygen saturation was noted to improve and a decision of non-intervention was made One hour later, repeat chest radiography showed the pneumothorax to have completely resolved. Pneumothorax, as a complication of pneumoperitoneum, was first noted in the 1940s, when pneumoperitoneum was used in the treatment of tuberculosis'. Subsequently, there have been many case reports and reviews in the literature of this complication following peritoneosc~py~-~. In 1973 Doctor and Hussain' promoted the use of carbon dioxide as an insufflating agent because ofits high diffusibility. This carbon dioxide pneumothorax resolved rapidly and suggests that there is a place for conservative management of carbon dioxide pneumothorax.
R. M. Heddle A. J. Platt Kent and Canterbury Hospital Canterbury Kent CTI 3NG UK
2. 3.
374
Murray DP, Rankin RA, Lackey C. Bilateral pneumothoraces complicating peritoneoscopy. Gastrointest Endosc 1984; 30: 45-6 (Letter).
Identification of bile duct stones in patients undergoing laparoscopic c holecystectomy
Tension pneumot hotax d ur ing Ia paroscopic c holecystectomy
1.
4.
Stein HF. Complications of artificial pneumoperitoneum. Am Rev Tuberc 1951; 64: 645-58. Doctor NH, Hussain 2. Bilateral pneumothorax associated with laparoscopy. Anaesthesia 1973; 28: 75-81. Pascual JB, Baranda MM, Tarrero MT, Gutierrez FM, Garrido IM, Errasti CA. Subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumopericardium after laparoscopy. End0scop.v 1990; 22: 59 (Letter).
Sir We read the recent paper by Joyce et al. ( B r J Surg 1991; 78: 1174-6) with great interest. We also perform routine preoperative intravenous cholangiography (IVC) to investigate the biliary tree before laparoscopic cholecystectomy and report similar results. Between October 1990 and September 1991, we performed elective laparoscopic cholecystectomy on 100 consecutive patients. In ten cases, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed because of jaundice (two patients), pancreatitis (two), abnormal liver function tests without clinical jaundice (two) and ultrasonographic evidence ofcommon bile duct (CBD ) obstruction (four). Stones were found in only three of the ten and were successfully removed endoscopically after sphincterotomy. The other 90 patients underwent preoperative IVC. One procedure was abandoned due to a vasovagal reaction, and there was a second patient who suffered a mild skin rash. In five patients unsuspected CBD stones were demonstrated by IVC and subsequently confirmed and removed by ERCP and sphincterotomy in four patients, with one falsepositive result. Of the 85 patients with normal IVCs, one patient required ERCP and sphincterotomy after laparoscopic cholecystectomy to remove a small stone from the lower end of the CBD which caused jaundice. Hence, by a combination of preoperative ERCP and IVC, we have prevented retained stones in 7 per cent of patients having laparoscopic cholecystectomy. We have not attempted operative cholangiography in any patient, relying entirely on preoperative IVC to demonstrate anatomy and identify ductal stones. This avoids the difficult decision of how to treat unexpected stones discovered during laparoscopic cholecystectomy. Until the techniques for exploration of the CBD laparoscopically are fully developed, we shall continue to determine the state of the ducts before operation and we entirely agree with the authors that IVC is a safe and effective method of doing this.
C. Hall P. Ganas N. J. Dorricott The General Hospital Steelhouse Lane Birmingham 84 6 N H
UK
Br. J. Surg., Vol. 79, No. 4, April 1992
Stubblefield PG. Intraovarian abscess treated with laparoscopic aspiration and povidone-iodine lavage. A case report. .I Reprod Med 1991; 36: 407-9. Rhodeheaver G , Bellami W, Kody M. Bactericidal activity and toxicity of iodine-containing solutions. Arch Surg 1982; 117: 181-6.
Sir We were interested to read the Case Report by Whiston et al. ( B r J Surg 1991; 78: 1325) of tension pneumothorax during laparoscopic cholecystectomy. We recently noted a large, right-sided pneumothorax developing at the end of the procedure on a 53-year-old woman. Pneumoperitoneum was achieved using carbon dioxide via a variable flow pressure-controlled insufflator. In recovery the patient's oxygen saturation (measured by continuous transcutaneous oxygen saturation monitoring) had dropped to 48 per cent. Clinical examination revealed a right-sided pneumothorax, confirmed on chest radiography. While preparations were being made to insert a chest drain, the oxygen saturation was noted to improve and a decision of non-intervention was made One hour later, repeat chest radiography showed the pneumothorax to have completely resolved. Pneumothorax, as a complication of pneumoperitoneum, was first noted in the 1940s, when pneumoperitoneum was used in the treatment of tuberculosis'. Subsequently, there have been many case reports and reviews in the literature of this complication following peritoneosc~py~-~. In 1973 Doctor and Hussain' promoted the use of carbon dioxide as an insufflating agent because ofits high diffusibility. This carbon dioxide pneumothorax resolved rapidly and suggests that there is a place for conservative management of carbon dioxide pneumothorax.
R. M. Heddle A. J. Platt Kent and Canterbury Hospital Canterbury Kent CTI 3NG UK
2. 3.
374
Murray DP, Rankin RA, Lackey C. Bilateral pneumothoraces complicating peritoneoscopy. Gastrointest Endosc 1984; 30: 45-6 (Letter).
Identification of bile duct stones in patients undergoing laparoscopic c holecystectomy
Tension pneumot hotax d ur ing Ia paroscopic c holecystectomy
1.
4.
Stein HF. Complications of artificial pneumoperitoneum. Am Rev Tuberc 1951; 64: 645-58. Doctor NH, Hussain 2. Bilateral pneumothorax associated with laparoscopy. Anaesthesia 1973; 28: 75-81. Pascual JB, Baranda MM, Tarrero MT, Gutierrez FM, Garrido IM, Errasti CA. Subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumopericardium after laparoscopy. End0scop.v 1990; 22: 59 (Letter).
Sir We read the recent paper by Joyce et al. ( B r J Surg 1991; 78: 1174-6) with great interest. We also perform routine preoperative intravenous cholangiography (IVC) to investigate the biliary tree before laparoscopic cholecystectomy and report similar results. Between October 1990 and September 1991, we performed elective laparoscopic cholecystectomy on 100 consecutive patients. In ten cases, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed because of jaundice (two patients), pancreatitis (two), abnormal liver function tests without clinical jaundice (two) and ultrasonographic evidence ofcommon bile duct (CBD ) obstruction (four). Stones were found in only three of the ten and were successfully removed endoscopically after sphincterotomy. The other 90 patients underwent preoperative IVC. One procedure was abandoned due to a vasovagal reaction, and there was a second patient who suffered a mild skin rash. In five patients unsuspected CBD stones were demonstrated by IVC and subsequently confirmed and removed by ERCP and sphincterotomy in four patients, with one falsepositive result. Of the 85 patients with normal IVCs, one patient required ERCP and sphincterotomy after laparoscopic cholecystectomy to remove a small stone from the lower end of the CBD which caused jaundice. Hence, by a combination of preoperative ERCP and IVC, we have prevented retained stones in 7 per cent of patients having laparoscopic cholecystectomy. We have not attempted operative cholangiography in any patient, relying entirely on preoperative IVC to demonstrate anatomy and identify ductal stones. This avoids the difficult decision of how to treat unexpected stones discovered during laparoscopic cholecystectomy. Until the techniques for exploration of the CBD laparoscopically are fully developed, we shall continue to determine the state of the ducts before operation and we entirely agree with the authors that IVC is a safe and effective method of doing this.
C. Hall P. Ganas N. J. Dorricott The General Hospital Steelhouse Lane Birmingham 84 6 N H
UK
Br. J. Surg., Vol. 79, No. 4, April 1992
