harris Δημοσιεύτηκε 10 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 10 Νοεμβρίου 2006 http://www.nlm.nih.gov/medlineplus/surgeryvideos.html ΑΝΤΕ ΚΑΙ ΚΑΛΗ ΓΝΩΣΗ Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
invitro Δημοσιεύτηκε 10 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 10 Νοεμβρίου 2006 Γειά σου ρε Χάρη που θες να μας διδάξεις κιόλας! Αλήθεια εκείνες τις κατατακτήριες στην ιατρική τις έδωσες ή ακόμα; Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
gor Δημοσιεύτηκε 10 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 10 Νοεμβρίου 2006 Σε ευχαριστώ harris για τα video. invitro ξεκόλλα. Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
harris Δημοσιεύτηκε 10 Νοεμβρίου 2006 Author Aναφορά Share Δημοσιεύτηκε 10 Νοεμβρίου 2006 ΝΑ ΚΑΙ ΕΝΑΣ ΠΟΥ ΕΧΕΙ ΜΑΘΕΙ ΤΗΝ ΣΗΜΑΣΙΑ ΤΗΣ ΛΕΞΗΣ ΕΥΧΑΡΙΣΤΩ... Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
Alexnet Δημοσιεύτηκε 10 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 10 Νοεμβρίου 2006 Κ εγώ που τις έδωσα...... έπρεπε να το ξανασκεφτώ ) Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
bromptonista Δημοσιεύτηκε 11 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 11 Νοεμβρίου 2006 Και μην ξεχνάμε τα http://www.websurg.com (απαιτείται δωρεάν εγγραφή) για να μάθετε επιτέλους ποιοι είναι οι Leroy και Dallemagne και http://www.e-laparoscopy.com όπου μπορείτε να δείτε βίντεο με τον απίστευτο JL Dulucq να κάνει Whipple λαπαροσκοπικά... Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
Αποφρακτικός_Ειλεός Δημοσιεύτηκε 11 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 11 Νοεμβρίου 2006 ωραία πράγματα. Θενκς Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
navis Δημοσιεύτηκε 11 Νοεμβρίου 2006 Aναφορά Share Δημοσιεύτηκε 11 Νοεμβρίου 2006 πολύ καλό το site!Θενκς κι από εμένα, harris πάντως μη μασάς κομπλεξικούς θα συναντήσεις πολλούς αλλά αν το γουστάρεις κάντο για τί κακά τα ψέματα και παρά τις γκρίνιες, κάποιες εμπειρίες που αποκτάς ως φοιτητής ιατρικής είναι once in a lifetime. Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
FLESHFORFANTASY Δημοσιεύτηκε 25 Δεκεμβρίου 2007 Aναφορά Share Δημοσιεύτηκε 25 Δεκεμβρίου 2007 πολυ καλο παιδια μπραβο! Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
lisaki Δημοσιεύτηκε 25 Δεκεμβρίου 2007 Aναφορά Share Δημοσιεύτηκε 25 Δεκεμβρίου 2007 Ευχαριστούμε Harris! Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
DimitrisPap Δημοσιεύτηκε 26 Δεκεμβρίου 2007 Aναφορά Share Δημοσιεύτηκε 26 Δεκεμβρίου 2007 Να προσθεσω το www.or-live.com Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
karanti_maria Δημοσιεύτηκε 1 Ιουνίου 2008 Aναφορά Share Δημοσιεύτηκε 1 Ιουνίου 2008 ΣΕ ΚΑΘΕ ΧΕΙΡΟΥΡΓΕΙΟ ΔΕΝ ΠΡΕΠΕΙ ΝΑ ΚΛΕΙΝΟΥΜΕ ΠΕΡΙΤΟΝΑΙΟ!ΝΑ ΓΙΑΤΙ: PERITONEAL CLOSURE 1. Introduction Closure of the parietal peritoneum at lower abdominal surgery has long been advocated in traditional surgical training. The reason for this is to establish normal anatomical relations, to prevent adhesion formation between the intestines and fascia or between uterus and fascia, to reduce the risk of infection and to reduce the risk of herniation or dehiscence.1 However, the advantages of this technique have not been proved by prospective randomised trials. Prior animal experiments and general surgery reports have shown that suture peritonealisation tends to cause tissue ischaemia, necrosis, inflammation, and foreign body reactions to suture material. These factors may slow down the healing process and are considered important precursors for adhesion formation. Peritoneum is a mesothelial organ. In contrast to epidermal repair, where healing occurs gradually from wound borders, peritoneum heals simultaneously throughout the wound because mesothelial cells initiate multiple sites of repair.1 If the peritoneum is left open, experimental studies have shown that a spontaneous reperitonealisation will appear within 48–72 hours after injuring the peritoneum with complete healing after five to six days.2,4 2. Methodology A review of literature was undertaken to establish the evidence for and against peritoneal closure. Medical databases were searched for reports of published clinical trials comparing peritoneal closure to non-closure in obstetric and gynaecological surgery (MeSH terms used were ‘peritoneum’, ‘caesarean section’, ‘hysterectomy’ and ‘laparotomy’). The trials were identified by searching Embase (1988–2001), Medline (1966–2001), and the Cochrane Controlled Trials Register database. All languages were included. References cited in all trials were searched iteratively to identify any missing studies, in addition to a reference search from a review article.5 3. Peritoneal closure versus non-closure at caesarean section 3.1 Operative benefits of peritoneal non-closure at caesarean section Non-closure of the parietal peritoneum is recommended during caesarean section because it results in significantly shorter operating time. Six randomised-controlled trials,6–11 involving 1615 patients undergoing caesarean section, assessed operative complications in relation to closure or non-closure of the parietal or parietal and visceral peritoneum. Four of these trials, involving 1194 Guideline No 15 Revised July 2002 RCOG Guideline No. 15 1 of 7 A Evidence level Ia women,6–9 were included in a Cochrane systematic review.12 This review showed that non-closure of the peritoneum during caesarean section saved operating time (weighted mean difference of -6.1 minutes, 95% confidence interval -8.0 to -4.3). Grundsell et al., in a randomised controlled trial involving 361 patients, also found that operating time was significantly shorter, in the non-closure group, by 7.9 minutes (P < 0.01).10 In the study by Galaal and Krolikowski, the average duration of operation for the peritoneal closure and non-closure groups were 61.9 minutes (± 12.7) and 53.6 (± 11.2), respectively (P < 0.01).11 3.2 Early postoperative morbidity and peritoneal closure at caesarean section Non-closure of the parietal peritoneum at caesarean section is recommended because it is associated with lower postoperative febrile morbidity and postoperative use of analgesics. Early postoperative complications assessed in studies include wound haematoma, postoperative febrile morbidity, wound infection and postoperative pain and analgesia. The Cochrane systematic review by Wilkinson and Enkin12 showed that there were no statistically significant differences in postoperative morbidity, analgesic requirements and length of hospital stay. However, there was a consistent, although non-significant, trend for improved immediate postoperative outcome if the peritoneum was not closed. In a more recent randomised controlled trial,13 visual analogue scales showed no difference in postoperative pain comparing closure and non-closure of parietal peritoneum. However, the use of postoperative analgesia was significantly lower in the non-closure group. Grundsell et al.,10 in their randomised controlled trial, reported that febrile morbidity and wound infection were significantly lower in the non-closure group (P < 0.001 and P < 0.05, respectively). In their study, hospital stay was one day less in the group where the peritoneum was left open. These findings made them conclude that nonclosure of the visceral and parietal peritoneum is associated with fewer postoperative complications. Recently, there have been a number of anecdotal reports of dehiscence of lower transverse wounds, perhaps associated with non-closure of the parietal peritoneum. This particular complication is infrequent and was not assessed in the above trials, but will be kept under review. Non-closure of the visceral peritoneum at caesarean section is recommended because it is associated with significantly shorter operating time and postoperative hospital stay, as well as significantly lower postoperative febrile and infectious morbidity. In a prospective trial, 549 women undergoing caesarean section were randomised to either closure or non-closure of the visceral peritoneum.14 The mean operating time (± SD) was significantly greater in the closed group (56.9 ± 17.9 minutes) than in the open group (50.6 ± 16.8 minutes) (P < 0.001). Comparison of the operating times in patients in whom caesarean section and tubal sterilisation were performed revealed no significant difference between both groups. Postoperative hospitalisation was also significantly longer in the closed group (7.9 ± 1.8 days) than in the open group (7.2 ± 1.6 days) (P < 0.001). Both temperature ≥ 38ºC for more than two postoperative days and the daily average temperature values during the first postoperative week were significantly higher with closure of the peritoneum (P < 0.001). RCOG Guideline No. 15 2 of 7 A Evidence level Ia Evidence level Ib A Evidence level Ib Evidence level Ia Non-closure of the peritoneum during caesarean section is recommended because it leads to a quicker return of bowel activity. In a retrospective study comparing closure versus non-closure of the visceral and parietal peritoneum during caesarean section, in two groups of patients, with 50 women in each group, McNally et al.15 found that urinary tract infection, endometritis, wound infection and respiratory infection occurred with similar frequency. However, the return of full bowel activity occurred at a significantly later time in the peritoneal closure group. 3.3 Peritoneal closure and adhesion formation Peritoneal closure increases the incidence of bladder adhesions following caesarean section and is therefore not recommended. Buckman et al.16 showed that deperitonealised surfaces, which have not been otherwise traumatised, heal without permanent adhesions because they retain their ability to lyse fibrinous adhesions before organisation can occur. Peritoneum that has been made ischaemic by grafting or tight suturing not only loses its ability to lyse fibrin, but also may actively inhibit fibrinolysis by normal tissue. In a retrospective analysis of the operative findings during the second lower-segment caesarean section in a group of women who had the visceral and parietal peritoneum closed and another group who had these left opened during their first caesarean section, the incidence of adhesions was found to be 28% in the closed group, compared with only 14% in the open group.15 The authors concluded that closure of the peritoneum at lower-segment caesarean section does not appear to confer any extra postoperative benefit and may increase morbidity because of prolonged operative time and subsequent risk of visceral injury, in particular to the bladder, due to adhesions. Stark et al.17 compared non-closure with closure of the visceral and parietal peritoneal layers. Adhesion formation was less during repeat operations in the nonclosure than closure groups (6.3 versus 38.8%, P < 0.05), although the number of repeat operations was not described. These findings were also confirmed more recently by other investigators.18 The CAESARean Section Surgical Techniques (CAESAR) study19 is a 2x2x2 factorial design randomised controlled trial evaluating three alternative caesarean section operative techniques. One of the aspects evaluated in the trial is closure versus non-closure of the pelvic peritoneum. The trial is currently in progress and should provide further valuable evidence regarding the management of the peritoneum at caesarean section. 3.4 Economic benefits of peritoneal non-closure at caesarean section Closure of the peritoneum during caesarean section is not recommended as it is not costeffective. Cost analysis to determine possible savings with omission of peritoneal closure was performed in two randomised trials.9,10 The first trial, which involved 248 women and was reported in 1991, calculated that possible savings, to their unit, would amount to US$100,286 per year. This calculation was based on cost of a single suture used for peritoneal closure, 6800 deliveries per annum and a 15.1% caesarean section rate. The authors took into account operating room time and anaesthesia RCOG Guideline No. 15 3 of 7 B Evidence level III B Evidence level III A Evidence level Ib expenses. Grundsell et al.,10 in 1998, estimated that the cost saving for each caesarean section when the visceral and parietal peritoneum was not closed would amount to US$330. In their calculation, the authors took into account that the hospital stay was one day less in the non-closure group. 4. Peritoneal closure versus non-closure at hysterectomy 4.1 Peritoneal closure at abdominal hysterectomy Visceral and/or parietal peritoneal closure at abdominal hysterectomy is not recommended as it lengthens the surgical time and anaesthesia exposure without providing immediate postoperative benefits. The question of whether peritoneal non-closure alters the operative or postoperative course at abdominal hysterectomy was addressed by two randomised clinical trials.20,21 In the study carried out by Nagele et al.,20 211 patients were randomised to closure or non-closure of the visceral peritoneum. Although there was no significant difference between the two groups in the temperature curves in the first week after surgery, the number of patients requiring antibiotics for various complications was significantly higher in patients of the closed group (P = 0.03). The authors concluded that non-closure of the visceral peritoneum simplifies the surgical technique and results in a smaller number of postoperative complications. Gupta et al.21 randomised 144 women, who underwent abdominal hysterectomy with or without salpingo-oophorectomy, to two groups, depending on whether the visceral and parietal peritoneum was closed or left open. The mean operative time was ten minutes shorter (P < 0.001) and there was a 45 ml reduction in the estimated blood loss in the non-closure group (P = 0.03). In their study, there were no differences in postoperative pain in the two groups. 4.2. Peritoneal closure at vaginal hysterectomy Peritoneal closure during vaginal hysterectomy is not recommended. The clinical outcomes of 106 patients who underwent vaginal hysterectomy with or without peritoneal closure were assessed in a randomised controlled trial.22 Postoperative complications were similar in both groups. The incidence of deepthrust dyspareunia at 6 and 12 months was also similar. In this study, there was no statistical difference between the two groups in the ovary-to-vaginal-cuff distances either overall or when patients with dyspareunia were considered separately. The authors concluded that the data from the study do not support routine closure of the peritoneum during vaginal hysterectomy. However, because of the small sample size and the lack of statistical power, the conclusion was considered to be a grade B recommendation, despite the study being a randomised controlled trial. 5. Peritoneal closure at radical abdominal surgery for gynaecological cancers Closure of the peritoneum at radical abdominal hysterectomy and node dissection is not recommended. Effects of peritoneal non-closure during radical surgery for gynaecological cancers were assessed in randomised controlled trials. Kadanali et al.23 and Than et al.24 assessed this in ovarian cancer surgery and cervical cancer surgery, respectively. They found improved outcomes (reduced adhesions and reduced fever) where the visceral RCOG Guideline No. 15 4 of 7 A Evidence level Ib B Evidence level Ib A Evidence level Ib Evidence level Ib peritoneum was left to heal on its own. In a randomised controlled study of 120 patients, Franchi and associates25 found that the amount of drainage was significantly higher in the closed group (median of 740 ml versus 340 ml; P < 0.005). There was no difference between the two groups in the incidence of symptomatic or asymptomatic lymphocysts, wound and pelvic infection, febrile morbidity and obstruction. Closure of the peritoneum after pelvic lymphadenectomy is not recommended, as it may increase the incidence of lymphocysts. The incidence of lymphocysts following pelvic lymphadenectomies in women who had peritoneal closure and those who did not were compared in two retrospective studies.26–27 The first study analysed 226 iliac lymphadenectomies.26 The incidence of lymphocysts in the peritoneal closure versus the non-closure group was 35.9% versus 17.4%, respectively. The other study analysed 157 patients who had external iliac lymphadenectomy with either closure or non-closure of the visceral peritoneum.27 Lymphoceles occurred in 23.1% of the cases in the peritonealisation group compared to 6.1% in the non-peritonealisation group. It is essential that operative details are clearly documented, including the time of onset of the procedure, details of any adhesions or operative difficulties, operative technique and suture materials used. References 1. Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet Gynecol Surv 1994;49:817–22. 2. Elkins TE, Stovall TG, Warren J, Ling FW, Meyer NL. A histologic evaluation of peritoneal injury and repair: implications for adhesion formation. Obstet Gynecol 1987;70:225–8. 3. McDonald MN, Elkins TE, Wortham GF, Stovall TG, Ling FW, McNeeley SG. Adhesion formation and prevention after peritoneal injury and repair in the rabbit. J Reprod Med 1988;33:436–9. 4. Hubbard TB, Khan MZ, Carag VR, Albites VE, Hricko GM. The pathology of peritoneal repair: its relation to the formation of adhesions. Ann Surg 1967;165:908–16. 5. Hema KR, Johanson R. Techniques for performing caesarean section. Best Practice & Research in Clinical Obstetrics & Gynaecology 2001;15:17–47. 6. Hull D, Varner M. A randomized study of closure of the peritoneum at Cesarean delivery. Obstet Gynecol 1991;77:818–21. 7. Irion O, Luzuy F, Beguin F. Non-closure of the visceral and parietal peritoneum at caesarean section: a randomised controlled trial. Br J Obstet Gynaecol 1996;103:690–4. 8. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or non-closure of the visceral peritoneum at caesarean delivery. Am J Obstet Gynecol 1996;174:1366–70. 9. Pietrantoni M, Parsons MT, O’Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or non-closure at cesarean. Obstet Gynecol 1991;77:293–6. 10. Grundsell HS, Rizk DEE, Kumar RM. Randomized study of non-closure of peritoneum in lower segment cesarean section. Acta Obstet Gynecol Scand 1998;77:110–15. 11. Galaal KA, Krolikowski A. A randomized controlled study of peritoneal closure at cesarean section. Saudi Med J 2000;21:759–61. 12. Wilkinson CS, Enkin MW. Peritoneal non-closure at caesarean section. Cochrane Database Syst Rev 2001;(3). 13. Hojberg KE, Aagaard J, Laursen H, Diab L, Secher NJ. Closure versus non-closure of peritoneum at cesarean section – evaluation of pain. Acta Obstet Gynecol Scand 1998;77:741–5. 14. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or nonclosure of the visceral peritoneum at caesarean delivery. Am J Obstet Gynecol 1996;174:1366–70. RCOG Guideline No. 15 5 of 7 B Evidence level III Evidence level Ib 15. McNally OM, Curtain AC. Does closure of the peritoneum during caesarean section influence postoperative morbidity and subsequent bladder adhesion formation? J Obstet Gynaecol 1997;17:239–41. 16. Buckman RF Jr, Buckman PD, Hufnagel HV, Gervin AS. A physiological basis for the adhesion-free healing of deperitonealized surfaces. J Surg Res 1976;21:67–76. 17. Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of combinations of procedures in cesarean section. Int J Obstet Gynecol 1995;48:273–6. 18. Joura EA, Nather A, Husslein P. Non-closure of peritoneum and adhesions: the repeat cesarean section. Acta Obstet Gynecol Scand 2001;80:286. 19. The CAESAR Study [www.npeu.ox.ac.uk/trials/Caesar.html]. 20. Nagele F, Kurz C, Staudach A, Steiner H, Grünberger W, Beck A, et al. Closure or nonclosure of the visceral peritoneum in abdominal hysterectomy. J Gynecol Surg 1995;11:133–9. 21. Gupta JK, Dinas K, Khan KS. To peritonealize or not to peritonealize? A randomised trial at abdominal hysterectomy. Am J Obstet Gynecol 1998;178:796–800. 22. Lipscomb GH, Ling FW, Stovall TG, Summitt RL. Peritoneal closure at vaginal hysterectomy: a reassessment. Obstet Gynecol 1996;87:40–3. 23. Kadanali S, Erten O, Kucukozkan T. Pelvic and periaortic peritoneal closure or non-closure at lymphadenectomy in ovarian cancer: effects on morbidity and adhesion formation. Eur J Surg Oncol 1996;22:282–5. 24. Than GN, Arany AA, Schunk E, Vizer M, Krommer KF. Closure or non-closure of visceral peritoneums after abdominal hysterectomies and Wertheim-Meigs radical abdominal hysterectomies. Acta Chir Hung 1994;34:79–86. 25. Franchi M, Ghezzi F, Zanaboni F, Scarabelli C, Beretta P, Donadello N. Nonclosure of the peritoneum at radical abdominal hysterectomy and pelvic node dissection: A randomised study. Obstet Gynecol 1997;90:622–7. 26. Pennehouat G, Mosseri V, Durand JC, Hamelin JP, Asselain B, Pilleron JP, et al. Lymphoceles et peritonisation après lymphadenectomies pour cancers de l’uterus. J Gynecol Obstet Biol Reprod 1988;17:373–8. 27. Thome Saint Paul M, Bremond A, Rochet Y. Absence de peritonisation après la chirurgie pelvienne carcinologique. J Gynecol Obstet Biol Reprod 1991;20:957–60 RCOG Guideline No. 15 6 of 7 APPENDIX Clinical guidelines are: ‘systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’. Each guideline is systematically developed using a standardised methodology. Exact details of this process can be found in Clinical Governance Advice No 1: Guidance for the Development of RCOG Green-top Guidelines (available on the RCOG website http://www.rcog.org.uk/medical/greentopguide.html). These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated. The evidence used in this guideline was graded using the scheme below and the recommendations formulated in a similar fashion with a standardised grading scheme. Classification of evidence levels Ia Evidence obtained from meta-analysis of randomised controlled trials. Ib Evidence obtained from at least one randomised controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomisation. IIb Evidence obtained from at least one other type of well-designed quasi-experimental study. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Grades of recommendations Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia, Ib) Requires the availability of well-controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa, IIb, III) Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV) Good practice point Recommended best practice based on the clinical experience of the guideline development group. GUIDELINE OF THE ROYAL COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS. ΕΧΕΙ ΝΟΜΙΚΗ ΑΞΙΑ! Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
mad cow Δημοσιεύτηκε 21 Σεπτεμβρίου 2008 Aναφορά Share Δημοσιεύτηκε 21 Σεπτεμβρίου 2008 Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
kostas26 Δημοσιεύτηκε 2 Αυγούστου 2010 Aναφορά Share Δημοσιεύτηκε 2 Αυγούστου 2010 τι λεει ελεος Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
Elpi Δημοσιεύτηκε 18 Δεκεμβρίου 2010 Aναφορά Share Δημοσιεύτηκε 18 Δεκεμβρίου 2010 Είσαι θεός! Thanksssssssssss Παράθεση Link to comment Μοιράσου σε άλλους δικτυακούς τόπους More sharing options...
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