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Query: UMLS:C0019270 (hernia)
 15,856 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Previous studies from our institution have shown that neonates with congenital diaphragmatic hernia (CDH), whose best postductal PaO2 (BPDPO2) was less than 100 mm Hg while on maximal conventional mechanical ventilation (CMV), had a mortality exceeding 90%. When combined with extracorporeal membrane oxygenation (ECMO), the mortality rose to 100% in those infants who developed hypercarbia following decannulation. Historically, those patients have required increasing ventilator support, leading to iatrogenic lung damage, and eventual death. Intratracheal pulmonary ventilation (ITPV) using the reverse thrust catheter (RTC) developed by Kolobow incorporates a continuous flow of humidified gas through a reverse Venturi catheter positioned at the distal end of the endotracheal tube. In animal studies, ITPV was shown to result in a reduced physiological dead-space (VD), to facilitate expiration, and to enhance CO2 elimination. In our current study, we have applied ITPV in two neonates with CDH who could not be weaned from ECMO because of uncontrollable hypercapnia, and who met above criteria for 100% mortality. In both cases, ITPV restored normal PaCO2 at low peak inspiratory pressure (PIP) with a substantial decrease in VD. We believe ITPV is suited to ventilating newborns with CDH in whom barotrauma is known to be common. Beyond its present use, ITPV may be useful to ventilate children with other forms of respiratory failure, and should be so considered along with other now available methods of mechanical pulmonary ventilation.
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PMID:Intratracheal pulmonary ventilation and congenital diaphragmatic hernia: a report of two cases. 846 66

More than 500,000 hernia procedures are performed annually in the United States alone. The authors have devised a new technique for laparoscopic hernia repair. The peritoneum is not incised, as the space between the abdominal wall and the peritoneum is developed with CO2 and blunt dissection. The trocars and laparoscope are placed within this preperitoneal space. Mesh is stapled to Cooper's ligament and the underside of the abdominal wall. From November 1990 to January 1992, 68 herniae have been repaired in 35 patients. The first 25 patients were kept overnight for observation and discharged the following day. Thirty-two patients (92%) were able to resume full physical activity within 1 week. Average follow-up was only 12 months, but there were no recurrent or retained herniae.
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PMID:Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision. Technique and early clinical results. 850 67

A 57-year-old woman, weighing 75 kg, with gastroesophageal sliding hernia, received laparoscopic Nissen fundoplication under general anesthesia. Although artificial ventilation was carried out uneventfully when the surgery started, sudden decreases in SpO2 and thoraco-pulmonary compliance were noted after insufflation of CO2. Breath sound was not audible on the left lung. We suspected that inadvertent pneumothorax was produced, but chest X-ray and transesophageal echocardiography at the end of surgery revealed the presence of left hemilateral hydrothorax with pulmonary atelectasis. She was ventilated artificially and given diuretics and albumin solution for 3-days before extubation. We speculated on two reasons for the event: a possibility of perforation of the diaphragm manipulated by surgeons, and that of transition of fluid used for irrigation just below the diaphragm. Pulmonary atelectasis could be induced with hemilateral lung ventilation because cephalad shifting of the diaphragm might follow the intraperitoneal insufflation. We conclude that laparoscopic surgery with insufflation of gas and irrigation with fluid requires careful attention if the laparoscopic surgery is sustained with insufflation and irrigation.
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PMID:[Hemilateral hydrothorax and atelectasis during laparoscopic Nissen fundoplication]. 872 4

This is the first report, to our knowledge, of a case of massive subcutaneous emphysema during totally preperitoneal laparoscopic hernia repair causing a "respiratory acidosis" with a systemic pH 7.20 and a pCO2 of 64 and PO2 of 84. The acidosis was corrected by increased mechanical ventilation. It appears that because of its lack of defined borders, the preperitoneal space is particularly vulnerable to the formation of massive subcutaneous emphysema. Thus, there is a large potential surface area for CO2 absorption. The complication may be prevented by increased attention to the length of fascial incisions, inflation of balloon expanding devices, and securing gripping devices in the port sites.
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PMID:Iatrogenic "respiratory acidosis" during laparoscopic preperitoneal hernia repair. 880 20

Understanding the complex multisystem dysfunction in the infant with a congenital hernia of the posterolateral diaphragm is still evolving and has changed radically during the last decade. The reduction in lung mass, in conjunction with surfactant deficiency and diminished compliance, leads to initial deficiencies in oxygenation and carbon dioxide (CO2) removal. This may then be potentiated by an extremely reactive hypoplastic pulmonary arterial system. Treatment no longer is focused on the operative repair but rather on the components of the pathophysiological process that are potentially reversible. Thus, extracorporeal membrane oxygenation and delay of repair until resolution of pulmonary artery hypertension have become mainstays of therapy and are probably responsible for increasing the survival rate in the patient who presents early with respiratory distress from 50% to 65%. Still far from acceptable, these results are giving impetus to new approaches to therapy including drugs such as nitric oxide, fetal intervention including open repair, and lung transplantation.
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PMID:Congenital diaphragmatic hernia: an overview. 893 50

Neonates with congenital diaphragmatic hernia (CDH) often suffer from respiratory insufficiency due to lung hypoplasia and pulmonary hypertension. Artificial ventilation is frequently required, and this leads to a high incidence of bronchopulmonary dysplasia. Long-term follow-up studies have shown persisting airway obstruction. To evaluate the long-term pulmonary sequelae in CDH, we studied 40 CDH patients of age 7 to 18 yr (median 11.7 yr) and 65 age-matched controls without CDH and lung hypoplasia who underwent similar neonatal treatment. Mild airway obstruction was found in both groups with more peripheral airway obstruction in CDH patients than in control subjects. Both groups had normal TLC and single-breath carbon monoxide diffusion capacity (DLCO). CDH patients had increased residual volume (RV) and RV/TLC compared with controls. Increased airway responsiveness to methacholine (MCH) was common but bronchoconstriction to inhaled metabisulfite (MBS) was rare both in CDH and control subjects. We conclude that this group of CDH patients has minor residual lung function impairment. Mild airway obstruction and increased airway responsiveness to inhaled MCH but not to MBS suggest that structural changes in distal airways are involved and not autonomic nerve dysfunction. Both artificial ventilation in the neonatal period and residual lung hypoplasia seem important determinants of persistent lung function abnormalities in CDH patients.
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PMID:Long-term pulmonary sequelae in children with congenital diaphragmatic hernia. 900 8

Several factors suggested to predict mortality in congenital diaphragmatic hernia (CDH) have not always been applicable in different centers. A retrospective review was conducted of 19 consecutive neonates in Singapore in whom CDH was diagnosed within 12 hours of birth to identify factors associated with mortality. Of the 19 cases, 15 (79%) were diagnosed using antenatal ultrasonography. Eight (42%) underwent primary repair at a median age of 23 hours (range, 12 to 50 hours). Of the 19 infants, 15 died (mortality rate, 79%). Survivors until hospital discharge were compared with nonsurvivors. Antenatal diagnosis and stomach position in left-sided defects had no effect on outcome, although polyhydramnios tended to be associated with nonsurvival. Significant postnatal factors associated with mortality included a low arterial pH level, low initial arterial-alveolar oxygen ratio, high initial alveolar-arterial oxygen gradient, as well as high oxygenation and ventilation indices. These results reflect difficulty in oxygenation because of pulmonary hypoplasia despite evidence of adequate ventilation. There was no difference between survivors and nonsurvivors in either their initial or best postductal blood gases. The "Bohn quadrants" did not aid in predicting survival of infants who underwent repair because all eight such infants had best postductal carbon dioxide values of less than 40 mm Hg and ventilation indices of less than 1,000. Yet only four (50%) survived until hospital discharge. Large-scale evaluation of these factors may be required in the future to demonstrate their validity and reliability because of changing management strategies for CDH.
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PMID:Mortality among infants with high-risk congenital diaphragmatic hernia in Singapore. 902 80

Pneumothorax was identified as a complication of endoscopic hernia repair in two patients with insufflation pressures of 15 mmHg and operating times exceeding 2 h. These patients also showed intraoperative perturbations in both oxygen saturation and end-tidal CO2 production. A prospective study was undertaken to determine whether similar complications would arise if preperitoneal insufflation pressures were limited to 10 mmHg. Postoperative chest x-rays were obtained on all patients to check for pneumothoraces, even clinically occult ones. Fifty patients were studied, with average operating times of 67 min. No patient demonstrated any hemodynamic or ventilatory changes, and none had any evidence of pneumothorax on x-ray. We conclude that these complications were not present when insufflation pressure was maintained at 10 mmHg and that routine x-ray is not warranted. Larger randomized trials of insufflation pressures are needed.
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PMID:Pneumothorax as a complication of laparoscopic inguinal hernia repair. 906 49

Hernia formation at trocar sites has been reported following laparoscopic surgical procedures. We present a case, however, of a healthy woman with signs, symptoms, and physical findings consistent with an incarcerated inguinal hernia 3 days after an uneventful laparoscopic cholecystectomy. Exploratory laparotomy revealed a small bile leak from an accessory duct of Luschka but did not identify an intra-abdominal process responsible for the patient's symptoms. Following the exploration, it was felt that the patient's presentation was likely due to tracking of carbon dioxide and bile-stained irrigation fluid to the right lower quadrant from the lateral laparoscopic trocar sites.
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PMID:Acute right-lower-quadrant mass presenting after laparoscopic cholecystectomy. 956 76

We have used an oesophageal Doppler to measure aortic blood flow velocity before, during and after induction of carbon dioxide pneumoperitoneum in 10 consecutive patients, mean age 58 yr, undergoing laparoscopic hernia repair. Derived values for stroke distance, minute distance and systemic vascular resistance showed considerable interpatient variation indicating unpredictable haemodynamic responses. Five minutes after insufflation of the abdomen there was a significant increase in mean arterial pressure from 82.5 to 103.6 mm Hg (P < 0.05) but both stroke distance and minute distance decreased significantly (mean 12.0 (SEM 1.4) cm to 9.0 (0.7) cm, P < 0.05; and 747.5 (82) cm min-1 to 596 (49) cm min-1, P < 0.05; respectively) indicating a significant decrease in cardiac output. There was a corresponding increase in the index of systemic vascular resistance from 1092 (747) to 2079 (400) (P < 0.05) which persisted after deflation of the abdomen. Oesophageal Doppler can provide continuous online haemodynamic data with a rapid response to acute changes and may have a role in non-invasive haemodynamic monitoring during laparoscopic procedures in older patients with cardiovascular disease.
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PMID:Assessment of cardiovascular changes during laparoscopic hernia repair using oesophageal Doppler. 917 64


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