flum verletzung

Schwerer Unfall beim Training von Eintracht Frankfurt: Nach einem Zusammenprall. Juni Das ist die Verletzungshistorie von Johannes Flum vom Verein FC St. Pauli. Auf dieser Seite werden Verletzungen sowie die Sperren und. 1. Dez. Frankfurt-Mittelfeldspieler Johannes Flum hat sich einen Bruch der Kniescheibe zugezogen. Das Training wurde abgebrochen, der. Es sah katastrophal aus. Wir empfehlen unseren kostenlosen t-online. Start Profis Flum-Verletzung schockt die Eintracht. Doch erst der letzte stoppte den Abwehrspieler. Trotz dieser enormen Leidensgeschichte kämpfte Bridesmaids Spielautomat von Microgaming – Jetzt gratis spielen sich immer lottogratis zurück und kommt Beste Spielothek in Kalchbergen finden Bundesliga-Spiele. Rangnick schimpft nach Leipzig-Pleite. Ein Passwort wird dir per E-Mail zugeschickt. Nonfatal technical complications included five bile leaks that required treatment. CBD injur y has been reported ranging betw een 0. Right nasal cavity of a patient having been subjected to a rhino-neurosurgical intervention for craniopharyngeoma with application of a naso-septal flap. From the patients perspective endonasal surgery for chronic rhinosinusitis can be considered effective [ 44 ]. Patienten mit einer GradVerletzung starben. The rate is about 1. Endoscopic endonasal sinus surgery makes up casino portoroz large part of routine operations of an otolaryngologist, being widely used as treatment for chronic rhinosinusitis. There were three postoperative fatalities 0. Seine Wunde trägt jeder nach heim! The aim of the study was to determine results obtained with LC at our setup. The increased intraorbital pressure is most likely to produce an Beste Spielothek in Machtsum finden upon the venous system [ 76 ], [ ], [ ].

verletzung flum -

Dies hatte eine MRT-Aufnahme ergeben. Daran aber konnte nach dem schweren Unfall keiner denken. Ich habe ihn total gern in der Mannschaft gesehen. Johannes Flum, ein kluger Kopf, hat nicht lange gezögert und einen bis datierten Vertrag beim abstiegsbedrohten Zweitligisten FC St. Diese multiresistenten Bakterien bekamen die Ärzte nicht mehr in den Griff, sodass Sammer nicht einmal mehr ohne Schmerzen Joggen konnte. Auch er fiel monatelang aus. Vielen Dank für Ihre Mitteilung. Die Rückkehr eines Totgesagten. Wulf Schwietzer war zur Unterstützung des Spielers in die Klinik gefahren. TV-Star trauert um Nichte Anzeige: Wulf Schwietzer war zur Unterstützung des Spielers in die Klinik gefahren. Auch er fiel monatelang aus. Sie nutzen einen unsicheren und veralteten Browser! Bitte halte dich in den Kommentaren an unsere Diskussionsregeln. Sein Beste Spielothek in Rogendorf finden Norbert Siegmann hatte ihm mit dem Stollen bei einer Grätsche den gesamten Oberschenkel aufgeschlitzt. Start Profis Flum-Verletzung schockt die Eintracht. Das teilte der Klub via Twitter mit. BVB — Atletico Madrid: Noch gar nicht so lang zurück liegt das Beispiel casino it Elkin Soto.

Flum Verletzung Video

Flum verletzt sich im Eintracht-Training Wulf Schwietzer war zur Unterstützung des Spielers in die Klinik gefahren. Doch auf sein altes Niveau schaffte es Concha nicht mehr. Medo seit Heute auch; von Flum gar nicht zu sprechen. Auch das Wadenbein wurde in Mitleidenschaft gezogen. An eine Fortsetzung seiner Karriere war in der Folge nicht mehr zu denken. Der wichtigste BVB-Star ist ein anderer. BVB — Atletico Madrid: Sein Gegenspieler Norbert Siegmann hatte ihm mit dem Stollen bei einer Grätsche den gesamten Oberschenkel aufgeschlitzt. Telekom empfiehlt Gratis-Aktion bis Frankfur schockt Nürnberg Vor Eintracht-Spiel: Frankfurt bejubelt Weiterkommen Frankfurt dank starker Offensive vorzeitig in der K. Trotzdem gibt der Mainzer nicht auf. Der damalige Bochumer wurde von Macchambes Younga-Mouhani 1. Der Winter kann kommen - neu bei Lidl.

Regarding inevitably larger defects after extended skull base surgery, local vascular pedicled flaps nasoseptal flaps [ ], flaps from the middle or inferior turbinate [ ], [ ] or, in special cases, also local flaps pericranial flap [ ], temporoparietal flap [ ], palatal flap [ ] are available [ ].

These flaps are superior to free grafts. The dorsal pedicled nasoseptal mucosal flap is most frequently used — postoperatively, however, due to the loss of large area of septal mucosa, un-negligible, long-term modification of the nasal physiology has to be taken into consideration [ ].

Mucoceles rarely develop in the sphenoid sinus after reconstruction with the nasoseptal flaps, even if the original mucous membrane has not been cleared out extensively before [ ], [ ].

The following factors are associated with an increased rate of unsuccessful reconstructions: The lowest rate of postoperative cerebrospinal fluid fistulas was observed in individual case series with a transcribriform approach, whilst the highest rate was observed in a transplanum-transtuberculum approach.

This is caused by a relatively high flow rate of cerebrospinal fluid due to open suprasellar or chiasmatic cisterns. Additionally the dense anatomy prevents the inserted grafts from adapting naturally [ ].

Other authors report a less favorable prognosis for large-area defects of the anterior base of the skull [ ]. Opinions differ as to whether, even after rhino-neurosurgical operations, there is any indication to provide a lumbar drain after reconstruction of the skull base.

In most cases this is decided individually, supporting a drainage in cases of large defects, heavy cerebrospinal fluid flow or increased cerebrospinal fluid pressure, history of radiotherapy or already preoperatively existing liquorrhea [ ], [ ].

An early drainage can help to relieve pressure variations within the area of transplantation during extubation [ ]. In a medico-legal respect , when cerebrospinal fluid fistulas are found in close proximity to radiologically normative ethmoidal cells, discussions often arise on whether an extended surgery is necessary, i.

As a matter of principle, in each individual case, the extent of the surgery has to be justified from a medical perspective and carefully documented and discussed with the patient.

In case the whole range of manipulations is used up within the boundaries of what had been discussed with the patient before, it is recommended to include an explanatory statement in the operative report.

The findings in preoperative imaging and preoperative endoscopic examination can be different [ ], [ ]. Hence, preoperative imaging does not determine the scope of the surgical procedure restrictively.

The surgeon should in fact remove diseased tissue according to intraoperative findings. In general, localized cerebrospinal fluid fistulas cannot always be avoided, even when the procedure is carried out very carefully [ ].

Functional endoscopic sinus surgery is always tailored to the anatomy of the individual and is not strictly standardized. This issue makes it difficult to analyze surgical results as well as define deficiencies in surgical technique — e.

Postoperatively the individualized anatomy is distorted in the process of healing — intranasal wounds generally undergo secondary healing.

The respective prospects of healing are less favorable for certain patient groups e. After complete ethmoidectomy, the ethmoid shaft scars and shrinks, which is proven radiologically.

In experiments with young animals, midfacial growth had changed postoperatively see 5. For the purpose of prevention, placing mucosal grafts onto the exposed bone in order to avoid a reactive ostitis with secondary thickening of the bone, is recommended [ ], [ ], [ ], [ ].

In principle, the size of an enlarged primary maxillary ostium is not decisive for the condition of the maxillary sinus mucosa; at a diameter of more than 2 mm these ostia are generally function normative [ ].

Synechiae represent a more complex problem. Hence, they are often not mentioned in statistics regarding complications [ 63 ], [ 76 ].

The benefit of special postoperative follow- up in order to optimize healing is partially questioned [ ], [ ], [ ].

On the contrary, the benefit of this treatment for prophylaxis of adhesions and synechiae is stressed by other sources [ 98 ], [ ], [ ], [ ], [ ].

Especially in differentiated and extended surgeries, e. A routine administration of antibiotics does not improve the result [ ].

Non absorbable nasal packing can help to avoid synechiae or adhesions [ ]. Specific placeholders have been developed with the same intention [ ].

Despite of a well-intended fenestration in the middle or, in rare cases, also the inferior nasal meatus, persistent symptoms arise in the corresponding maxillary sinus [ ], [ ] Figure 2 Fig.

Treatment comprises the microsurgical unification of the two ostia with excision of the uncinate process.

The treatment again, consists in a surgical unification of the ostia see above. Preserved, intact uncinate process and persistent obstruction of the natural maxillary sinus ostium due to mucosal edema of the neighbouring mucosa.

The use of a shaver prevents this development [ ]. CT-scan of a patient having been subjected to anterior ethmoidectomy.

Lateralization of the right sided vertical lamella of the middle turbinate causing inflammatory retentions in the ethmoidal cavity.

The lateralization of the vertical lamella of the turbinate with its possible adverse effects, e. This may be performed especially in case of an evidently fractured or destabilized vertical lamella during surgery.

Nevertheless, many authors approve of conserving the turbinate [ ], [ ], [ ]. The rate of recurrent nasal polyposis was lower [ ] and there was a tendency of improved olfactory function [ ].

The number of lateral synechiae also decreased, although the synechiae developing during therapy in spite of partial resection were more challenging [ ], [ ], [ ].

In human anatomy the exact dimension of the olfactory region is unknown. In general, postoperative smell deficits may occur after direct mechanical trauma, after removal of olfactory mucosa accompanied by scarification of the latter, caused by a progressive inflammation of the mucosa or even by a postoperative modification of the nasal air passage.

A partial resection of the lower third of the anterior middle nasal turbinate does not affect the ability to smell - in routine resections, there was no evidence of olfactory mucosa in the surgical specimens [ ].

On the other hand, a complete postoperative anosmia was reported, following a resection of the superior nasal turbinate that was done by mistake [ ].

Olfactory fibers in the turbinate bone can also be damaged without any resection, e. After surgery, many of these patients can expect an improvement or a normalization.

For medico-legal reasons, these circumstances suggest that a preoperative measure of olfactory ability should always be performed.

After extensive nasal surgery, secondary atrophic rhinitis may develop Figure 4a Fig. Literature focuses on consecutive states of excessive surgical procedures performed on the inferior nasal turbinate [ ].

However, such an iatrogenic, secondary atrophic rhinitis can also develop after extensive and usually recurrent sinus surgeries, with removal of larger areas of mucous membrane and resection of the middle or superior nasal turbinate.

Right nasal cavity of a patient having been subjected to a rhino-neurosurgical intervention for craniopharyngeoma with application of a naso-septal flap.

Patients complain about a paradox nasal obstruction, in the presence of an objective wide inner nose. Further symptoms are dyspnea, a dry feeling in nose and pharynx, hyposmia and depression.

If the sphenopalatine ganglion is intensively exposed towards nasal airflow after extensive tissue resection, additional pain may be caused.

For unknown reasons, only very few patients develop an ENS after generous resection of turbinate tissue apart from the inferior turbinate - possibly due to the fact that due to the underlying chronic rhinosinusitis, hyperplastic mucous membrane often forms postoperatively.

ENS often develops with a latency period of several years postoperative [ ], [ ], [ ], [ ], [ ], [ ]. In oncological surgeries of the maxillary sinus, the only precaution which can be taken consists in a temporary displacement of the inferior turbinate [ ], [ ].

In routine surgery of chronic rhinosinusitis, the rate of postoperative atrophic rhinitis is roughly between 0.

Therapy is mainly conservative, based upon intensive moistening, local care with the administration of ointments or oils [ ], [ ].

Rhino-neurosurgical procedures often lead to a serious, long-term and substantial restriction of postoperative nasal physiology [ ], [ ].

As a matter of principle, an irritating crust formation, accompanied by a restricted nasal physiology, occurs in up to one third of all cases [ 42 ], [ ].

Attaching laminar, pedicled mucous membrane flaps to the nasal septum adjusts this dysfunction [ ]. The extremely irritating crust formation lasts for at least days [ ].

Further possible consequences are synechiae, septum perforations, burns or mechanical skin damage at the nasal vestibulum caused by drills and other instruments [ 42 ], [ ].

In a rather aggressive mode of preparation or when electrosurgical measures are applied in the maxillary sinus, an injury of the infraorbital n. Bony dehiscences in the channel of the infraorbital nerve increase the risk of such a complication.

As a consequence, facial sensibility is affected postoperative [ 76 ], [ ] Figure 5 Fig. The same applies to the alveolar nerves.

In justified individual cases of endonasal procedures, a complementary, localized transoral puncture of the maxillary sinus is recommended in order to remove hyperplastic mucosa in hidden anatomical areas, e.

In an adverse case, a branch of the infraorbital n. A relatively safe location for a complementary puncture is the intersection of two reference lines, i.

In transpterygoid rhino-neurosurgical approach, amongst others, the maxillary or the vidian n. Past references depict single cases of severe orbital complications of vidian neurectomy.

Recent literature only reports occasional cases of e. Concerning the orbital haematoma, the slowly developing, venous hematoma is distinguished from the comparatively fast evolving arterial hematoma [ ].

The incidence of orbital hematomas is around 0. With right handed surgeons, orbital complications are supposed to occur more often on the right side, whilst other authors report a preference of the opposite side [ ], [ ].

A threatening venous bleeding is mostly observed with a delay, i. It is safe to assume that an accumulation of 5 ml of blood can already lead to a dangerous intraorbital increase in pressure, causing a loss of vision.

Therefore, even in case of seemingly slightly developed orbital hematomas, vision must be controlled repeatedly.

A simultaneous control of color vision is recommended — here, restrictions occur in a relatively early stage [ 76 ], [ ]. As a basic principle, cooling compresses are applied and the top end of the bed is raised [ ].

In case of threatening development, an emergency ophthalmic consultation is recommended. Nasal packing is removed and the intraocular pressure is measured.

The digital ocular massage is recommended various times in literature; it is, however, contraindicated in patients with illnesses of the bulbus and is debatable even in patients without a special ophthalmological anamnesis see below.

Further conservative treatment and possibly surgery as therapy of threatening venous hematoma is identical to the therapy for arterial bleeding [ ], [ ].

The retrobulbar hematoma as an arterial bleeding with a swift increase in intraorbital pressure is dreaded Figure 6b Fig.

It appears intraoperatively and often even with delay, e. Literature points out rare cases of a hematoma occurring hours later — for outpatient surgery, this has to be taken into consideration [ ].

Patient revealing major right-sided intraorbital hematoma in the course of ethmoidectomy. Lateral canthotomy and also inferior canthoysis have been performed.

Consequently a progressive proptosis with chemosis, pain, congestion of the conjunctival vessels and, eventually, ecchymoses or subconjunctival bleeding develops.

During palpation, a distinct resistance of the orbital tissue is felt and an increased intraocular pressure is noticed.

Ocular motility is disturbed and the pupil reaction is pathological in side comparison, reduced or absent pupil reaction , resulting in visual field loss and loss of vision.

The orbital hematoma is a clinical diagnosis. It is not necessary to wait for a radiological confirmation [ ]. The most frequent cause is an injury of the anterior ethmoidal a.

Alternatively, the blood vessel is pulled out of its bed at the base of the skull, together with the onset of the vessel inside the orbit [ 82 ].

A similar event rarely occurs in the posterior ethmoidal a. There is a risk of blindness, though the pathogenesis is not completely clear: A pressure-related occlusion or a spasm of the ophthalmic or the central retinal a.

Other mechanisms are a blockage in the blood flow of the posterior ciliary arteries, caused by pressure or tension.

The increased intraorbital pressure is most likely to produce an effect upon the venous system [ 76 ], [ ], [ ]. According to literature, in case of imminent loss of vision, a maximum duration of about 90 minutes remains until definite amaurosis.

This basically depends on the ischemic tolerance of the retina [ 68 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. A pressure-related interruption of the axonal transport in the optic n.

In animal testing, slightly longer durations — about minutes were determined for the retina [ ], [ ]. Individual factors among others, a preexisting subclinical vasculopathy and anatomical factors can generally strongly modify the tolerance of the organism in regard to an increase in orbital pressure [ ].

The dynamics of the increase in pressure may also play a role [ 76 ]. As animal testing for orbital hematoma cannot be easily standardized, it is sometimes problematic to transfer the scientific findings to humans [ ].

Sinus surgeons should have a clear action-algorithm in the case of an orbital hematoma. In principle, there is no solid proof of effectiveness regarding conservative treatment.

Analogies from traumatology form the basis for the recommendations, partly any effect is denied [ 71 ], [ 82 ], [ ], [ ], [ ].

The regimes are variable, e. Partly acetazolamide is prescribed in a lower dose or administered for longer periods — mg i.

In individual cases, the therapy with cortisone is based on other substances e. The indication for a surgical approach is often discussed in literature on the basis of an objective measurement of the intra-ocular pressure IOP [ ], [ ].

However, in daily routine the indication mainly takes place clinically, the pressure conditions can be estimated via comparative bilateral palpation [ ], [ ], [ ].

With individual differences, the orbital pressure is approx. Generally surgery of the paranasal sinuses has no effect on the intra-ocular pressure [ ].

Emergency indication for canthotomy and cantholysis is assumed for an IOP above 40 mmHg [ ], [ ], [ ], [ ], [ ].

In different references, surgery is necessary if the intra-ocular pressure IOP is higher than the mean arterial pressure minus 20 mmHg [ ].

Lateral canthotomy results in a reduction of the intra-ocular pressure by approx. An orbital decompression may cause an additional pressure reduction of 10 mmHg [ ].

With complementary measures e. Lateral canthotomy with cantholysis is an emergency procedure. It is simple and every sinus surgeon should be able to handle it.

The surgery can take place almost everywhere e. At first a straight, small vascular clamp is placed from the lateral canthus towards the border of the bony orbit between the upper and lower eyelid and is compressed.

To restrict surgery merely to this horizontal incisure is not recommended by the majority [ ], [ ] — the inferior and, if necessary, the superior cantholysis should complement canthotomy.

The lateral inferior palpebral ligament between conjunctiva and external skin of the eyelid is identified during the inferior cantholysis.

The palpebral ligament is completely dissected in caudal direction — during this process, it is repeatedly identified by palpation.

The immediate release of the inferior eyelid is noticed when the forceps is held into place with a certain tension at the lower eyelid [ ], [ ], [ ], [ ], [ ], [ ].

Many authors suggest to perform the canthotomy [ ], [ ], [ ] followed by inferior cantholysis only. Others recommend an additional incisure of the upper palpebral ligament if the canthotomy with inferior lysis is not effective [ ], [ ], [ ], [ ].

It is important to consider that the effects of this procedure are limited in time [ ]. If the angle of this protrusion is less than degree, the eye is definitively at risk [ ] Figure 7 Fig.

As a rule, however, the wound is sutured with a delay of 2 to 5 days, e. For secondary reconstruction of the lateral palpebral ligament, the special anatomy of the anchorage of the lateral canthus must be considered [ ], [ ], [ ].

Regarding prognosis it is known from traumatological literature that the risk of permanent blindness with manifest retrobulbar hematoma with accompanied loss of vision is approx.

Vision recovery takes place within a time frame of approx. Prognosis for younger patients is better [ ].

As a consequence the intra-ocular pressure was raised up to a pressure level of 54 mmHg IOP. Canthotomy and inferior cantholysis reduced the pressure to 32 mmHg and there were no relevant permanent damages [ ].

In other cases, a paraffinoma may develop especially within the region of the eyelids after a sinus operation. In the event of a often minimal injury of the lamina papyracea with a often mild orbital haemorrhage and if a paraffinic nasal packing ointment strip or ointment is inserted into the nose the paraffin can be absorbed via the mucosal wound in individual cases and transported via blood into the soft tissue of the orbit, respectively eyelids.

In rare cases, the inflammation continues as sclerosing lipogranulamatosis or as orbital pseudotumour, in a rare case this may lead to the development of a sinogen orbital phlegmon.

Spontaneous, partial regressions are rare. Classic paraffinomas should not occur any longer due to modern types of nasal packing in use and due to tendencies to disclaim packing at all.

Despite this fact, appropriate casuistic case reports still exist [ ], [ ], [ ], [ ], [ ], [ ]. If the history of the patient does not include a sinus operation, differential diagnoses are, among others: Two special cases of a lipogranulomatous tissue reaction were reported 2 to 14 days following an endonasal sinus operation, where no oily material was inserted.

There was a palpable tumour of the eyelid, eye movement disorder and proptosis. The granulomas were externally removed by surgery and oral corticoids and also an antibiotic were administered.

Concerning pathogenesis, an intraoperative injury of the orbit with focal fat necrosis and a consecutive tissue reaction on extracellular fat were assumed [ ].

The treatment of paraffinomas is surgical excision. A complete resection is usually impossible because of the diffuse tissue infiltration [ ].

Myospherulosis is related to the paraffinoma. It corresponds to a foreign body reaction of the mucosa to ointments containing lipids.

Typical aggregates of erythrocyte residuals are histologically found in the vacuoles. Factors that predispose the development of myospherulosis are not yet clarified.

Patients tend to present a higher rate of postoperative synechia leading to a high number of revision surgeries [ ].

Myospherulosis granulomas also may form within the area of the eyelid following sinus surgeries with intraoperative haemorrhage of the eyelids and perioperative use of nasal packing with ointment [ ].

The microanatomy of the pterygopalatine fossa and the sphenopalatine foramen plays an important role in sinus surgery [ ]. Further terminal branches of the maxillary a.

If the routine opening of the maxillary sinus in the middle nasal meatus is systematically enlarged in dorsal direction, up to the level of the posterior wall of the maxillary sinus, then, in individual cases, it will be necessary, for anatomical reasons, to cut through a branch of the sphenopalatine a.

Bleeding from the root of the sphenopalatine a. During extended surgical procedures in the area of the infratemporal fossa severe bleeding from the maxillary a.

Instructions to identify the sphenopalatine a. In rare cases, a pseudoaneurysm may form as a result of an injured sphenopalatine artery.

It was discovered 13 days after sinus surgery took place, which is quite early. The authors prefer embolization rather than targeted endoscopic treatment clipping of the maxillary a.

When entering the sphenoid sinus, the surgeon encounters the septal branch of the sphenopalatine a. In the area of the anterior wall of the sphenoid sinus, it is mostly divided into three branches which supply the nasal mucous membrane [ ].

Within the scope of ENT routine surgery, an electrosurgical handling of this vessel is possible without any complication.

In case or repeated perioperative bleeding, angiography with selective embolization will only be performed in extremely rare cases [ ], [ ], [ ], [ ].

This applies especially for embolization in case of a treatment-resistant nose bleeding after routine sinus surgery when the source of bleeding does not evolve the internal carotid artery.

The exposure of radiation during embolization is relevant around 18 minutes in single series. The pharyngeal ramus of the sphenopalatine a. It is a rare source of bleeding, e.

The anterior ethmoidal a. In some of the cases the artery is located directly in the area of the osseous skull base, and more frequently ca.

According to anatomical studies, the anterior ethmoidal a. Arteries at risk are those with a larger distance to the skull base, arteries with bony dehiscences or those running within a ground lamella [ ].

Lateral injuries in the area of a funnel-shaped, medial-directed protrusion of the orbital wall can result in a threatening orbital hematoma, after retraction of the vessel stump see above.

It is situated in the level below the superior oblique m. If the artery has been injured and is bleeding into the ethmoidal cavity, a bipolar or monopolar coagulation is generally used to stop the bleeding [ ].

Many authors avoid the monopolar coagulation at the skull base due to possible secondary damage to the meninges [ ], [ ], [ ]. Alternatively, clips are suggested, which, however, are not always effective, due to anatomical reasons [ ], [ ], [ ].

With a diameter of ca. The distance between the anterior and the posterior ethmoidal artery is approximately 10—14 mm and the distance from the latter to the optic nerve as well as to the anterior wall of the sphenoid is about 8—9 mm [ 12 ], [ ], [ ], [ ].

In a coronal CT, a tip-like protrusion of the medial orbital wall at the location of the posterior ethmoidal a. As a general rule, the posterior ethmoidal a.

A case report depicts a secondary orbital hematoma without significant proptosis, but with blindness [ ]. A subperiosteal orbital hematoma with visual impairment should be equally rare — symptoms were reversible after an emergency hematoma decompression [ ].

Uncomplicated hemorrhages in the posterior shaft of the ethmoid bone are treated with electrocoagulation [ ]. There are important neighbouring anatomical structures, especially the optic n.

The distance between the internal carotid a. Surgery performed in the sphenoid sinus requires sufficient preoperative diagnostic measures based on cross-sectional imaging [ 95 ], [ 97 ].

Particularly in the axial CT, significant anatomical details or variants are displayed: In principle, the carotid a.

Dorsally, another prominence of the artery can occur in the lateral wall of the sphenoid sinus.

The bony canal of the artery is 0. The exact incidence rate of carotid injuries in paranasal sinus surgery is unknown.

According to literature, carotid artery injuries occur with a rate of 0. In the last mentioned operations, the risk increases considerably in revision surgery, after radiation therapy or if there is a tumor infiltration of the carotid [ ].

In routine paranasal sinus surgery, the most frequent defect site of the carotid a. In the scope of extensive rhino-neurosurgical procedures, further sources of bleeding, also from smaller branches of the carotid a.

As a matter of principle, every ENT surgeon and every clinic should therefore have clear action plan at hand for the emergency of an internal carotid a.

For paranasal sinus surgery, the following measures are recommended in case of an injury of the cavernous internal carotid a Revision surgery of the respective sphenoid sinus revealing a partly exposed coil green arrow: Additionally, the arterial injury can no longer be identified in the angiographic image, so that the otolaryngologist has to loosen the nasal packing and the angiography is repeated [ 95 ], [ ], [ ], [ ].

Due to the former reason the otolaryngologist should be present during neuroradiological diagnostics and intervention [ ].

In case of a very small lesion in the carotid vessel — provided appropriate local conditions, sufficient medical status of the patient and capabilities to pack the nose repeatedly — the surgeon should at first create an optimum access to the sphenoid sinus.

The placement of an autologous muscle graft or allogenic material is recommended. This construction is fixed with fibrin glue and is tightened with packing.

Alternatively, under favorable conditions, a specific vessel clip may be used [ 97 ], [ ]. Occasional reports point out that such a supply was permanently successful preserving the arterial circulation [ 96 ].

For this reason an angiography is indicated postoperatively [ 95 ], [ 97 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ].

In case of an aneurysm secondary neuroradiological treatment is performed. During a primary neuroradiological intervention after an accidental lesion of the carotid a.

Here, specific complications, such as a vessel dissection, thrombosis, embolism or a vessel perforation have to be kept in mind. Balloons can get displaced and then may increase the risk of new bleeding.

Postoperatively, patients with vessel stents receive anticoagulant drugs Clopidogrel, ASS mg [ 95 ], [ ], [ ], [ ], [ ], [ ], [ ]. Within the first 24 hours after the neuroradiological intervention, a CCT control should be performed.

Later on a control angiography should take place [ ], [ ]. The defect site in the sphenoid sinus should be covered secondarily, for example with fascia [ 95 ] Figure 9 Fig.

Hemorrhages from the cavernous sinus are mostly much less demanding. Bleeding is interrupted by placing hemostatic material directly and applying smooth pressure.

The material is inserted, covered with neuro-cotton wool and lightly pressed [ ]. In principle, hemostasis during rhino-neurosurgical procedures as well as during sinus surgery is based upon bipolar coagulation, compression, nasal packing or ligature as well as upon the application of clips.

However, in case of an exposed dura, a sufficient compression is not always possible and an external nasal packing additionally creates the risk of bleeding in intracranial direction.

Immediately after the incidence, a second suction is introduced into the operating field and the endoscope is directed to a protected place; if applicable, equipped with a rinsing and suction device.

In favorable individual cases, it might be possible to direct the jet of blood into the suction, to display small lacerations of the artery and to fuse and glue them by means of bipolar coagulation [ ], [ ], [ ].

The use of an intraoperative Doppler is recommended as a measure of prevention [ ], [ ]. If an ordinary hemostasis is not successful, further nasal packing is applied and an emergency transfer of the patient to the neuroradiological ward is carried out [ ].

The prognosis of an injury of the carotid a. An injury of the carotid a. This condition is treated through neuroradiological intervention [ 89 ], [ ], [ ].

Even after a successful occlusion-test complications following the definitive occlusion cannot be excluded [ 95 ], [ 97 ], [ ], [ ].

In this regard, very different frequencies are found in literature: The average bone thickness in the direction of the sphenoid sinus is 0. Hence it is even more important to look out for a history of previous eye defects preoperatively.

Perioperatively, this damage might only appear to deteriorate, e. As a consequence, unnecessary emergency measures might be taken, even medico-legal problems might arise [ ].

Perioperative blindness in paranasal sinus surgery occurs in case of a direct injury of the nerve, a drug-induced interruption of local blood supply or a hematoma in extremely rare cases also by an emphysema, see above or in case of damaging the central nervous system, as, for instance through meningitis [ 76 ].

Direct mechanical damage to the optic nerve is only reported in exceptional individual cases [ ], [ ]. Here, during removal of the covering bone, the nerve can be damaged or destroyed in the cranial, lateral wall of the sphenoid sinus [ ] or within the orbit [ ].

In other cases, injuries of the optic n. A case report of a severe, direct injury of the eyeball across the lamina papyracea caused by an electrosurgical tube without direct nerve damage seems to be exceptional [ ].

In case of an injury of the optic n. Compared with direct lesions, indirect injuries of the optic nerve caused by a retrobulbar hematoma occur more frequently [ 83 ], [ ].

Loss of vision as a complication of adrenaline-soaked e. Adrenaline resorption with consecutive spasm of the vessel network around the optic n.

After every postoperatively noticed or supposed visual reduction, an ophthalmological emergency consultation should occur.

MRI is strongly recommended [ ]. After mechanical injury of the nerve, collateral damage has to be searched for, e. If the optic n.

Even if nerve continuity is preserved, the immediate treatment of the perioperative visual reduction is problematic. The regimen is individualized and is under ophthalmological guidance.

If neurapraxia or a hematoma is suspected, a high dose corticosteroid treatment is followed out e. The concept is aligned to the treatment of traumatic optic neuropathy — evidence of which, however, still remains a subject of debate [ 71 ].

Traumatology and neurology provide some experimental evidence to suggest that corticosteroids may also hinder the restitution of an optic nerve [ ], [ ], [ ], [ ], [ ].

In specific cases, decompression of the nerve may be discussed — however, its benefit has not been proven yet [ 12 ], [ 76 ]. Under certain, adverse conditions, the symptoms of an ischemic optic-neuropathy may appear within the scope of sinus surgery, a disease of which little is known.

In these rare cases, neither mechanical injury of the nerve has occurred nor has the lamina papyracea been damaged. The exact pathogenesis is not yet known.

The resulting loss of vision or visual field reduction emerges immediately or with a delay of several hours to days.

MRI displays a vaguely defined and swollen optic n. A decompression of the optic nerve does not always seem appropriate.

Administration of cortisone e. An immediate normalization of blood pressure and hemoglobin by means of transfusions seems essential [ ].

A case report described residual ethmoidal cells revealing opacification. An emergency revision surgery was performed with decompression of the orbit and periorbital incisure.

Additionally, high dose corticosteroid treatment Prednisolone mg intravenously and calculated antibiotic treatment was initiated. Within a period of 4 weeks the condition of the patient improved.

In another case, the optic n. These two cases were interpreted as a consequence of an infectious impairment of the optic n. In endonasal surgery of the paranasal sinuses, an impairment of the medial rectus m.

In general, these injuries result of a fracture of the inferior lamina papyracea with perforation, destruction or incarceration of the muscle.

The middle or posterior ethmoid is most at risk — as hardly any fat is situated between the muscle and the bony orbital wall [ 76 ], [ ], [ ], [ ].

In rare cases, there is a particular risk due to a congenital or posttraumatic bulge of the lamina papyracea with or without direct embedding of parts of the muscle [ ], [ ].

Other eye muscles are distinctly less often injured intraoperatively: The inferior rectus muscle may be damaged in surgeries involving the maxillary sinus and the superior oblique trochlea muscle may be lacerated in extended endonasal frontal sinus surgery with a drill for instance.

Injuries of the inferior oblique m. In the majority of cases, only one eye muscle is damaged, with a relevant orbital hematoma developing additionally in one quarter of patients.

Occasionally, however, severe combined damage affecting three muscles, for example, has been observed with additional bleeding, retinal damage or lesions of the optic n.

Generally 5 typical causes for a postoperative motility disorder of the eye may be distinguished:. Muscle tissue that is surprisingly evident in routine histologic specimens Figure 10 Fig.

In general, periorbital damage should be detectable intraoperatively by means of the bulbus pressure test [ ]. If, beyond that, intraoperatively suspected eye muscle damage occurs, an ophthalmologist should be notified and consulted immediately [ ], [ ].

With few exceptions, diplopia appears immediately after the operation as a result of the injury [ ]. All relevant findings should be submitted immediately for evaluation by means of imaging.

The clarification of an eye muscle injury with displacement or incarceration or the display of a contraction of the dorsal muscle parts most likely succeeds after complete sectioning with a contrast-enhanced MRI; evaluation is done in three planes.

At best, multipositional MR imaging might allow to draw conclusions about the contractility of the muscles. In the further course, a repeated MRI may also document stages of repair, as swelling of muscle tissue is followed by atrophy.

Other sources recommend a CT as initial diagnostic measure for all orbital complications, as differentiated analysis of the injury is hindered initially through hematomas and accompanying edema [ 71 ], [ 76 ], [ ], [ ], [ ], [ ], [ ].

Generally, the findings of CT and MRI correlate well with the ophthalmological functional examinations [ ]. Regarding treatment of acute, iatrogenic eye muscle damage, an early surgical intervention should be performed within 1 to 2 weeks, if a muscle was completely intersected or if an incarceration of tissue or a skewering of bone fragments into the muscle is suspected clinically or via imaging [ 71 ], [ ], [ ], [ ].

A reconstruction of the medial rectus m. In case of excessive destruction, a muscle transposition might be sought; alternatives are graft interpositions or specific suturing techniques [ ], [ ], [ ], [ ].

In order to exclude corresponding damage in revision surgery, aggressive orbital dissections should be avoided during further surgical therapy [ ]. Reconstruction of the medial orbital wall directed to the ethmoidal cavity, using alloplastic material, often cannot prevent a secondary, bothering scar formation [ ], [ ].

In individual cases, an immediate cortisone therapy is applied in an effort to minimize the inflammatory response of the orbital tissue [ 71 ].

In case of partial damage, literature recommends both an observant and an active approach [ ]. Contractures of the antagonists of damaged muscles can already be observed after 2 weeks.

Especially in cases of severe injuries, revision surgery performed before fibrosis begins to occur, i. In contrast, spontaneous improvements were observed within a period of three months after slighter neuronal, vascular or direct muscle damage [ 71 ], [ ], [ ].

By means of botulinum toxin injections into the antagonists of damaged muscles, diplopic images can be improved faster, a secondary contracture of the antagonist is prevented and the traction force applied to the damaged muscle is reduced.

For reasons which are not fully known, the injection can make a positive contribution to a long-term functional alignment of the extraocular muscles [ 76 ], [ ], [ ], [ ].

In appropriate cases, the injection is combined with a surgical muscle reconstruction [ ], [ ]. Other forms of impairment are treated conservatively in the beginning [ ].

If the muscle is only affected by bruising, neural or vascular damages, it may be justified to wait for 3—12 months [ 71 ], [ ], [ ].

Two to three months after a damage caused to the medial rectus m. In two thirds of cases, several operations will be necessary [ ], [ ].

Extremely severe damages of the ocular muscles and the orbital tissue have been reported after the use of the microdebrider [ 71 ], [ 76 ], [ ], [ ].

The medial rectus m. This may also occur without any prominent orbital injury. Often the surgeon is not even aware of the damage. The perforation in the lamina papyracea may be difficult to identify, even in postoperative imaging [ 17 ], [ 71 ], [ ], [ ], [ ].

In other cases, motility limitations can be distinctly higher than the damage seen at imaging. After injuries caused by the shaver, chances to reconstruct the medial rectus muscle successfully are rather limited [ ].

In rhino-neurosurgical operations, especially in the parasellar and suprasellar region, in the area of the cavernous sinus or the clivus, thermal injuries or transections may lead to injuries of the abducens n.

Frequently the oculomotor nerve recovers postoperatively from damages as long as the continuity of the nerve is preserved [ ]. For various reasons, a mydriasis can occur during paranasal sinus surgery:.

In individual cases, pupil differences without pathological substrate can occur during anesthesia. In a small percentage of the population, an observable anisocoria i.

Under general anesthesia, the light reflex cannot be judged. Therapy with opiates e. Fentanyl leads to miosis which, however, can decrease, due to an intraoperative sympathicus stimulus.

Individual factors affect the size of the pupils during extubation; in some cases even, side differences, lasting about 20 minutes may occur during this process.

Based on the described circumstances, a number of recommended precautions can be deduced:. During the operation, the eyes should always remain free from textile covering.

The scrub nurse should get used to control the eye from the outside while surgery continues in the inside of the nose.

Hence complications are indicated by a passive concurrent movement of the globe and can be noticed early.

Generally, a serious acute narrow angle glaucoma can be triggered by sympathomimetica in predisposed patients [ ].

The placeholder had perforated the dorsal orbital apex and caused permanent changes in the pupils. Even an emergency revision surgery with removal of the foreign material did not result in an improvement [ ].

Paranasal sinus surgery, in the broader sense, with extensive removal of the mucosa can cause a scarred distortion of the entire ethmoidal cavity in adults, combined with a medialization of the lamina papyracea.

These transformations can be identified by postoperative imaging and may be associated with a subclinical enophthalmos [ ], [ ].

In children, after paranasal sinus surgery, a postoperative hypoplasia of the maxillary sinus with no external changes was described radiologically [ ].

After unilateral ethmoidectomy in a pediatric case of an imminent orbital complication, merely a minimal facial asymmetry was visible in the postoperative CT [ ].

A similar case of a postoperative scarred stenosis of the maxillary ostium and a secondary maxillary sinus atelectasis with postoperative enophthalmos 3 mm was also observed in an adult patient [ ].

Studies in traumatology revealed that even with minor injuries 0. Individual cases are reported which tend to concur with this observation, describing a postoperative enophthalmos after injury of the medial orbital wall and the medial rectus m.

Surgeons performing a paranasal sinus operation should be familiar with position and size of the efferent lacrimal ducts: In half of the cases, the lacrimal sac is covered by parts of the agger nasi and in almost two thirds of all cases, the uncinate process is overlapping the lacrimal sac [ ].

The distance between the free edge of the uncinated process and the anterior edge of the lacrimal sac is 5 mm 0—9 mm [ ], for the maxillary sinus ostium the distance is approximately 4 mm 0.

The lacrimal bone is very fragile, compared to the frontal process of the anterior maxilla. Epiphora develops in about 0.

Under favorable circumstances, such cases correlate with an unintended dacryocystorhinostomy [ ], [ ], [ ] Figure 11 Fig.

An injury mostly occurs during infundibulotomy uncinectomy , during surgery on the anterior frontal recess or during maxillary sinus fenestration in the anterior middle nasal passage — in the latter, particularly during the use of the backward cutting punch [ 71 ], [ ].

Injuries occurring during a fenestration in the inferior nasal meatus should have become rare [ 91 ].

During the course of a routine sinus operation, frequently parts of the lacrimal bone or parts of the frontal process of the maxilla are removed in an undirected manner, without any direct malfunctions resulting.

In right handed surgeons, the left side is supposed to be affected more frequently [ ]. Pressure applied on the medial angle of the eye under endonasal endoscopic control can help to identify the tissue of the lacrimal sac and to prevent it from damaging during further manipulations [ ].

After a relevant lesion of the efferent major tear ducts, the symptoms appear directly after the operation or with a delay of weeks. Postoperative epiphora can subside spontaneously if the inflammatory reaction caused by the surgery has decreased [ 68 ], [ ].

Each patient with postoperative epiphora should be examined thoroughly. In case of doubt, an ophthalmologist should be consulted. There are often no direct consequences and the patient is kept under observation.

If after one week, epiphora is still present, advanced diagnostic measures are indicated. In special cases, a CT with dacryocystogram can produce additional information.

The treatment of symptomatic iatrogenic lacrimal duct stenosis in general is dacryocystorhinostomy [ 98 ], [ ], [ ].

Success of the operation may be limited due to an insufficient position or size of the lacrimal duct fenestration, combined with portions of bone or remains of the medial lacrimal sac left behind.

During the first 4 weeks after the operation, the intranasal neo-ostium is shrinking regularly and then remains stable. The result of the surgery is affected by an excessive scar formation or enhanced granulations, for instance after extensive resection of mucosa.

Further causes are synechiae, e. Irregular scars can trigger frontal sinusitis. Mechanical rinsing of the tear ducts from outside is retained in these cases [ ], [ ], [ ], [ ], [ ].

Skin injury in the medial corner of the eye should be extremely rare, additionally, retrobulbar hematomas, eye muscle injury, burns at the nostril, stenosis of the canaliculi or conjunctival fistulas may occur [ ].

The same applies for a case report of a cerebrospinal fluid fistula during the mechanical reclination of a deviated nasal septum for the purpose of exposing the lacrimal ducts [ ].

If splints for lacrimal ducts stents are applied intraoperatively, this may result in a conjunctival irritation for example, the formation of a loop , secondary injury of the lacrimal punctum or a premature loss of the splinting [ ].

In individual cases, problems arise during or after removal of the splint, e. In case of doubt, an inefficient dacryocystorhinostomy should be followed by endonasal revision surgery.

Depending on their location, synechiae can be treated by a reduction of the tip of the medial turbinate or even correction of the nasal septum [ ].

Patients should be reminded that postoperatively, even after a successful surgery, air might get constantly blown into the medial corner of the eye whilst blowing their noses.

A pneumocephalus is the presence of gas air in the cranial cavity. In most cases, it is based on a communication between extracranial and intracranial space.

The air can be present in epidural, subdural, subarachnoid, intraventricular or intracerebral spaces. It might be tolerated well in one case, yet in other cases it could be responsible for dangerous findings and symptoms [ ].

However, air entrapment is not obligatory in every skull base injury Figure 12 Fig. A second pathomechanism is air being sucked in, after cerebrospinal fluid has been discharged.

As a result intracranial pressure increases gradually and a tension pneumocephalus develops. Symptoms are an altered state of consciousness, restlessness, headache, nausea, vomiting, eye motility disorders, ataxia, and spasms.

If the underlying process is not interrupted, a pressure effect in the interhemispheric fissure close to the motor cortex might induce a diplegia.

Additionally rupture of bridging veins may cause subdural hematomas and finally cardiac arrest [ ], [ ], [ ], [ ]. In individual cases, the neurological symptoms may have a latent period of several days [ ].

The mass effect of air does not always have to be spectacular and is not always bilateral [ ]. After the diagnosis has been confirmed in the emergency CT scan, immediate neurosurgical decompression has to take place, e.

Intracerebral tension pneumocephelus may occur in rare cases. In those few cases, ineffective defect closure at the skull base was followed by a progressive accumulation of air subcortically in the frontal brain.

The pathophysiology and therapy are consistent with the usual tension pneumocephalus; the intracerebral air bubble may be released by means of a puncture.

The same applies for extremely rare cases of an intraventricular tension pneumocephalus after paranasal sinus surgery. The specific cause for this intraventricular accumulation of air is not yet known [ ], [ ].

Postoperative meningitis is rare, although it represents the most frequent intracranial complication in paranasal sinus surgery.

It spreads through dural lesions, perivascular or vascular paths or even via perineural spaces of the olfactory fibers [ 90 ].

In rare individual cases only, an intracranial abscess or septic thrombosis of the cavernous sinus can be classified as a true complication of paranasal sinus surgery [ ].

More frequently, they develop on the basis of a preexisting inflammation of the mucosa in the paranasal sinuses [ 90 ]. The incidence is within the same range as in conventional intracranial surgery or in pituitary surgery [ ], [ ], [ ], [ ], [ ], [ ].

Meningitis may occur with a delay of e. When suspecting meningitis a CT scan has to be ordered immediately followed by a lumbar puncture. Symptoms or findings are e.

The patient should be monitored intensively and an active cerebrospinal fluid fistula needs to be detected [ ]. Mainly responsible are staph. Acute sinusitis is more frequent postoperatively, for instance in the area of the surgical corridor of the sphenoid bone.

Here, revision surgery including a microbial probe is recommendable [ ], [ ]. Most studies imply that prophylactic administration of antibiotics does not reduce the risk of meningitis or brain abscess in skull base surgery [ ].

In case of antibiotic prophylaxis, it should be applied half an hour before the first incision; in uncomplicated rhino-neurosurgical operations, it may be restricted to 24—48 h [ ], [ ], [ ], [ ].

Other rhinological references recommend antibiotic treatment 3 days preoperatively for 7—14 days — depending on the duration of nasal packing [ ], [ ], [ ], [ ].

Preoperative microbial swabs are inappropriate for calculated antibiotic treatment [ ], [ ]. When there is an intolerance, vancomycin or clindamycin are also recommended [ ], [ ], [ ], [ ], [ ], [ ].

Uncomplicated cerebrospinal fluid fistulas have been mentioned in 4. They may lead to severe complications, e. Additionally this may result in an epidural, subdural or intracerebral haematoma, a localized cerebral infarction or even a traumatic aneurysm [ 90 ], [ 91 ], [ ].

Instantaneous fatal bleeding can possibly occur due to an injury of the internal carotid a. Serious damage can also be triggered by induced arterial spasms [ 90 ].

The defect at the skull base can cause a secondary herniation of brain tissue [ ]. An iatrogenic encephalocele can develop slowly within months and might only become apparent though meningitis [ ].

After extensive reconstruction of the frontobasal region and after a large amount of CSF has been discharged, intracranial pressure may drop, which in turn can result in displacement of the graft or tension on the bridging veins causing a subdural haematoma.

For these reasons, a lumbar drainage is contraindicated in case of a prominent pneumocephalus. After extensive surgical procedures, a CT control must be performed on the first or second postoperative day [ ].

Fatal, partially lethal complications with mechanical destruction of cerebral tissue are limited to extremely rare cases in routine paranasal sinus surgery.

Corresponding reports are mostly from earlier decades [ ], [ ]. In individual cases, severe combined injuries of brain and vessels can occur, e.

Smaller case series report a clustering of corresponding incidents, partly on the right hand side and partly on the left hand side [ ], [ ].

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PubMed Cite this publication. Yousef A M S Hussain. Common bile duct CBD injury is one of the most serious complications of laparoscopic cholecystectomy LC.

Misidentification of the CBD during dissection of the Calot's triangle can lead to such injuries. The aim of the authors in this study is to present a new safe triangle of dissection.

This is then followed by dividing the lateral peritoneal attachment. The floor of the triangle is then divided to delineate both cystic duct and artery in an area relatively far from CBD.

There were little significant immediate or delayed complications. The mean operating time was 68 minutes, nearly equivalent to the conventional method.

Dissection at TST appears to be a safe procedure which clearly demonstrates the cystic duct and may help to reduce the CBD injuries.

Figures - available via license: Cystic Artery white arrows and junction between cystic duct and artery black arrow and the Triangle of Safety.

Hinda wi Publishing Corporation. V olume , Article ID , 5 pages. M ethodolog y R epor t. T r iang le of Safety T echnique: A N ew A pproac h to.

Laparosco pic Cholecystectom y. A bdulrahman Faraj Alm utairi. Correspondence should be addressed to Y ousef A.

Rec ommended by Guntars Pupelis. Backgrounds and Study Aims. Common bile duct CBD injur y is one of the most serious complications of laparoscopic.

This is then followed by dividing the lateral. Dissection at TST appears to be a safe. This is an open access ar ticle distr ibuted under the Creativ e Commons.

Attribution License, which p ermits unrestricted use, dist ributio n, and reproduction in any medium, pro vided the original work is.

Laparosc opic cholecystectom y has become the standard. The technique most c ommonly employ ed is the. Issues lik e poor surgical.

The pur pose of our new technique is to. W e believe that. Ope rativ e Proc edure. The procedure is car ried out using. Fig u re 1: Po rts site in LC.

Fig u re 2: T ract ion of GB. The borders of tr iangle of safety are dissec ted out in four. First step is dissecting the per itoneum over the GB wal l in.

The cystic arter y. I n these cases. Second step is dividing the small br anches of the cystic. Fig u re 3: T his is usually easily. Further more, any bleeding can easily and safely be.

W ith this step the GB is. The posterior wall of the gal lbladder and the cystic duct-. Third step is releasing the lateral peritoneal attachment.

Figures 5 a — 5 c. Fourth step is dividing tissues ly ing among the borders. Finally is clipping and dividing the cystic arter y over the.

This wil l leave. Fig u re 4: Cystic Ar tery white ar rows and junction between cystic. There were females and males.

The mean operative time was. P atients how underwent c onv ersion to open. There was one case con verted to open due to.

This was considered to. Pr evention of injur y to the ductal system continues to be a. An increased incidence of.

CBD injur y has been reported ranging betw een 0. Few methods hav e been advocated to reduce the inci-. Man y guidelines have been suggested to.

Fig u re 5: Strasberg suggested that no clipping or cutting should be. Ho wever it was left to the surgeon to decide the safest.

Fig u re 6: Dividing tissues in T riang le of Safet y. Fig u re 7: Clipping the cystic arter y over the GB wall and the duct. There are four newly int roduced steps in this technique.

U pon rev iewing the cystic duc t and ar tery anomalies. TST spares this area. In fact the cystic. Mo reov er , following the cystic ar tery branches from the.

TST appears to be a safe technique which clearly demon-. As TST dissect ion occurs at a distance f rom. R eddick and D. Dellinger , and L.

Surgical Endoscopy , vol. Journal of Surgery , vol. England Journal of Medicine , vol. Lear y , and C. Sackier , and M. Og iwara, et al. Surg er y , vol.

Report of a repair of an accessor y bile duct and review of the. Critical view of safety faster and safer technique during laparoscopic cholecystectomy?

In this study, we will see whether CVS technique is faster and safer compared to conventional infundibular technique.

Total of patients were divided into two groups. Two groups were compared for operating time and BDI. Minor leaks were comparable 0.

Dissection of the duct is performed over the gallbladder corpus near this junction, and Calot's triangle is by-passed. This approach is considered to be more useful in the presence of vascular and ductal variations and to prevent probable injuries [24].

In general, the right-handed surgeons start to the dissection of the Calot's triangle from the point of cystic artery and medial side of the gallbladder.

Data including demographic characteristics of the patients, cystic duct dissection time, cystic artery dissection time, and intraoperative bleeding amount were recorded.

The median cystic duct and cystic artery dissection times were In Group 1, these values were In Group 2, the median cystic duct and cystic artery dissection times were Our study results suggest that this technique can be safely performed in an acceptable time in LC patients.

It also appears to be a safe alternative option for residents, left-handed surgeons, and patients with biliary and vascular abnormalities.

While establishing the CVS cannot entirely protect against CBD injury, this technique is applicable to daily clinical practice and may have advantages over traditional approaches in case of significant inflammation [46].

The reviewed literature suggests that judicious establishment of CVS could decrease bile duct injury rate, from an average 0.

Examples of large institutional retrospective series that have demonstrated efficacy of CVS include Yegiyants et al.

IRCAD recommendation on safe laparoscopic cholecystectomy. An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy LC with the goal of deriving expert recommendations for the reduction of biliary and vascular injury.

Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC.

Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants.

The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety CVS , systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down fundus-first cholecystectomy.

Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques.

The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

It is actually a potential space used for dissection of its contents without bile duct damage which is the important and challenging maneuver for laparoscopic cholecystectomy [18,19].

Lymph node is also a content of Calot's triangle, is an important landmark for the recognition of cystic artery and duct during for laparoscopic cholecystectomy [20].

To evaluate the cystic lymph node in triangle of Calot's and to detect the association of cystic artery to cystic lymph node at tertiary care teaching hospital Patients and Methods: All the patients who were planned for elective laparoscopic cholecystectomy were admitted and included in this study.

All the participants were evaluated by ultrasound before surgical procedure while laparoscopic cholecystectomy was performed under general anesthesia by applying four port techniques.

The frequencies of the cystic lymph node and associated variations were observed. The cystic lymph node was observed in twenty seven participants with association to cystic artery.

Critical View of Safety: The incidence of bile duct injury after laparoscopic cholecystectomy is 0. This may cause post-operative morbidity to the patients.

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