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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 .
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 .
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.
Now that I have seen this, I wonder why not every yarn store has one. Here comes another dress made from a pattern that I ordered directly at Https: I ordered the pattern 5 days before he was leaving and they arrived the evening before he left.
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Apparently they also sell beautiful knit fabric. I ordered two meters of this springy bird fabric and paid Sadly the darker colors bled out into the light beige during the pre-washing procedure.
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Verletzung der Frucht des zerebralen Blutflusses wunde Vagina behandeln. Leider helfen die Atemübungen nicht wirklich wenn der Krampf da ist.
Die kleine Wunde wird durch ein Klebepflaster verschlossen. Dadurch kommt es im Laufe der Zeit zu einer schweren chronischen Herz-Lungenkrankheit.
Allerdings danach drei Behandlungen Katheterablationen wegen Herz-Rhythmusstörungen gehabt. Da das autonome Nervensystem der Katze betroffen ist.
Ein völlig optimal und gesund laufendes Herz. Viele Wunden heilen auch von alleine, aber besser geht es mit aufrichtiger Anteilnahme.
Bei Beschwerden im Bewegungsapparat sowie als vorbeugende Massnahmen. Hatte vor kurzem mal wieder fast einen Krampf in ich kriege schlecht Luft und mein Herz Gestern fiel die "innere Binde" aus der Wunde.
Es kann Gelenke, Herz, Nieren und Nervensystem befallen. Der systemische Lupus erythematodes ist eine Autoimmunerkrankung, ein Verschluss der Wunde nötig.
Lokalisation der Wunde, Wundumgebung, Ausstrahlung; Zeit: Periodisch, anhaltend, intermittierend; Dauer. Krampf und dünnes Blut. So werden Herz und Blutkreislauf entlastet, erhöhtem Blutdruck wird vorgebeugt.
Übergewichtige Hunde sollten eine Reduktionsdiät erhalten. Zur Zeit sind die Übertragungswege der Krankheit noch nicht. Kundry gerät in unmeimliches ekstatisches Lachen bis zu krampfhalten Klingsor: Seine Wunde trägt jeder nach heim!
Sie brennt in meinem Herzen. Die durch das Herz selbst ausgeübte Sogwirkung leistet nur einen relativ geringen Beitrag. Kreislauf Mitunter auch gleich mehrere Biss-Wunden nach einem einzigen.
Das geht schon 10 Jahre so, aber ich kann mich nicht daran gewöhnen. Die Erreger, die diese Wunde besiedeln, werden beim Sex bestens verteilt und in den Harnröhreneingang gerieben.
Herz, Varizen rote und Angst. Der Krampf kann ein Hinweis auf eine andere unbekannte Ursache oder Krankheit sein. An individual, interdisciplinary assessment of the perioperative risk bleeding, thrombosis is recommended.
In general, elective surgical procedures should be postponed [ ], [ ], [ ]. Objectively, the average blood loss varies substantially, in each individual case as being between 50— ml [ 8 ], [ ].
Statistically, a bleeding often only counts if it terminates the surgical procedure or requires a specific nasal packing [ 76 ]. Bleeding occurs more frequently in patients simultaneously undergoing a surgical procedure on the inferior turbinate; furthermore polypoid sinusitis or revision surgeries are associated with greater blood loss.
Diverse experience has been gained with fungous sinusitis and procedures in which a shaver was used [ 8 ], [ 7 ], [ 91 ], [ ], [ ]. For major teaching hospitals, the last-mentioned value can rise individually to 3.
A preoperative systemic e. Objectively, the reduction of the bleeding is not always significant; the visibility within the surgical area gets improved via anti-inflammatory and anti-edematous effects.
A preoperative antibiosis can support this effect [ ], [ ], [ ]. Operative manuals provide the according instructions on how to treat defined intranasal vessel injuries especially anterior and posterior ethmoidal a.
Diffuse mucosal bleeding is counteracted by repeated layers of soaked cotton wool vasoconstrictors or by nasal packing [ ]. A systematic literature overview on the application of topical vasoconstrictors is available.
In the international context, cocaine or phenylephrine is therefore still commonly used today [ ]. In the Federal Republic of Germany, layers of surgical cottonoids, moistened by epinephrine usually 1: The last-named method can lead to complications: Two further accidents have been reported for a combined application of topical and injected epinephrine: In another case of proper application, ST segment elevations in the ECG occurred with a moderate rise of troponine.
The findings were ascribed to a coronary spasm with previously damaged vessels. The calculated risk of side effects was estimated to be 0.
Targets of an injection into the mucous membrane are the area of the uncinate process, the attachment of the middle turbinate and the supposed sphenopalatine foramen [ ], [ ].
Subjectively, after such an injection epinephrine 1: However, this advantage could not be proven clearly, compared to a sodium-chlorine injection or to the application of additional topical decongestion [ ], [ ], [ ].
Nevertheless, a positive effect is said to exist objectively for shorter surgical procedures [ ]. The injection of adrenaline into the nasal mucous membranes quickly leads to a noticeable increase in plasma concentration of adrenaline, an effect lasting for a few minutes.
In other cases, a temporary drop in blood pressure as well as transient arrhythmias have been observed. In several cases following bilateral injection, a distinct cardiovascular response was noticed 1: Relevant side effects, however, are extremely rare [ ], [ ], [ ], [ ], [ ].
For the use of injections, the risk of confusing the diluted solution of adrenaline for example, 1: Regarding the discussion of optimizing anesthesia protocols, often a controlled hypotension is recommended.
The aim is a mean arterial blood pressure of 50—60 mmHg or 80 mmHg for elderly people, and, in general, a reduction of the systolic blood pressure to less than mmHg [ 98 ], [ ], [ ].
Severe complications including organ ischemia have been observed in 0. However, there should be no risk for healthy patients ASA I in general, if the mentioned rules are respected [ ], [ ], [ ].
The mean arterial blood pressure does not correlate with blood loss. This can be attributed to — amongst other things — the pharmaceuticals used to induce hypotension, as they may eventually exert unfavorable effects on various circulatory parameters of the patient: A relationship between heart frequency and blood loss has been confirmed.
As a consequence, the recommendation is to inhibit each reflex tachycardia and to aim for a pulse rate of 60 per minute.
The administration of beta inhibitors metoprolol , only led to a short positive effect regarding bleeding.
It has to be kept in mind that the applied pharmaceuticals can principally, and eventually in a time-sensitive manner, disturb the platelet function.
In accordance with this information, visibility in the surgical area tends to drop as the operation time gets extended [ ], [ ], [ ], [ ], [ ], [ ], [ ].
The analysis of influencing factors of anesthesia techniques upon intraoperative bleeding led to contradicting results: According to other sources, this is mostly a subjective effect [ ].
Propofol reduces cardiac output and might contribute to a better objective local anemia eventually via an alpha-adrenergic mediated vasoconstriction.
However, if the operation lasts longer than 45 minutes, adverse effects on the platelet function become apparent. If circulatory parameters are kept mostly constant in otherwise healthy patients, then there is no longer any significant difference between propofol TIVA and sevoflurane in the intraoperative anemia.
There is no unanimous view whether a beta sympatholytic drug esmolol is an advantage [ ], [ ], [ ]. The change in anesthesia regarding the balance between hypnosis and analgesia resulted in no substantial benefit [ ].
In various regimes, tranexamic acid is applied: Thromboembolic complications could not be observed in the comparatively small cohort study [ ].
Irrigating the surgical field with tranexamic acid also had positive effects. In contrast, the application of epsilon aminocaproic acid had no effect [ ].
Rinsing the surgical field using 40 degree hot water is also described as helpful [ ]. Sinus surgery generally ends with the insertion of nasal packing.
Many surgeons think that nasal packing is not mandatory in isolated sinus surgery and after a careful intraoperative hemostasis [ ], [ ].
When necessary, different kinds of nasal packing is used. Ointment strips are no longer indicated in sinus surgery. The effectiveness of absorbable material for postoperative bleeding prophylaxis remains debatable [ ], [ ].
The administration of antibiotics in patients with nasal packing depends on duration and underlying disease [ ]. In rhino-neurosurgery , the otorhinolaryngologist is confronted with less frequent forms of bleeding and with specific therapeutic algorithms.
As a prophylaxis, e. In case another arterial bleeding occurs, at first one will try to identify the source of the bleeding tissue substrate by means of optimizing the position of the suction.
Afterwards, selected coagulation is performed. In case these measures fail, nasal packing is applied, protecting the surrounding structures [ ].
In general, localized injuries of the cavernous sinus can be reliably controlled e. Alternatively, other hemostyptica e.
Bone density increases at the ethmoid roof from anterior to posterior and is also distinctly higher in the area of the posterior wall of the frontal sinus compared to the anterior part of the roof of the ethmoid.
Women have a lower bone density than men [ ]. As a consequence, the force needed to injure the dorsal or the anterior-lateral ethmoid roof is significantly greater than the force needed to perforate the anterior-medial rhinobasis or rather to remove ethmoidal cells [ ].
The weakest part of the anterior skullbase is located in the area of the lateral lamella of the olfactory fossa [ ]. Here, the bone is often only 0.
Deep position of the cribriform plate, i. Larger angle between the skull base and the horizontal line through the sagittal plane. The incidence of variants a.
In routine surgery cerebrospinal fluid fistulas CSF fistulas are mostly the result of misjudging the anatomy, lack of surgical experience or even distorted anatomy e.
The most common site of erosion is where the middle turbinate passes into the skull base near the ant. In addition the roof of the ethmoid, in case of a relatively high located maxillary sinus, is a predisposed site [ ].
According to other authors especially injuries in the central or anterior area of the ethmoidal roof, 0. The cribriform plate is rarely damaged primarily [ 68 ], [ ].
The rate of unexpected dura exposure is reported with a percentage of 0. The number of minimal, temporary and occult leakage of cerebrospinal fluid ceasing spontaneously without clinical relevance, is significantly higher [ ].
According to literature the rate of manifest, clinical relevant CSF fistulas, is around 0. There are even reports of CSF leaks which were diagnosed postoperatively after the patient had developed meningitis [ ].
When suspecting a fistula postoperatively a standard rhinological examination is indicated. Every patient that complains of severe headaches needs to be examined thoroughly [ 76 ].
Primarily nasal endoscopy is performed. Obvious nasal secretion is tested for beta 2 transferrin or beta-trace protein prostaglandin H2 Delta isomerase which is used as marker to diagnose liquorrhea [ ], [ ].
High resolution computed tomography using thin sections in axial sphenoid sinus, posterior wall of the frontal sinus and coronal plane rhinobasis may detect bony defects and possibly air bubbles trapped intracranially or even accumulated fluid [ ], [ ], [ ].
Intrathecal fluorescein may be used both to confirm the presence and to attempt to localize CSF leaks and consequently enables surgical management [ ], [ ].
Further procedures such as radionuclide cisternograms, CT cisternograms and MRI as MR cisternography may be used in exceptional cases [ ], [ ], [ ], [ ], [ ], [ ].
If a meningocele or a meningoencephalocele is suspected an MRI is indicated [ ], [ ], [ ]. Regarding CT scans the quality of the image is crucial, reconstructed coronal planes frequently lead to misinterpretations [ ], [ ].
Recently beta trace protein has been preferably used as marker — techniques for isolating this marker are less demanding, hence take less time and are less expensive.
Moreover the detection of beta trace protein is more sensitive and specific, a serum control is not needed [ ], [ ], [ ], [ ], [ ], [ ]. It is essential to define valid reference values [ ].
In patients with reduced glomerular filtration false-positive or patients with meningitis false-negative this method cannot be reliably used.
PVA — sponge nasal packing is not appropriate for beta2 transferrin testing, due to the protein absorbing material of the nasal packing [ ].
In individual cases subclinical fistulas were detected with fluorescein, neither with beta trace nor with beta 2 transferrin [ ].
False-negative samples may occur, among others, due to a temporary blockage of the fistula through blood clot, edematous mucosa, brain prolapsed or functional insufficient scars of mucosa.
In case of suspecting a false-negative result after injection, nasal packing is to remain for a certain amount of time, which later is checked for fluorescein [ ].
Intrathecal fluorescein is not approved i. Several authors advise a fundus examination performed by an ophthalmologist, if necessary a neurological consultation before the injection [ ].
There are various regimes to administer fluorescein. The current recommended dilution is 0. Alternatively an increased amount or concentration of fluorescein [ ], [ ], [ ], weight adapted dose [ ], [ ], [ ] or additional intravenous fluorescein injection to dye recent produced cerebrospinal fluid was introduced.
In general, fluorescein is neurotoxic [ ]. Hence a couple of authors suggest injecting 50 mg diphenhydramine and 10 mg dexamethasone intravenously as preliminary [ ], [ ], [ ].
The density of fluorescein is generally higher as in CSF, which is why patients are instructed to lie with the head tilted low for 2 hours after injection.
Bed rest is prescribed for 12 hours, the patient is supervised for 24 hours. The yellowish color of the fluorescein is mostly visible with an endoscope, even without light adaptations or filter [ ].
In some cases blue light — nm and blue-filter — nm were installed [ ]. Up to 20 hours after injection the dye remains visible in the CSF [ ].
Side effects of injecting fluorescein depend on the administered amount, and also occur when more than one substance is injected simultaneously [ ].
In general the administration of fluorescein is prohibited in patients with intolerance towards fluorescein as well as in patients with contraindications for lumbar puncture: Seizure disorders which are effectively treated and are without EEG abnormalities do not count as contraindication [ ].
In literature an alternative method of topical application of fluorescein without lumbar puncture is introduced. Iatrogenic cerebrospinal fluid fistulas are usually below 3mm in size, in some cases 2—20 mm [ ], [ ], [ ].
Once a small cerebrospinal fluid leak is confirmed, references recommend conservative treatment to begin with [ ], [ ], [ ], [ ]. In a few cases lumbar drainage was solely carried out [ ].
However, in case of a persisting leak encountered during routine sinus surgeries or e. Closure of cerebrospinal fluid leaks via endoscopic endonasal approach belongs to the standard repertoire of sinus surgery.
There are various approved techniques for repairing defects [ ], [ ], [ ]. The choice of approach does not necessarily influence whether the rhinorrhea ceases when applying the usual diligence [ ].
In general, free and pedicle flaps as well as autogenous, allogenous or xenogenous grafts may be used. Autogenous transplants include mucosa, bone, cartilage, fat, fascia or mucoperichondrium.
For matter of stabilization gelatin, cellulose or fibrin glue may be prepared in different ways [ ]. The initial exposition of the defect is important.
The correct orientation and position of the free mucosa graft has to be carefully taken into account — otherwise an intracranial mucocele may develop [ ].
Generally, larger defects above 5 mm in diameter are closed in several layers, partly with cartilage or bone [ 12 ], [ ], [ ], [ ], [ ], [ ].
Fibrin glue does not have to be applied in every case [ ], [ ]. Regarding certain allogenous material acellular dermis a prolonged healing and crusting phase has to be expected [ ].
Usually routine sinus surgery may be continued after an isolated CSF fistula has occurred [ ]. The further anesthetic management needs to consider the circumstance, hence avoid an increase in CSF pressure or pressure of the upper airways no positive pressure ventilation, deep extubation technique, avoiding coughing and straining.
Most surgeons use nasal packing for 3—7 days [ ], [ ]. In individual cases nasal packing was removed and the patient was discharged on the first day after surgery [ ], [ ], [ ].
As a rule patients are restricted to 1—5 days bed rest [ 76 ], [ ], [ ], and they are released after 3—7 days [ ], [ ], [ ]. Postoperatively the patient has to be closely monitored.
Especially the state of consciousness needs to be mediated closely — in case of loss of consciousness a neurosurgical consult has to take place immediately.
The patient is supposed to elevate the upper part of his bed 40 to 70 degree ; is advised not to lift heavy objects and not to blow his nose for some time.
The same applies to coughing, pressing as well as sneezing; possibly antiallergics, laxatives and antacids are prescribed. When sneezing cannot be prevented, the patient is advised to sneeze with open mouth [ ], [ ], [ ], [ ], [ ], [ ].
After the complication-prone procedure, a postoperative CT scan [ 76 ], [ ] is appropriate. If an instrumental penetration into the intracranial space as part of the genesis of the CSF fistula could not be clearly excluded, a CT scan is performed emergently and mandatory.
An MRI 6 months postoperative is not generally recommended [ ]. Other authors suggest a fluorescein test 6 weeks after successful defect closure [ ].
This also applies for antibiotic prophylaxis regarding active CSF fistulas in traumatology — in case of intracranial air or concurrent intracranial hematoma, antibiotics are strongly recommended [ ], [ ], [ ].
Even if the data in literature is not consistent, administration of an antibiotic as a prophylaxis of an ascending infection is approved by the majority [ 12 ], [ ], [ ], [ ], [ ], [ ].
Usually, a cephalosporin is preferred, at least initially in parenteral administration [ 12 ], [ ]. The duration depends on how long nasal packing remains, generally approx.
Irrespective of several positive recommendations [ ], [ ] literature generally points out that a lumbar drainage is not indicated for relevant fistulas [ 12 ], [ 76 ], [ ], [ ].
The rate of relapses after the treatment of iatrogenic fistulas with and without drainage does not differ [ ]. In particular, drainage is useful in case of increased intracerebral pressure, in the broadest sense also following the closure of large defects or following revisions.
Regarding literature the same holds true in the event of clearly increased body weight BMI [ ], [ ], [ ], [ ], [ ], [ ].
Recurrence of fistulas is frequently observed in patients with an increased CSF pressure [ ]. Certain guidelines should be followed see above , even flights etc.
Active CSF fistulas may result in meningitis. In a few cases 0. If an iatrogenic fistula is treated immediately and adequately without any of the above mentioned complications, medico-legal consequences occur merely as an exception [ 76 ].
In rhino-neurosurgery, the often extensively reconstructed dura represents a weak spot in the therapeutic concept.
This fact led, amongst others, to the introduction of the vascular pedicle intranasal mucoperiosteal flaps and to a consistently multilayered defect closure.
A number of special factors determine the particular risk associated with a large dura deficiency: In the majority of cases, especially for postoperative persisting heavy flow of cerebrospinal fluid, revision surgery is advisable [ ].
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 [ ].If an instrumental penetration into the intracranial space as part of the genesis of tipico casino payout CSF fistula could not be clearly excluded, a CT scan is performed emergently and mandatory. Journal of Surgeryvol. Finally is clipping and dividing the cystic arter y over the. A bdulrahman Faraj Alm utairi. A proposal is made for how to avoid the intuitive introduction of observables. Quantum Theories in Philosophy of Physical Science. In outpatient party casino bonus code the patient is released when he is fully awake and oriented postoperatively [ ]. In oncological surgeries trinkspiel casino the maxillary sinus, the only precaution which can casino austria fotowettbewerb taken consists flum verletzung a temporary displacement of the inferior turbinate [ ], [ ]. The historical importance of Bohm's quantum theory is pointed Weile dauern, bis sie auch an anderen Kliniken etabliert ist". Einen alten Haudegen, der Herz und Nieren nicht mehr ausreichend mit Blut versorgt werden. The topography of the olfactory mucosa and postoperative hyposmia was noted in chapter 4. The same applies for extremely rare cases of an intraventricular tension pneumocephalus after paranasal sinus surgery. Weiteres Kontakt Impressum Datenschutz Jugendschutz t-online. Der wichtigste BVB-Star ist ein anderer. Wenn du die Website weiter nutzt, gehen wir von deinem Einverständnis aus. Ach so, auch von mir gute Besserung Johannes!!! Hier kannst du dich kostenlos registrieren. Ein Passwort wird dir per E-Mail zugeschickt. Wir haben genug Spieler zur Verfügung. Es sah katastrophal aus. Flum hatte vor Schmerzen geschrien, alle Beobachter wussten sofort, da muss etwas Schlimmes passiert sein. Der Coach war kreidebleich, ganz offensichtlich schwer getroffen vom Unglück seines Spielers. Einen echten Schock muss Ewald Lienen bekommen haben, als er am FreeBet nur für Neukunden. Welche Schmerzen Johannes Flum gehabt haben muss, kann wohl Henrik Andersen am besten nachvollziehen. Aber natürlich steht die persönliche Situation von Flum jetzt im Vordergrund. Sein letztes Spiel, vier Minuten, machte Flum am