when the vessel contracted and closed off. The procedure was completed without any warning signs and in the recovery room the patient went into shock from sudden loss of blood when the vessel began bleeding again. Only an emergency surgery saved the young man's life. It should not have happened!
In general, laparoscopic surgery saves the patient a big incision, the dividing of abdominal wall muscles, and affords a much more rapid recovery, much less pain, and less tissue damage. The patients are often only in the hospital for the day and are back to work in a few days. We will discuss other laparoscopic procedures under their appropriate specialty in Part II, along with diagrams showing where the holes in the skin are made. Laparoscopy is relatively simple and much less invasive with less tissue morbidity than the older methods, but does require expertise and special training.
Once laparoscopic cholecystectomy became popular, several other procedures were tried and several specialties began using the same basic method for their procedures. We will go into specifics under each specialty in Part II. As of now, the laparoscopic procedures that have been accepted by surgeons are: cholecystectomy, diagnostic laparoscopy—which means just looking around inside—including those for cancer diagnosis, appendectomy, hernia repair, liver biopsies, and hiatus hernia repairs. There are also small and large intestine resections, taking away adhesions, and lymph node biopsies.
Surgeons have also done the following procedures, but to a limited degree, and their acceptability will be increased in the coming years. These include: cancer operations on the colon, stomach operations, ulcer operations, and certain bypass operations. Gynecologists are now using the procedure to make diagnosis of gynecologic pathology, both benign and malignant, and can frequently remove lymph nodes and small tumors laparoscopically. Of course, tubal ligations have been done this way for a long time. The chest surgeons use scopes to examine the lungs in a procedure called thoracoscopy and can do some biopsies and other procedures in this manner.
Orthopedic surgeons are now looking into joints with arthroscopes to repair ligaments and clean out disreputable joints.
Laparoscopy and its cousin procedures have made a strong impact on several different kinds of surgery, and we shall discuss this more with each specific subspecialty as indicated, including an overview of the types of complications which may ensue using this modality.
Chapter 16
PERITONITIS
Before the time of Lister and Pasteur,
Opening the belly would cause a disaster.
If one allowed germs to get inside us
We patients would die of a peritonitis.
Before we can talk about peritonitis or inflammation of the peritoneum, we had better clarify to the non-medical person what the peritoneum is. Imagine a room filled with chairs, tables, dishes, and other objects. Then take an imaginary plastic spray gun and cover everything with a thick plastic coating. This coating would essentially make a contiguous connecting sheet around everything and leave the center of the room inside the plastic coating or balloon. That is essentially what the peritoneum does. It covers all structures in the abdomen as if we had blown up a balloon inside.
The peritoneum is a real structure with blood supply and nerves and can be important to a physician when something causes it to be disrupted or get infected. Inflammation of the peritoneum, or peritonitis, has many causes. The more common causes of peritonitis are ruptured appendicitis, perforated diverticulitis or hole in the colon secondary to infected diverticulae (see the chapter on Colon), perforated ulcer of the stomach or duodenum, problems of infection in the abdomen secondary to injury (as by local “knife and gun club activity”), and breakdown of connections called anastomoses made by a surgeon.
The symptoms of peritonitis are abdominal pain, fever with chills, and sometimes diarrhea, nausea, and vomiting. The abdomen will often be distended and very tender and, when the physician listens to the belly with his stethoscope, he may not hear any sounds. Normally we can hear bowel sounds, indicating the normal back and forth movement of the intestines. A silent abdomen is often indicative of something wrong.
Why, then, have a chapter on peritonitis? Mainly, because it can act to warn the patient and his doctor that something is going on inside, that some one had better do some studies and find out what it is! Although most people recover from peritonitis when the underlying cause is treated, as with removing the diseased appendix or colon, it remains the greatest cause of death following abdominal surgery. When a patient comes to the physician with abdominal pain, one of the first things the doctor will do will be to determine if the patient has peritonitis, looking for peritoneal irritation signs of pain, tenderness, fever, or silent abdomen. He will look for something called rebound tenderness, which means that, when he pushes in on the abdomen and lets go suddenly, there is a sudden, severe pain due to sudden movement of an inflamed or infected peritoneum.
If the doctor determines that there is peritonitis, then he needs to do xray and laboratory studies to pinpoint the cause and make plans to correct the problem. He will generally want to start an intravenous line, since the patient is often dehydrated from vomiting and not eating, and will give pain medication and some broad spectrum antibiotics.
Peritonitis means something is wrong
Inside us!
Chapter 17
REHABILITATION
Habilitate means to make one suitable,
Especially those who haven't a cluetable.
So to re habilitate,
Assumes you were once in a suitable state.
Now most people I know are downright strange,
With behaviors and actions that they oughta change.
They wouldn't do well with rehabilitation,
For that would only cause more frustration.
Instead of re anything, I would suggest
Buying a large metallined chest,
And take all the people you want to rehabilitate,
And ship them all off to a totally different state.
There's an old expression that has become overused: “Let nature take its course.” When surgeons in days past completed their handiwork, the patient was sent home to heal and, more often than not, nature took its course—right to the grave. In the twentieth century we developed the concept of rehabilitation, which focuses on the individual as a functional member of society. It was not enough just to have a successful surgery; it was the responsibility of the physician to bring the patient, as close as possible, back to his prior normal physical and emotional status.
Over one hundred years ago it was shown that early ambulation of patients reduced complications, and yet it took another fifty years for physicians and patients to believe this line of thinking. It's almost as if, when you treat the patient as being sick, he will continue to be sick; if you try to get him functioning again, he will recover more rapidly.
In situations where patients have been critically ill with tremendous weight loss and thereby muscle loss, the program of rehabilitation may take months, whereas after simple surgeries it may take several days or weeks.
We need to understand that rehabilitation nowadays is a comprehensive
